TMS治疗方案参考.docx

TMS治疗处方参考一，怎样选择和确定治疗方案：1, 明确诊断：详细体检，神经系统检查、神经影像学检查（ CT/MRI）、生化检查、神经功能影像学检查（fMRI/PET）,电生理检查，（MEP、EEG、EMG、SEP）等检查确 定病变部位、性质、神经网络回路，了解病程病因病理2, 明确TMS参数对于皮质可塑性调节机理，高频高强度刺激（＞5Hz）和间歇性Theta爆发刺激（iTBS）可兴奋大脑皮质，产生长时程增强（LTP）的可塑性变化，刺激部位 脑血流增加，脑源性神经营养因子（BDNF）增加，刺激回路垂体神经内分泌相关激 素增加，细胞内钙离子增加，磷酸激酶增加， DNA转录增加，多种蛋白合成增加，促进突触连接功能和神经网络形成低频低强度刺激和 cTBS作用相反，可治疗皮质某些功能区亢进性疾病.3, 刺激参数主要为：强度、频率、刺激时间、间歇时间、重复次数 （总的刺激时间和刺激脉冲个数），以上参数组成不同的刺激序列和刺激方案.（见表1）其中的花样刺激 模式是2005年以后新方法，刺激量小，治疗时间短，治疗效果优于传统刺激方法值 得临床治疗优先考虑.4, 根据检查、诊断结果，确定治疗的观察指标、量表，比较疗效.一般年轻、病程短、病情轻、没有明显的器质性改变，治疗时间、治疗次数可缩短。

而年老、病重、遗传 性、器质性、药物难治性、慢性疾病可增加刺激量和治疗时间 .每次治疗不超过30分钟,避免治疗适应和效果饱和疗程太短则疗效不能巩固 .5, 注意事项：治疗过程中要给病人带耳塞，预防听觉受累，如出现头痛、恶心等副作用，可减少刺激量和治疗时间万一诱发癫痫，马上停止治疗，保护病人不要受伤 ，一般不用抗癫痫药物，可自行恢复.目前没有诱发多次癫痫的报道.二，常见疾病治疗处方参考：1, , 抑郁症：低频刺激右侧额叶背外侧 （LDPFC）,高频刺激左LDPFCo （图1）2, 狂躁症、焦虑症、强迫症：高频刺激右侧 LDPFC,双侧运动皮质3, 精分症:改善阴性症状，高频刺激左 LDPFC或圆线圈刺激前额中部4, 精分症：治疗幻听、耳鸣，低频刺激左颗顶叶5, 孤独症（自闭症）：低频刺激左LDPFC,高频刺激前额叶中部6, 老年性痴呆：高频刺激双侧LDPFC7, 帕金森病：高频刺激左LDPFC,低频刺激患侧运动皮质（M1）,高频刺激健侧 M1区8, 肌张力异常、不自主抽动：低频刺激患侧皮质运动区9, 癫痫：低频刺激病灶区或 M1区10,偏头痛：低频刺激枕叶视觉皮质区或高频刺激左 LDPFC11 ,顽固性神经性慢性疼痛、纤维肌痛、内脏痛：高频刺激单侧（左）M1区，低频刺激外周患 侧神经根、高频刺激左LDPFC,低频刺激右LDPFC12,中风缺血性脑梗塞、偏瘫:高频刺激患侧病灶附近， 低频刺激健侧M1区，外周功能 性磁刺激。

