Thomas W. McAllister, MD

Repetitive Transcranial Magnetic Stimulation After Acute Ischemic Stroke

Khedr EM, Ahmed MA, Fathy N, Rothwell JC: Therapeutic trial of repetitive transcranial magnetic stimulation after acute ischemic stroke. Neurology 2005, 65:466–468.

Rating: •Of importance.

Background: Repetitive transcranial magnetic stimula-tion (rTMS) uses magnetic fields to induce local electricalcurrents in brain tissue. It has been used in exploratoryefforts to treat various neuropsychiatric conditions includ-ing movement disorders, epilepsy, migraine, and mooddisorders (see Fregni and Pascual-Leone in this issue).Depending on the frequency of the stimulation, rTMS canresult in increased or decreased cortical activity. This hasled to the suggestion that rTMS may be useful in the treat-ment of functional deficits after stroke.

Methods: Twenty-six patients with hemiplegia afterrecent thromboembolic strokes in the territory of themiddle cerebral artery were randomized to real or shamrTMS. Real rTMS consisted of a 10-day trial of 10 10-second trains of 3-Hz stimulation with 50 secondsbetween trains, applied over the affected motor cortex.Sham treatment consisted of use of the same parameterswith the coil angled away from the head. Participants wereblind to their treatment group assignment. Participantswere evaluated at baseline, immediately after the 10-day

treatment intervention, and again 10 days after the finalsession by a neurologist blind to treatment conditionusing the Scandinavian Stroke Scale, the National Insti-tutes of Health Stroke Scale, and the Barthel Index Scale.All participants also continued to receive usual rehabilita-tive interventions during the trial.

Results: Twenty-six participants in each of the two treat-ment groups completed the trial. rTMS was well tolerated.Groups were well matched in terms of stroke parametersand demographics. Two-factor analysis of variance for eachof the outcome measures showed highly significant time Xtreatment interactions with greater improvement in thereal rTMS group on each outcome measure.

Editor’s comments

This study suggests a potential role for rTMS in the treat-ment of motor deficits after stroke. There are several issuesthat should temper the interpretation, including possibleunblinding of the participants attributable to motorresponse associated with real rTMS, the relatively smallstudy sample, and the lack of long-term follow-up. It alsois unclear if rTMS is working independently of, or as anadjunct to, usual rehabilitation interventions. Neverthe-less, it is a well-designed study with provocative results thatshould serve to encourage additional work in this area.

Risperidone for Autistic Disorder

Research Units on Pediatric Psychopharmacology Autism Network: Risperidone treatment of autistic disorder: longer-term benefits and blinded discontinuation after 6 months. Am J Psychiatry 2005, 162:1361–1369.

Rating: •Of importance.

Background: Autistic spectrum disorders are often com-plicated by challenging behaviors such as irritability, objectaggression, self-injurious behavior, or assaultiveness. Thesebehaviors frequently contribute to caregiver burden, anddetract from the quality of life of the individual withautism. There are few clinical trials to inform treatment ofthese behaviors. An earlier report from this group [1]

suggested that risperidone was associated with improve-ment in challenging behaviors during an 8-week period.This article reports on the efficacy of risperidone over anadditional 4-month period, and an 8-week placebo-substitution and risperidone withdrawal study

Methods: Participants included 63 children (5 to 17 yearsof age) with carefully characterized autistic disorder fromthe earlier study [1] who were judged risperidone respond-ers on the basis of a 25% or greater improvement in the Irri-tability subscale of the Aberrant Behavior Checklist –Community version, and a rating of improved or very muchimproved on the Clinical Global Impression severity scaleafter the 8-week initial double-blind, placebo-controlledtrial. Participants were treated for 4 months in an open-label