Research Explorer | The University of Manchester



Rapid improvement in brain and swallowing behaviour induced by cerebellar repetitive transcranial magnetic stimulation in post-stroke dysphagia: a single patient case controlled studyDipesh H Vasant1, Ayodele Sasegbon2, Emilia Michou3, Craig Smith4, Shaheen Hamdy2Neurogastroenterology, Manchester University Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom.Gastrointestinal (GI) Sciences, Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Salford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC)), Salford, United Kingdom.Technological Educational Institute of Western Greece, Department of Speech and Language Therapy, Patras, Greece.Division of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, University of Manchester, Salford Royal NHS Foundation Trust, United Kingdom.Correspondence sent to:Prof Shaheen Hamdy PhD FRCPProfessor of NeurogastroenterologyHonorary Consultant Physician and GastroenterologistGI SciencesDivision of Diabetes, Endocrinology and GastroenterologySchool of Medical SciencesFaculty of Biology, Medicine and HealthUniversity of ManchesterClinical Sciences BuildingSalford Royal Hospital (part of the Manchester Academic Health Sciences Center (MAHSC))Eccles Old RoadSalford M6 8HD, UKEmail: shaheen.hamdy@manchester.ac.ukAbstractIntroduction: The cerebellum has been showed by numerous studies to be active during the process of swallowing. Cortically targeted repetitive transcranial magnetic stimulation (rTMS) is a technique which has been shown to result in beneficial electrophysiological and behavioural changes in healthy participants and patients with post-stroke dysphagia. Cerebellar rTMS is a relatively unstudied area of this emerging field. Here we apply cerebellar targeted rTMS to a patient with post stroke dysphagia in an attempt to improve their swallowing. Methods: A 67 year old woman with post stroke dysphagia was recruited to undergo a crossover active rTMS versus sham rTMS study. Outcome measures were: motor evoked potential (MEP) amplitude and cumulative penetration aspiration score (cPAS). The patient attended the laboratory on two occasions. During each attendance they had baseline MEP and cPAS measurements followed by either active or sham rTMS. Following this they had repeated MEP and cPAS measurements at 30 minutes. Results: Active cerebellar rTMS was able to increase both MEP amplitude (55% over baseline) and improve swallowing safety (17% below baseline). Sham rTMS did not result in any beneficial MEP or cPAS changes. Conclusion: Our results suggest that cerebellar rTMS has plausible therapeutic potential for post-stroke dysphagia.Key pointsThe cerebellum has been shown to be active during the process of swallowing. Despite this, no studies have been done using cerebellar repetitive transcranial magnetic stimulation (rTMS) on patients with post stroke dysphagia.This study demonstrates that cerebellar rTMS is able to improve the swallowing function of a patient with post stroke dysphagia.Cerebellar rTMS is a therapy that plausibly has a future role in the treatment of post stroke dysphagia. IntroductionRepetitive transcranial magnetic stimulation (rTMS) targeted over pharyngeal motor cortical areas is an emerging therapy for post-stroke dysphagia which has been demonstrated to be effective at improving swallowing function in healthy subjects PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WYXNhbnQ8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA (5, 6). Despite this, the cerebellum has only recently become a focus of interest in the field of neuromodulation. In a seminal study in 2011, Jayasekeran et al first demonstrated that pharyngeal motor evoked potentials (PMEPs) could be measured following cerebellar transcranial magnetic stimulation ADDIN EN.CITE <EndNote><Cite><Author>Jayasekeran</Author><Year>2011</Year><IDText>Non-invasive magnetic stimulation of the human cerebellum facilitates cortico-bulbar projections in the swallowing motor system</IDText><DisplayText>(7)</DisplayText><record><dates><pub-dates><date>Sep</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Animals</keyword><keyword>Brain Stem</keyword><keyword>Cerebellum</keyword><keyword>Deglutition</keyword><keyword>Electromyography</keyword><keyword>Evoked Potentials, Motor</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Motor Cortex</keyword><keyword>Neural Pathways</keyword><keyword>Pharynx</keyword><keyword>Transcranial Magnetic Stimulation</keyword><keyword>Young Adult</keyword></keywords><urls><related-urls><url> magnetic stimulation of the human cerebellum facilitates cortico-bulbar projections in the swallowing motor system</title><secondary-title>Neurogastroenterol Motil</secondary-title></titles><pages>831-e341</pages><number>9</number><contributors><authors><author>Jayasekeran, V.