刺激外周神经带动瘫痪肌收缩 .13,中风引起的偏侧视觉忽略：低频刺激健侧枕叶视觉皮质 .14,中风引起的失语症：低频 1Hz刺激右侧布洛卡对应区15,中风引起的吞咽障碍：低频刺激健侧 Cz前2-4cm外侧4-6cm下颌舌骨运动区16,脊髓损伤：高频刺激脊髓损伤相关皮质运动区和受损下端神经根17,脊髓损伤并发症，胃肠功能障碍、便秘：高频 T9、l3相继刺激，促进肠蠕动.18,脊髓损伤并发症，排尿障碍：高频刺激舐部神经根19,脊髓损伤并发症，呼吸困难：高频刺激 C6-C7增加吸气，T9—T10增加呼气.20,脊髓损伤弁发症，肌痉挛、萎缩、预防深部静脉血栓，高频刺激周围神经21,睡眠障碍：低频刺激顶叶 Cz后1cm,或右侧LDPFC,高频刺激左LDPFC22,成瘾性疾病：可卡因、酒精：高频刺激右 LDPFCo香烟、尼古丁 ：高频刺激左LDPFC o三.详细处方1,抑郁症：模式刺激部位刺激量RMT频率Hz串时间s串间歇s脉冲总数（个）治疗时间m （分钟）次/周疗程 周1常规左额叶背外侧0.8—1110—201 —58-301000-200020-3056-82常规右额叶背外侧08 — 11 0.3— 15-102-51000-200020-3056 — 8花样 模式刺激部位刺激量AMT丛内 频率丛内 脉冲丛间 频率串时间S （秒）串间歇s （秒）脉冲 总数治疗时间m （分）次/周疗程 周3cTBS右额叶背外侧0.850Hz35Hz2060600-9002—354-64iTBS左额叶背外侧0。

850Hz35Hz28600-9003—554-6参考：如下Table 1 rTMS treatment trials in MDDStudySubjectsrTMS parametersSignificantdifference3ResultsAvery et 口产68 patients with TRD15 节es写ions delivered to left DLPFC at 110% of RMT (32 trains of 10-Hz rTMS delivered in 5-seccnd trains)Sham_4E" coil tiltYesHDRS scones showed a significantly greater decrease over time in the TMS group, compared with the sham group; response rate for the IMS group was 30.6% greater than the 6.1% rate in the sham groupBerman et alJZ20 patients with TRD10 sessions, 20 gins of 2 seconds, 20-Hz stimulation, with 58-second intervals, delivered at 80% RMTSham-45p coil tiltYes1 of 10 subjects neceiving active treatment demonstrated a robust response (that is, HDRS decreased from 47 to 7 points); 3 other patients demonstrated 40% to 45% decreases in HDRS scores; no patients receiving sham demonstrated partial or full responsesFitzgerald50 patients3 trains of LFR-rWS to the right PFC ofYesSignificant decrease in MAD RS scones foretal^5with TRD140second duration at 1 Hz were applied dailyh followed immediately by 15 trains of 5-second duration of HFL-rTMS at 10 Hz for 6 weeksSharrH-45* coil tiltactive treatment group at 2 week号 and across the full duration of the study; those receiving active treatment met response (11 of 25 [44%]) or remission (9 of 25 [36%]) criteria by study end, compared with sham stimulation group (2 of 25 [8%) and none of 25h respectively)Firtzgerald etal660 patients with TRD20 trains of 5-second HFL-TMS at 10 Hz and 5 trains of 60-second LFR-TMS at1 Hz dailySh dYesSignificant reduction in MAD RS scones between the HFL-TMS and sham groups and between the LFR-TMS and sham groupsGeorge et m 产 12 depressed20 sessions of 2-second, 20-Hz stimuli atYesDuring the active phase, HD RS scoresadults80% of the RMT over left DLPFCSham-45" coil tiltIl Klein eta 产79 inpatients with MDD10 sessions, 1 Hz, OJ-millisecond pulse duration at 10% above RMT (60 stimuli over1 minute)YesSignificant reduction in depression scores as shown by the HDRS and MADRS after 2 weeks of active treatmentIl Klein et al2179 inpatients with MDD10 sessions, 1 Hz, OJ-millisecond pulse duration at 10% above RMT (60 stimUi over 1 minute)YesSignrfiGant reduction in depression scores as shown by the HDRS and MADRS after 2 weeks of active treatmentQ1 Reardon301 medication-5 days per week for 4 to 6 weeks. 10 pulses YesActive TMS was significantly superior tcetal38free patientsper second at 120% of the RMT, 3000sham on the MADRS at 加启佻 4 as well as1with MDDpulses per session over left DLPFCSham—separate coil with embedded magnetic fieldHDRS at weeks 4 and 6Pascual-Leone17 patients5 sessions, 20 trains, 10-second duration YesLeft DLPFC rTMS resulted in a significanteta尸with me。