Safety of ipsilesional anodal transcranial direct current stimulation in acute photothrombotic stroke: implications for early neurorehabilitation.

Early rehabilitation in the acute phase of stroke, that bears unique neuroplastic properties, is the current standard to reduce disability. Anodal transcranial direct current stimulation can augment neurorehabilitation in chronic stroke. Studies in the acute phase are sparse and held back by inconclusive preclinical data pointing towards potential negative interaction of the excitability increasing tDCS modality with stroke-induced glutamate toxicity. In this present study, we aimed to evaluate structural and behavioral safety of anodal tDCS applied in the acute phase of stroke. Photothrombotic stroke including the right primary motor cortex was induced in rats. 24 h after stroke anodal tDCS was applied for 20 min ipsilesionally at one of four different current densities in freely moving animals. Effects on the infarct volume and on stroke induced neuroinflammation were assessed. Behavioral consequences were monitored. Infarct volume and the modified Neurological Severity Score were not affected by anodal tDCS. Pasta handling, a more sensitive task for sensorimotor deficits, and microglia reactivity indicated potentially harmful effects at the highest tDCS current density tested (47.8 A/m2), which is more than 60 times higher than intensities commonly used in humans. Compared to published safety limits of anodal tDCS in healthy rats, recent stroke does not increase the sensitivity of the brain to anodal tDCS, as assessed by lesion size and neuroinflammatory response. Behavioral deficits only occurred at the highest intensity, which was associated with increased neuroinflammation. When safety limits of commonly used clinical tDCS are met, augmentation of early neurorehabilitation after stroke by anodal tDCS appears to be feasible.

Cx3cr1 deficiency interferes with learning- and direct current stimulation-mediated neuroplasticity of the motor cortex.

Microglia are essential contributors to synaptic transmission and stability and communicate with neurons via the fractalkine pathway. Transcranial direct current stimulation [(t)DCS], a form of non-invasive electrical brain stimulation, modulates cortical excitability and promotes neuroplasticity, which has been extensively demonstrated in the motor cortex and for motor learning. The role of microglia and their fractalkine receptor CX3CR1 in motor cortical neuroplasticity mediated by DCS or motor learning requires further elucidation. We demonstrate the effects of pharmacological microglial depletion and genetic Cx3cr1 deficiency on the induction of DCS-induced long-term potentiation (DCS-LTP) ex vivo. The relevance of microglia-neuron communication for DCS response and structural neuroplasticity underlying motor learning are assessed via 2-photon in vivo imaging. The behavioural consequences of impaired CX3CR1 signalling are investigated for both gross and fine motor learning. We show that DCS-mediated neuroplasticity in the motor cortex depends on the presence of microglia and is driven in part by CX3CR1 signalling ex vivo and provide the first evidence of microglia interacting with neurons during DCS in vivo. Furthermore, CX3CR1 signalling is required for motor learning and underlying structural neuroplasticity in concert with microglia interaction. Although we have recently demonstrated the microglial response to DCS in vivo, we now provide a link between microglial integrity and neuronal activity for the expression of DCS-dependent neuroplasticity. In addition, we extend the knowledge on the relevance of CX3CR1 signalling for motor learning and structural neuroplasticity. The underlying molecular mechanisms and the potential impact of DCS in rescuing CX3CR1 deficits remain to be addressed in the future.

Direct current stimulation increases blood flow and permeability of cortical microvasculature in vivo.

BACKGROUND AND PURPOSE: Transcranial direct current stimulation (DCS) structurally and functionally modulates neuronal networks and microglia dynamics. Neurovascular coupling adapts regional cerebral blood flow to neuronal activity and metabolic demands. METHODS: In this study, we examined effects of anodal DCS on vessel morphology, blood flow parameters, permeability of cortical microvasculature, and perivascular microglia motility by time-lapse two-photon microscopy in anaesthetized mice. RESULTS: Low-intensity DCS significantly increased vessel diameter and blood flow parameters. These effects were transient and dependent on the spontaneous vasomotion characteristics of the individual vessel. Vessel leakage increased significantly after DCS at 1.1 and was more pronounced at 2.2 A/m2 , indicating a dose-dependent increase in vascular permeability. Perivascular microglia exhibited increased soma motility post-DCS at both intensities, potentially triggered by the extravasation of intravascular substrates. CONCLUSIONS: Our findings demonstrate that DCS affected only vessels with spontaneous vasomotion. This rapid vascular response may occur as an adaptation of regional blood supply to neuronal excitability altered by DCS or as a direct effect on the vessel wall. In contrast to these immediate effects during stimulation, increases in cortical vessel permeability and perivascular microglia motility appeared after the stimulation had ended.