</author><author>Rothwell, J.</author><author>Hamdy, S.</author></authors></contributors><language>eng</language><added-date format="utc">1483484168</added-date><ref-type name="Journal Article">17</ref-type><rec-number>478</rec-number><last-updated-date format="utc">1483484168</last-updated-date><accession-num>21838728</accession-num><electronic-resource-num>10.1111/j.1365-2982.2011.01747.x</electronic-resource-num><volume>23</volume></record></Cite></EndNote>(7) (TMS). Furthermore, conditioning TMS pulses delivered over the cerebellum were able to facilitate cortical PMEP responses ADDIN EN.CITE <EndNote><Cite><Author>Jayasekeran</Author><Year>2011</Year><IDText>Non-invasive magnetic stimulation of the human cerebellum facilitates cortico-bulbar projections in the swallowing motor system</IDText><DisplayText>(7)</DisplayText><record><dates><pub-dates><date>Sep</date></pub-dates><year>2011</year></dates><keywords><keyword>Adult</keyword><keyword>Animals</keyword><keyword>Brain Stem</keyword><keyword>Cerebellum</keyword><keyword>Deglutition</keyword><keyword>Electromyography</keyword><keyword>Evoked Potentials, Motor</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Motor Cortex</keyword><keyword>Neural Pathways</keyword><keyword>Pharynx</keyword><keyword>Transcranial Magnetic Stimulation</keyword><keyword>Young Adult</keyword></keywords><urls><related-urls><url> magnetic stimulation of the human cerebellum facilitates cortico-bulbar projections in the swallowing motor system</title><secondary-title>Neurogastroenterol Motil</secondary-title></titles><pages>831-e341</pages><number>9</number><contributors><authors><author>Jayasekeran, V.</author><author>Rothwell, J.</author><author>Hamdy, S.</author></authors></contributors><language>eng</language><added-date format="utc">1483484168</added-date><ref-type name="Journal Article">17</ref-type><rec-number>478</rec-number><last-updated-date format="utc">1483484168</last-updated-date><accession-num>21838728</accession-num><electronic-resource-num>10.1111/j.1365-2982.2011.01747.x</electronic-resource-num><volume>23</volume></record></Cite></EndNote>(7). Following this, our group demonstrated that 250 pulses at 10 Hertz (in contrast to 5 Hertz over the pharyngeal motor cortex) was the optimum excitatory rTMS paradigm over the cerebellum, and produced similar increases in cortical PMEP amplitudes to those produced by cortical rTMS ADDIN EN.CITE <EndNote><Cite><Author>Vasant</Author><Year>2015</Year><IDText>High-frequency focal repetitive cerebellar stimulation induces prolonged increases in human pharyngeal motor cortex excitability</IDText><DisplayText>(8)</DisplayText><record><rec-number>2370</rec-number><foreign-keys><key app="EN" db-id="rvewxztxvdv2zzew5rxpa95mp55zwpvsappv">2370</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vasant, D. H.</author><author>Michou, E.</author><author>Mistry, S.</author><author>Rothwell, J. C.</author><author>Hamdy, S.</author></authors></contributors><auth-address>Gastrointestinal Centre, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Salford Royal NHS Foundation Trust, Salford, UK.&#xD;Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, UK.</auth-address><titles><title>High-frequency focal repetitive cerebellar stimulation induces prolonged increases in human pharyngeal motor cortex excitability</title><secondary-title>J Physiol</secondary-title></titles><periodical><full-title>J Physiol</full-title></periodical><edition>2015/09/01</edition><dates><year>2015</year><pub-dates><date>Aug 28</date></pub-dates></dates><isbn>1469-7793 (Electronic)&#xD;0022-3751 (Linking)</isbn><accession-num>26316351</accession-num><urls><related-urls><url>;(8). Most recently, we have shown that cerebellar rTMS is both able to reverse the suppressive MEP effects and negative behavioural effects caused by a cortical ‘virtual lesion’ in healthy participants ADDIN EN.CITE <EndNote><Cite><Author>Sasegbon</Author><Year>2018</Year><IDText>Magneto-electric stimulation of the human cerebellum prevents swallowing dysfunction induced by a cortical virtual lesion</IDText><DisplayText>(9, 10)</DisplayText><record><titles><title>Magneto-electric stimulation of the human cerebellum prevents swallowing dysfunction induced by a cortical virtual lesion</title><secondary-title>Gut</secondary-title></titles><pages>A209</pages><contributors><authors><author>Sasegbon, A.