03/10/2025
When my friend, the Egyptian interventional psychiatrist Adel Marei (now practicing in the US) posted about doing TMS on a Parkinson’s patient who had Deep Brain Stimulation (DBS) electrodes last year, I was very surprised and intrigued. Electrodes are normally a strict contraindication in TMS because two disastrous outcomes could potentially happen: 1) The magnetic field could cause the electrode to overheat and irreversibly burn brain tissue. 2) The magnetic field could potentially move the electrode away from its target, thereby restoring the tremors that a brilliant team of neurosurgeons, nurses, and neurologists had worked very hard to correct.
I shared Adel’s post with my former boss, mentor, and neurosurgical pioneer, Dr. Richard Bucholz, at Saint Louis University School of Medicine. Known as “The Father of Neuronavigation” Dr. Bucholz had invented what later became known as the StealthStation from MedTronic back in the 1990’s. In overly simplistic terms, this was essentially “GPS for the Brain” whereby one could take pre-surgical MRI’s of the brain, upload them to the StealthStation, and with a probe utilizing IR reflective spheres, would update in 3D, where you are in the brain, helping to ensure complete removal of brain tumors and greatly improve outcomes.
This technology also enabled the precise targeting of electrodes to make DBS surgery possible. This is a life-changing surgery that Dr. Bucholz has done numerous times.
Not long after I sent the post to Dr. Bucholz, he referred a DBS patient to Precision TMS. This patient had successfully undergone DBS surgery for his Parkinson’s and his tremors were no longer occurring. However, he was still severely depressed. After trying medications to no avail, Dr. Bucholz sent him to us.
After reading Adel’s work and consulting with him, Dr. Bucholz, and Dr. Vadim Baram, we determined that since his electrodes were MR-compatible, they might be safe for TMS. We examined the specifications for the electrodes to confirm that they were non-ferrous, had non-magnetic properties, and were MR-compatible.
Still…I was nervous. Despite confirming all this, the fear of possibly causing irreversible harm gave me pause.
Instead of the normal DASH protocol at 10Hz, or theta-burst (50Hz) over left DLPFC, I wanted to use as little energy as possible, so I proposed we try 1Hz over right DLPFC. This is usually done to reduce anxiety in patients, but it is also antidepressant. I also like it because it is gentler and more easily tolerated by patients.
With an initial PHQ-9 of 22, after 17 sessions, his reported PHQ-9 was down to a 5. After the devastating loss of a family member, the patient reported an increased PHQ-9 of 12. After this personal loss and increase in PHQ-9, we did add the DASH protocol to the right DLPFC, but did not see further improvement in his scores.
Despite this, being able to safely perform TMS on Parkinson’s patients with MR-compatible DBS electrodes may open the door to an effective therapy for hundreds if not thousands of patients still suffering from depression and anxiety post DBS surgery.
I would like to thank Adel Marei, Dr. Bucholz, Dr. Vadim Baram, and my team at Precision TMS for helping make this happen.
I was honored to be able to present this case study at the Elsevier Brain Stimulation Journal 6th Annual 2025 Conference in Kobe, Japan.
A Case Study: Efficacy & Safety of TMS for Treatment of Major Depression in Parkinson’s Disease Patient with MR-Compatible DBS Electrodes.