Electrified microglia: Impact of direct current stimulation on diverse properties of the most versatile brain cell.

BACKGROUND: Transcranial direct current stimulation [(t)DCS], modulates cortical excitability and promotes neuroplasticity. Microglia has been identified to respond to electrical currents as well as neuronal activity, but its response to DCS is mostly unknown. OBJECTIVE: This study addresses effects of DCS applied in vivo to the sensorimotor cortex on physiological microglia properties and neuron-microglia communication. METHODS: Time lapse in vivo 2-photon microscopy in anaesthetized mice was timely coupled with DCS of the sensorimotor cortex to observe microglia dynamics on a population-based and single cell level. Neuron-microglia communication during DCS was investigated in mice with a functional knock out of the fractalkine receptor CX3CR1. Moreover, the role of voltage gated microglial channels and DCS effects on phagocytosis were studied. RESULTS: DCS promoted several physiological microglia properties, depending on the glial activation state and stimulation intensity. On a single cell level, process motility was predominantly enhanced in ramified cells whereas horizontal soma movement and galvanotaxis was pronounced in reactive microglia. Blockage of voltage sensitive microglial channels suppressed DCS effects in vivo and in vitro. Microglial motility changes were partially driven by the fractalkine signaling pathway. Moreover, phagocytosis increased after DCS in vitro. CONCLUSION: Microglia dynamics are rapidly influenced by DCS. This is the first in vivo demonstration of a direct effect of electrical currents on microglia and indirect effects potentially driven by neuronal activity via the fractalkine pathway.

Manipulating Single-Trial Motor Performance in Chronic Stroke Patients by Closed-Loop Brain State Interaction.

Motor impaired patients performing repetitive motor tasks often reveal large single-trial performance variations. Based on a data-driven framework, we extracted robust oscillatory brain states from pre-trial intervals, which are predictive for the upcoming motor performance on the level of single trials. Based on the brain state estimate, i.e. whether the brain state predicts a good or bad upcoming performance, we implemented a novel gating strategy for the start of trials by selecting specifically suitable or unsuitable trial starting time points. In a pilot study with four chronic stroke patients with hand motor impairments, we conducted a total of 41 sessions. After few initial calibration sessions, patients completed approximately 15 hours of effective hand motor training during eight online sessions using the gating strategy. Patients' reaction times were significantly reduced for suitable trials compared to unsuitable trials and shorter overall trial durations under suitable states were found in two patients. Overall, this successful proof-of-concept pilot study motivates to transfer this closed-loop training framework to a clinical study and to other application fields, such as cognitive rehabilitation, sport sciences or systems neuroscience.

Prevention of schizophrenia deficits via non-invasive adolescent frontal cortex stimulation in rats.

Schizophrenia is a severe neurodevelopmental psychiatric affliction manifested behaviorally at late adolescence/early adulthood. Current treatments comprise antipsychotics which act solely symptomatic, are limited in their effectiveness and often associated with side-effects. We here report that application of non-invasive transcranial direct current stimulation (tDCS) during adolescence, prior to schizophrenia-relevant behavioral manifestation, prevents the development of positive symptoms and related neurobiological alterations in the maternal immune stimulation (MIS) model of schizophrenia.

Direct current stimulation-induced synaptic plasticity in the sensorimotor cortex: structure follows function.

BACKGROUND: Non-invasive direct current stimulation (DCS) of the brain induces functional plasticity in vitro and facilitates motor learning across species. The effect of DCS on structural synaptic plasticity is currently unknown. OBJECTIVE: This study addresses the effects and the underlying mechanisms of anodal DCS on structural plasticity and morphology of dendritic spines in the sensorimotor cortex (M1/S1). METHODS: A DCS electrode setup was combined with a chronic cranial window over M1/S1 in transgenic Thy1-GFP mice, to allow for in vivo 2-photon microscopy and simultaneous DCS. Contralateral electrical forepaw stimulation (eFS) was used to mimic the second synapse specific input, a previously shown requirement to induce functional plasticity by DCS. Changes in spine density and spine morphology were compared between DCS/eFS and sham, as well as two control conditions (sham-DCS/eFS, DCS/sham-eFS). Furthermore, the role of BDNF for stimulation-induced changes in spine density was assessed in heterozygous Thy1-GFP x BDNF+/- mice. RESULTS: Combined DCS/eFS rapidly increased spine density during stimulation and changes outlasted the intervention for 24 h. This effect was due to increased survival of original spines and a preferential formation of new spines after intervention. The latter were morphologically characterized by larger head sizes. The DCS-induced spine density increase was absent in mice with reduced BDNF expression. CONCLUSION: Previous findings of DCS-induced functional synaptic plasticity can be extended to structural plasticity in M1/S1 that similarly depends on a second synaptic input (eFS) and requires physiological BDNF expression. These findings show considerable parallels to motor learning-induced M1 spine dynamics.