</author><author>Simons, A.</author><author>Michou, E.</author><author>Vasant, DH.</author><author>Hamdy, S.</author></authors></contributors><added-date format="utc">1547383187</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2018</year></dates><rec-number>50339</rec-number><publisher>BMJ</publisher><last-updated-date format="utc">1547383867</last-updated-date><volume>67</volume><num-vols>1</num-vols></record></Cite><Cite><Author>Watanabe</Author><Year>2017</Year><IDText>Ten hz repetitive cerebellar magnetic stimulation reverses cortical suppression in the healthy human pharyngeal motor system</IDText><record><titles><title>Ten hz repetitive cerebellar magnetic stimulation reverses cortical suppression in the healthy human pharyngeal motor system</title><secondary-title>Gut</secondary-title></titles><pages>A269</pages><contributors><authors><author>Watanabe, M.</author><author>Michou, E.</author><author>Raginis-Zborowska, A.</author><author>Magara, J.</author><author>Inoue, M.</author><author>Hamdy, S</author></authors></contributors><added-date format="utc">1547383692</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2017</year></dates><rec-number>50340</rec-number><last-updated-date format="utc">1547383867</last-updated-date><volume>66</volume><num-vols>1</num-vols></record></Cite></EndNote>(9, 10). In this case study, we describe, for the first time, a case of post stroke dysphagia wherein cerebellar rTMS was applied in an attempt to discover if: a) increases in cortical PMEPs could be induced and b) if these changes translated into a measurable improvement in swallowing function. Case reportA 67 year old female was admitted to a regional Stroke Centre following a right posterior inferior cerebellar artery territory infarction involving the right lateral medulla and right cerebellum infero-medially (Figure 1). She had persistent severer oropharyngeal dysphagia at 56 days post ictus. Fibre-optic endoscopic evaluation of swallowing confirmed persistent risk of pulmonary aspiration on all consistencies of diet and fluids, despite engagement with speech and language therapy. She remained nil by mouth and enteral nutrition was provided via percutaneous endoscopic gastrostomy (PEG) tube (Functional Oral Intake Scale: 1). Other than dysphagia, she had very little other physical disability (National Institutes of Health Stroke Scale: 1). This prompted a referral to our dysphagia research group for consideration of inclusion into a trial of an experimental neurostimulation intervention. She had no contraindications to magnetic stimulation or confounding factors such as previous swallowing problems or the use of medication which acts on the central nervous system. Written informed consent was obtained and ethical approval was granted by a local research ethics committee (Greater Manchester west research ethics committee reference: 06/Q1405/38). Materials and Methods(Sham versus real rTMS design)The recruited patient attended our laboratory on two occasions one week apart. Randomisation determined that active cerebellar rTMS (10 Hz frequency, 250-pulses at 90% thenar resting motor threshold via a figure-of-eight coil connected to a Magstim super-rapid stimulator, The Magstim Company, Wales) was administered on the first visit. We chose to deliver this intervention to the relatively undamaged left cerebellar hemisphere. The coil was positioned over the pharyngeal motor representation of the cerebellum (4.3 cm lateral and 2.4 cm below the inion) ADDIN EN.CITE <EndNote><Cite><Author>Vasant</Author><Year>2015</Year><RecNum>2370</RecNum><DisplayText>(8)</DisplayText><record><rec-number>2370</rec-number><foreign-keys><key app="EN" db-id="rvewxztxvdv2zzew5rxpa95mp55zwpvsappv">2370</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vasant, D. H.</author><author>Michou, E.</author><author>Mistry, S.</author><author>Rothwell, J. C.</author><author>Hamdy, S.</author></authors></contributors><auth-address>Gastrointestinal Centre, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Salford Royal NHS Foundation Trust, Salford, UK.