Correspondence Address:
Suk Yun Kang
Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong, Gyeonggi-do, 18450
Republic of Korea

Full Text



Dear Editor,

Locked-in syndrome is a very serious condition with desperate quality of life due to profound paralysis, and there is no effective treatment other than rehabilitation. Repetitive transcranial magnetic stimulation (rTMS) seems to be benefit in motor recovery of stroke patients and other neurological disorders.^[1] However, the rTMS effect of brainstem stroke was unclear.^[2],[3],[4] Moreover, long-term treatment is important to maintain the rTMS effect, but few information of long-term treatment protocol and safety is available in the literature. Therefore, we like to report our experience of long-term maintenance treatment of rTMS in locked-in syndrome.

A 57-year-old man with bilateral brainstem infarction was administered with rTMS at 3-month after acute stroke. He was severe locked-in-state, and stable without further improvement. Despite active rehabilitation, because there is no further substantial improvement, we decided to apply rTMS to him. On neurological examination, motor power was grade 0/5 in the right upper and lower limbs, grade 1 in the left upper and lower limbs. Brain magnetic resonance imaging showed multiple acute infarctions in the bilateral midbrain, right pons, bilateral cerebellum, right middle cerebellar peduncles, and left parieto-occipital lobe. At first, bilateral rTMS was delivered over bilateral motor cortex on weekdays for 1 week (5 sessions). After that the rTMS was given once a week for 1 month (4 sessions), and then twice a week for 3 months (26 sessions). rTMS protocol was the same as previously described procedure.^[5] There was no side effect during the treatment period. After completion of total 35 sessions, there was slight improvement of hand function in the left side, but no improvement in the right side. There was also increased amplitude of MEP on the right motor cortex [Table 1].{Table 1}

This study shows that long-term, bilateral high-frequency rTMS may be tolerable and safe, suggesting maintenance treatment may be applicable in stroke patients, and that there might be a possible therapeutic effect of rTMS on severe brainstem stroke with locked-in syndrome. However, because it is only one case study, further studies are needed to confirm our results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

The study was previously submitted as a poster to the 3^rd International Brain Stimulation Conference, Vancouver, Canada, and also presented as a poster at the Spring Conference of the 23^rd Korea Neurophysiological Society, Seoul, Republic of Korea, in 2019.

Financial support and sponsorship

Nil.

Conflicts of interestb

There are no conflicts of interest.

References