Resting-state brain network features associated with short-term skill learning ability in humans and the influence of N-methyl-d-aspartate receptor antagonism.

Graph theoretical functional magnetic resonance imaging (fMRI) studies have demonstrated that brain networks reorganize significantly during motor skill acquisition, yet the associations between motor learning ability, brain network features, and the underlying biological mechanisms remain unclear. In the current study, we applied a visually guided sequential pinch force learning task and graph theoretical analyses to investigate the associations between short-term motor learning ability and resting-state brain network metrics in 60 healthy subjects. We further probed the test-retest reliability (n = 26) and potential effects of the N-methyl-d-aspartate (NMDA) antagonist ketamine (n = 19) in independent healthy volunteers. Our results show that the improvement of motor performance after short-term training was positively correlated with small-worldness (p = 0.032) and global efficiency (p = 0.025), whereas negatively correlated with characteristic path length (p = 0.014) and transitivity (p = 0.025). In addition, using network-based statistics (NBS), we identified a learning ability-associated (p = 0.037) and ketamine-susceptible (p = 0.027) cerebellar-cortical network with fair to good reliability (intraclass correlation coefficient [ICC] > 0.7) and higher functional connectivity in better learners. Our results provide new evidence for the association of intrinsic brain network features with motor learning and suggest a role of NMDA-related glutamatergic processes in learning-associated subnetworks.

Transcranial Direct Current Stimulation Enhances Motor Skill Learning but Not Generalization in Chronic Stroke.

BACKGROUND: Motor training alone or combined with transcranial direct current stimulation (tDCS) positioned over the motor cortex (M1) improves motor function in chronic stroke. Currently, understanding of how tDCS influences the process of motor skill learning after stroke is lacking. OBJECTIVE: To assess the effects of tDCS on the stages of motor skill learning and on generalization to untrained motor function. METHODS: In this randomized, sham-controlled, blinded study of 56 mildly impaired chronic stroke patients, tDCS (anode over the ipsilesional M1 and cathode on the contralesional forehead) was applied during 5 days of training on an unfamiliar, challenging fine motor skill task (sequential visual isometric pinch force task). We assessed online and offline learning during the training period and retention over the following 4 months. We additionally assessed the generalization to untrained tasks. RESULTS: With training alone (sham tDCS group), patients acquired a novel motor skill. This skill improved online, remained stable during the offline periods and was largely retained at follow-up. When tDCS was added to training (real tDCS group), motor skill significantly increased relative to sham, mostly in the online stage. Long-term retention was not affected by tDCS. Training effects generalized to untrained tasks, but those performance gains were not enhanced further by tDCS. CONCLUSIONS: Training of an unfamiliar skill task represents a strategy to improve fine motor function in chronic stroke. tDCS augments motor skill learning, but its additive effect is restricted to the trained skill.

Transcranial Electrical Brain Stimulation in Alert Rodents.

Transcranial electrical brain stimulation can modulate cortical excitability and plasticity in humans and rodents. The most common form of stimulation in humans is transcranial direct current stimulation (tDCS). Less frequently, transcranial alternating current stimulation (tACS) or transcranial random noise stimulation (tRNS), a specific form of tACS using an electrical current applied randomly within a pre-defined frequency range, is used. The increase of noninvasive electrical brain stimulation research in humans, both for experimental and clinical purposes, has yielded an increased need for basic, mechanistic, safety studies in animals. This article describes a model for transcranial electrical brain stimulation (tES) through the intact skull targeting the motor system in alert rodents. The protocol provides step-by-step instructions for the surgical set-up of a permanent epicranial electrode socket combined with an implanted counter electrode on the chest. By placing a stimulation electrode into the epicranial socket, different electrical stimulation types, comparable to tDCS, tACS, and tRNS in humans, can be delivered. Moreover, the practical steps for tES in alert rodents are introduced. The applied current density, stimulation duration, and stimulation type may be chosen depending on the experimental needs. The caveats, advantages, and disadvantages of this set-up are discussed, as well as safety and tolerability aspects.