&#xD;Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, UK.</auth-address><titles><title>High-frequency focal repetitive cerebellar stimulation induces prolonged increases in human pharyngeal motor cortex excitability</title><secondary-title>J Physiol</secondary-title></titles><periodical><full-title>J Physiol</full-title></periodical><edition>2015/09/01</edition><dates><year>2015</year><pub-dates><date>Aug 28</date></pub-dates></dates><isbn>1469-7793 (Electronic)&#xD;0022-3751 (Linking)</isbn><accession-num>26316351</accession-num><urls><related-urls><url>;(8). At the subsequent visit sham cerebellar rTMS was delivered over the same site. Sham cerebellar rTMS was administered using the coil tilt technique, wherein the coil is held at 90° to the surface of the scalp with one wing of the coil in contact with it. Any pulses administered will be delivered into the air whilst reproducing a similar sensation of pressure on the scalp and making the same clicking sound as is produced for active rTMS. For both active and sham interventions, single-pulse transcranial magnetic stimulation (TMS) and electromyography were used to record pharyngeal and thenar MEPs as measures of pharyngeal and thenar cortical excitability at baseline, immediately and 30 minutes post-intervention. In addition, videofluoroscopy (VFS) was performed at baseline and 30 minutes post-intervention, assessing the safety of 6 swallows each of a of 5ml bolus of liquid barium (60% w/v, EZ-HD?, E-Z-EM Limited, UK) using the 8-point penetration-aspiration scale ADDIN EN.CITE <EndNote><Cite><Author>Rosenbek</Author><Year>1996</Year><RecNum>293</RecNum><DisplayText>(11)</DisplayText><record><rec-number>293</rec-number><foreign-keys><key app="EN" db-id="rvewxztxvdv2zzew5rxpa95mp55zwpvsappv">293</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rosenbek, J. C.</author><author>Robbins, J. A.</author><author>Roecker, E. B.</author><author>Coyle, J. L.</author><author>Wood, J. L.</author></authors></contributors><auth-address>Department of Neurology, William S. Middleton Memorial Veterans Hospital, University of Wisconsin School of Medicine, Madison, USA.</auth-address><titles><title>A penetration-aspiration scale</title><secondary-title>Dysphagia</secondary-title></titles><periodical><full-title>Dysphagia</full-title></periodical><pages>93-8</pages><volume>11</volume><number>2</number><edition>1996/01/01</edition><keywords><keyword>Deglutition</keyword><keyword>Deglutition Disorders/*diagnosis</keyword><keyword>Humans</keyword><keyword>Inhalation</keyword></keywords><dates><year>1996</year><pub-dates><date>Spring</date></pub-dates></dates><isbn>0179-051X (Print)&#xD;0179-051X (Linking)</isbn><accession-num>8721066</accession-num><urls><related-urls><url>;(11) to calculate a cumulative penetration-aspiration score (cPAS). Post-interventional MEPs and VFS data were then compared to baseline for each visit. The patient and the investigator that interpreted the VFS swallowing data were blinded to the intervention (Active and Sham). ResultsBaseline VFS at each visit confirmed oropharyngeal dysphagia (Figure 2). Cerebellar rTMS was delivered at 47% of stimulator output and was well tolerated. Active intervention increased cortico-pharyngeal excitability immediately post-stimulation by +55% without any cortico-thenar changes (Figure 3). By contrast, sham cerebellar rTMS had no effect on pharyngeal motor cortical excitability. Videofluoroscopy showed that only the active intervention resulted in an improvement in swallowing safety. CPAS fell from a pre-stimulation baseline of 13 to 11 (out of 48), 30 minutes post active cerebellar rTMS (Figure 4). By contrast, the cPAS increased from a baseline of 12 to 17, 30 minutes post sham cerebellar rTMS. In the weeks to months following treatment with cerebellar rTMS, the patient was able to tolerate syrup thick fluids safely at 2 months post discharge, and was able to eat and drink normally 5 months post discharge with PEG removal at 7 months post discharge.DiscussionOur case-study examined the short-term effects of a single application of cerebellar rTMS on cortical excitability and swallowing function in a patient with severe oropharyngeal dysphagia. During the course of the study, cerebellar rTMS appeared safe and was well tolerated. Our findings demonstrate that promising clinical effects can be provoked by stimulationg the unaffected cerebellum in a patient with a posterior circulation infarction. While it is impossible to solely attribute the resolution of the atients dysphagia in the months after cerebellar rTMS to the intervention, the findings are intriguing and provide plausible promise. More work will need to be done to establish the effects of cerebellar rTMS on the recovery of swallowing function over a longer period of time. The unaffected cerrebellum was chosen as the site for cerebellar rTMS because of the discovery by Hamdy et al in 1998 that recovery of swallowing function in post stroke dysphagia is associated with increased activity over the unaffected cortical hemisphere ADDIN EN.CITE <EndNote><Cite><Author>Hamdy</Author><Year>1998</Year><IDText>Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex</IDText><DisplayText>(12)</DisplayText><record><dates><pub-dates><date>Nov</date></pub-dates><year>1998</year></dates><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Brain Mapping</keyword><keyword>Cerebrovascular Disorders</keyword><keyword>Deglutition</keyword><keyword>Deglutition Disorders</keyword><keyword>Electromyography</keyword><keyword>Female</keyword><keyword>Hand</keyword><keyword>Humans</keyword><keyword>Image Processing, Computer-Assisted</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Motor Cortex</keyword><keyword>Neuronal Plasticity</keyword><keyword>Pharynx</keyword><keyword>Reaction Time</keyword><keyword>Severity of Illness Index</keyword></keywords><urls><related-urls><url> of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex</title><secondary-title>Gastroenterology</secondary-title></titles><pages>1104-12</pages><number>5</number><contributors><authors><author>Hamdy, S.</author><author>Aziz, Q.</author><author>Rothwell, J. C.</author><author>Power, M.</author><author>Singh, K. D.</author><author>Nicholson, D. A.</author><author>Tallis, R. C.</author><author>Thompson, D. G.</author></authors></contributors><language>eng</language><added-date format="utc">1483481048</added-date><ref-type name="Journal Article">17</ref-type><rec-number>468</rec-number><last-updated-date format="utc">1483481048</last-updated-date><accession-num>9797365</accession-num><volume>115</volume></record></Cite></EndNote>(12). While cerebellar and cortical neurophysiology and neuroanatomy are not analagous, it was felt that stimulating the unaffected hemisphere would result in the greatest chance of inducing a beneficial effect to MEP amplitude and swallowing behaviour, with a lesser chance of ‘kindling’ in the damaged brain provoking seizures. There is a need for more studies in this area to inform optimal clinical cerebellar rTMS paradigms in the future. The observed reduction in penetration-aspiration scores after cerebellar rTMS is comparable with the effects of other neurostimulation interventions in dysphagic stroke PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWNob3U8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA (3). However, in contrast to the healthy subject TMS data, where the excitatory effects of 10 Hz cerebellar stimulation persisted for over an hour ADDIN EN.CITE <EndNote><Cite><Author>Vasant</Author><Year>2015</Year><RecNum>2370</RecNum><DisplayText>(8)</DisplayText><record><rec-number>2370</rec-number><foreign-keys><key app="EN" db-id="rvewxztxvdv2zzew5rxpa95mp55zwpvsappv">2370</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vasant, D. H.</author><author>Michou, E.</author><author>Mistry, S.</author><author>Rothwell, J. C.</author><author>Hamdy, S.</author></authors></contributors><auth-address>Gastrointestinal Centre, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Salford Royal NHS Foundation Trust, Salford, UK.&#xD;Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, UK.</auth-address><titles><title>High-frequency focal repetitive cerebellar stimulation induces prolonged increases in human pharyngeal motor cortex excitability</title><secondary-title>J Physiol</secondary-title></titles><periodical><full-title>J Physiol</full-title></periodical><edition>2015/09/01</edition><dates><year>2015</year><pub-dates><date>Aug 28</date></pub-dates></dates><isbn>1469-7793 (Electronic)&#xD;0022-3751 (Linking)</isbn><accession-num>26316351</accession-num><urls><related-urls><url>;(8), the cortical effects were immediate, being undetectable 30 minutes post-intervention. Despite this, these effects appear to have provoked a detectable clinical improvement which persisted for at least 30 minutes. Unfortuantely