Anodal Transcranial Direct Current Stimulation Enhances Survival and Integration of Dopaminergic Cell Transplants in a Rat Parkinson Model.

Restorative therapy concepts, such as cell based therapies aim to restitute impaired neurotransmission in neurodegenerative diseases. New strategies to enhance grafted cell survival and integration are still needed to improve functional recovery. Anodal direct current stimulation (DCS) promotes neuronal activity and secretion of the trophic factor BDNF in the motor cortex. Transcranial DCS applied to the motor cortex transiently improves motor symptoms in Parkinson's disease (PD) patients. In this proof-of-concept study, we combine cell based therapy and noninvasive neuromodulation to assess whether neurotrophic support via transcranial DCS would enhance the restitution of striatal neurotransmission by fetal dopaminergic transplants in a rat Parkinson model. Transcranial DCS was applied daily for 20 min on 14 consecutive days following striatal transplantation of fetal ventral mesencephalic (fVM) cells derived from transgenic rat embryos ubiquitously expressing GFP. Anodal but not cathodal transcranial DCS significantly enhanced graft survival and dopaminergic reinnervation of the surrounding striatal tissue relative to sham stimulation. Behavioral recovery was more pronounced following anodal transcranial DCS, and behavioral effects correlated with the degree of striatal innervation. Our results suggest anodal transcranial DCS may help advance cell-based restorative therapies in neurodegenerative diseases. In particular, such an assistive approach may be beneficial for the already established cell transplantation therapy in PD.

Effects of tDCS on motor learning and memory formation: A consensus and critical position paper.

Motor skills are required for activities of daily living. Transcranial direct current stimulation (tDCS) applied in association with motor skill learning has been investigated as a tool for enhancing training effects in health and disease. Here, we review the published literature investigating whether tDCS can facilitate the acquisition, retention or adaptation of motor skills. Work in multiple laboratories is underway to develop a mechanistic understanding of tDCS effects on different forms of learning and to optimize stimulation protocols. Efforts are required to improve reproducibility and standardization. Overall, reproducibility remains to be fully tested, effect sizes with present techniques vary over a wide range, and the basis of observed inter-individual variability in tDCS effects is incompletely understood. It is recommended that future studies explicitly state in the Methods the exploratory (hypothesis-generating) or hypothesis-driven (confirmatory) nature of the experimental designs. General research practices could be improved with prospective pre-registration of hypothesis-based investigations, more emphasis on the detailed description of methods (including all pertinent details to enable future modeling of induced current and experimental replication), and use of post-publication open data repositories. A checklist is proposed for reporting tDCS investigations in a way that can improve efforts to assess reproducibility.

Sleep recalibrates homeostatic and associative synaptic plasticity in the human cortex.

Sleep is ubiquitous in animals and humans, but its function remains to be further determined. The synaptic homeostasis hypothesis of sleep-wake regulation proposes a homeostatic increase in net synaptic strength and cortical excitability along with decreased inducibility of associative synaptic long-term potentiation (LTP) due to saturation after sleep deprivation. Here we use electrophysiological, behavioural and molecular indices to non-invasively study net synaptic strength and LTP-like plasticity in humans after sleep and sleep deprivation. We demonstrate indices of increased net synaptic strength (TMS intensity to elicit a predefined amplitude of motor-evoked potential and EEG theta activity) and decreased LTP-like plasticity (paired associative stimulation induced change in motor-evoked potential and memory formation) after sleep deprivation. Changes in plasma BDNF are identified as a potential mechanism. Our study indicates that sleep recalibrates homeostatic and associative synaptic plasticity, believed to be the neural basis for adaptive behaviour, in humans.

Glia: A Neglected Player in Non-invasive Direct Current Brain Stimulation.

Non-invasive electrical brain stimulation by application of direct current (DCS) promotes plasticity in neuronal networks in vitro and in in vivo. This effect has been mainly attributed to the direct modulation of neurons. Glia represents approximately 50% of cells in the brain. Glial cells are electrically active and participate in synaptic plasticity. Despite of that, effects of DCS on glial structures and on interaction with neurons are only sparsely investigated. In this perspectives article we review the current literature, present own dose response data and provide a framework for future research from two points of view: first, the direct effects of DCS on glia and second, the contribution of glia to DCS related neuronal plasticity.