we did not perform videofluoroscopy immediately post-intervention to allow correlation of VFS measurements with cortical excitability and did not take any recordings with either TMS or VFS at additional time points post-intervention where we may have observed more sustained after effects. An additional limitation is the fact that we did not perform a repeat VFS at five months post discharge when the patient was judged to have regained the ability to eat and drink normally. If a repeat VFS had been performed at this point it would have allowed direct comparison and more objective quantification of any improvements. Future work to optimise cerebellar stimulation may include a dose ranging study in stroke patients to elucidate the most appropriate regimen to treat dysphagia, and drive more sustained effects on cortical plasticity in patients. In summary, our case study experience suggests that cerebellar rTMS is safe and has plausible therapeutic potential for post-stroke dysphagia vindicating further mechanistic and clinical research to develop this technique further. Authorship statementDHV performed the studies and helped write the manuscript. AS read through patient notes and helped write the manuscript. EM performed frame by frame blinded analysis on the videofluoroscopic images offline to determine the penetration-aspiration scores. CS helped write the manuscript. SH conceptualised the case study and helped write the manuscript.The authors would like to acknowledge our GI radiographers Lisa Lyon, Jackie Johnson, Danielle Burgess and Rachael Rae.References ADDIN EN.REFLIST 1.Vasant DH, Mistry S, Michou E, Jefferson S, Rothwell JC, Hamdy S. Transcranial direct current stimulation reverses neurophysiological and behavioural effects of focal inhibition of human pharyngeal motor cortex on swallowing. J Physiol. 2014;592(Pt 4):695-709.2.Jefferson S, Mistry S, Michou E, Singh S, Rothwell JC, Hamdy S. Reversal of a virtual lesion in human pharyngeal motor cortex by high frequency contralesional brain stimulation. Gastroenterology. 2009;137(3):841-9, 9 e1.3.Michou E, Mistry S, Jefferson S, Tyrrell P, Hamdy S. Characterizing the mechanisms of central and peripheral forms of neurostimulation in chronic dysphagic stroke patients. Brain Stimul. 2014;7(1):66-73.4.Suzuki M, Asada Y, Ito J, Hayashi K, Inoue H, Kitano H. Activation of cerebellum and basal ganglia on volitional swallowing detected by functional magnetic resonance imaging. Dysphagia. 2003;18(2):71-7.5.Zald DH, Pardo JV. The functional neuroanatomy of voluntary swallowing. Ann Neurol. 1999;46(3):281-6.6.Sasegbon A, Hamdy S. The anatomy and physiology of normal and abnormal swallowing in oropharyngeal dysphagia. Neurogastroenterol Motil. 2017;29(11).7.Jayasekeran V, Rothwell J, Hamdy S. Non-invasive magnetic stimulation of the human cerebellum facilitates cortico-bulbar projections in the swallowing motor system. Neurogastroenterol Motil. 2011;23(9):831-e341.8.Vasant DH, Michou E, Mistry S, Rothwell JC, Hamdy S. High-frequency focal repetitive cerebellar stimulation induces prolonged increases in human pharyngeal motor cortex excitability. J Physiol. 2015.9.Sasegbon A, Watanabe M, Simons A, Michou E, Vasant D. H, Magara J, Bath P. M, Rothwell J, Inoue M, Hamdy S. Cerebellar repetitive transcranial magnetic stimulation restores pharyngeal brain activity and swallowing behaviour after disruption by a cortical virtual lesion. J Physiol. 2019.10.Watanabe M, Michou E, Raginis-Zborowska A, Magara J, Inoue M, Hamdy S. Ten hz repetitive cerebellar magnetic stimulation reverses cortical suppression in the healthy human pharyngeal motor system. Gut. 2017;66:A269.11.Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11(2):93-8.12.Hamdy S, Aziz Q, Rothwell JC, Power M, Singh KD, Nicholson DA, et al. Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex. Gastroenterology. 1998;115(5):1104-12.Figure 1: MRI brain scan showing infarction of right medulla and cerebellum.188595020320Figure 2: VFS image showing entry of contrast into the airway (arrow) contacting vocal cords with failure to be ejected (PAS=5). Figure 3: The effects of cerebellar rTMS on cortical motor excitability (both pharyngeal hemispheres combined) Figure 4: The effects of cerebellar rTMS on cumulative penetration-aspiration scores at VFS were worse after sham, improving after active intervention. ................
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