Safety of Transcranial Direct Current Stimulation: Evidence Based Update 2016.

This review updates and consolidates evidence on the safety of transcranial Direct Current Stimulation (tDCS). Safety is here operationally defined by, and limited to, the absence of evidence for a Serious Adverse Effect, the criteria for which are rigorously defined. This review adopts an evidence-based approach, based on an aggregation of experience from human trials, taking care not to confuse speculation on potential hazards or lack of data to refute such speculation with evidence for risk. Safety data from animal tests for tissue damage are reviewed with systematic consideration of translation to humans. Arbitrary safety considerations are avoided. Computational models are used to relate dose to brain exposure in humans and animals. We review relevant dose-response curves and dose metrics (e.g. current, duration, current density, charge, charge density) for meaningful safety standards. Special consideration is given to theoretically vulnerable populations including children and the elderly, subjects with mood disorders, epilepsy, stroke, implants, and home users. Evidence from relevant animal models indicates that brain injury by Direct Current Stimulation (DCS) occurs at predicted brain current densities (6.3-13 A/m(2)) that are over an order of magnitude above those produced by conventional tDCS. To date, the use of conventional tDCS protocols in human trials (≤40 min, ≤4 milliamperes, ≤7.2 Coulombs) has not produced any reports of a Serious Adverse Effect or irreversible injury across over 33,200 sessions and 1000 subjects with repeated sessions. This includes a wide variety of subjects, including persons from potentially vulnerable populations.

Contribution of the Cholinergic System to Verbal Memory Performance in Mild Cognitive Impairment.

Acetylcholine is critically involved in modulating learning and memory function, which both decline in neurodegeneration. It remains unclear to what extent structural and functional changes in the cholinergic system contribute to episodic memory dysfunction in mild cognitive impairment (MCI), in addition to hippocampal degeneration. A better understanding is critical, given that the cholinergic system is the main target of current symptomatic treatment in mild to moderate Alzheimer's disease. We simultaneously assessed the structural and functional integrity of the cholinergic system in 20 patients with MCI and 20 matched healthy controls and examined their effect on verbal episodic memory via multivariate regression analyses. Mediating effects of either cholinergic function or hippocampal volume on the relationship between cholinergic structure and episodic memory were computed. In MCI, a less intact structure and function of the cholinergic system was found. A smaller cholinergic structure was significantly correlated with a functionally more active cholinergic system in patients, but not in controls. This association was not modulated by age or disease severity, arguing against compensational processes. Further analyses indicated that neither functional nor structural changes in the cholinergic system influence verbal episodic memory at the MCI stage. In fact, those associations were fully mediated by hippocampal volume. Although the cholinergic system is structurally and functionally altered in MCI, episodic memory dysfunction results primarily from hippocampal neurodegeneration, which may explain the inefficiency of cholinergic treatment at this disease stage.

Pre-Trial EEG-Based Single-Trial Motor Performance Prediction to Enhance Neuroergonomics for a Hand Force Task.

We propose a framework for building electrophysiological predictors of single-trial motor performance variations, exemplified for SVIPT, a sequential isometric force control task suitable for hand motor rehabilitation after stroke. Electroencephalogram (EEG) data of 20 subjects with mean age of 53 years was recorded prior to and during 400 trials of SVIPT. They were executed within a single session with the non-dominant left hand, while receiving continuous visual feedback of the produced force trajectories. The behavioral data showed strong trial-by-trial performance variations for five clinically relevant metrics, which accounted for reaction time as well as for the smoothness and precision of the produced force trajectory. 18 out of 20 tested subjects remained after preprocessing and entered offline analysis. Source Power Comodulation (SPoC) was applied on EEG data of a short time interval prior to the start of each SVIPT trial. For 11 subjects, SPoC revealed robust oscillatory EEG subspace components, whose bandpower activity are predictive for the performance of the upcoming trial. Since SPoC may overfit to non-informative subspaces, we propose to apply three selection criteria accounting for the meaningfulness of the features. Across all subjects, the obtained components were spread along the frequency spectrum and showed a variety of spatial activity patterns. Those containing the highest level of predictive information resided in and close to the alpha band. Their spatial patterns resemble topologies reported for visual attention processes as well as those of imagined or executed hand motor tasks. In summary, we identified subject-specific single predictors that explain up to 36% of the performance fluctuations and may serve for enhancing neuroergonomics of motor rehabilitation scenarios.