While some experts consider intracranial aneurysm clips a contraindication to TMS [1], others view such clips as potentially surmountable obstacles to treatment IF the clips are constructed of non-ferromagnetic titanium [2]. We present a case of severe treatment-resistant major depression successfully treated with deep TMS, followed by conventional TMS, in a patient status-post a ruptured cerebral aneurysm treated with a titanium aneurysm clip. We summarize guidelines from the MRI literature supporting the use of TMS in patients with titanium aneurysm clips. Although caution is warranted, an absolute contraindication surrounding aneurysm clips in TMS patients may cause more harm than good by pre-empting access to TMS by patients who might otherwise benefit from TMS treatment. Saxby Pridmore and Fiona Lawson demonstrated that non-ferromagnetic aneurysm clips do not significantly move when subjected to pulses from a figure8 coil, even held at unrealistically close distances [3]. We performed an analogous trial with a Brainsway H-1 coil device with similar results. Additionally, patients with nonferromagnetic intracranial aneurysm clips have been undergoing MRI’s safely for decades. With the field strength of even deep TMS coils being roughly equivalent to current MRI machines, TMS should be safe in patients with non-ferromagnetic aneurysm clips. We treated a 73-year-old womanwho suffered a ruptured aneurysm at the age of 53 that was treated with a titanium aneurysm clip. Persisting balance, memory, and executive function impairment, as well as a treatment-resistant depression, followed her aneurysm. Previous unsuccessful medication trials included 5 SSRI’s and 2 TCA’s augmented with 4 atypical antipsychotics, triiodothyronine, buspirone, lithium, bupropion, lamotrigine, pramipexole, methylphenidate, mixed amphetamine salts, atomoxetine, dextroamphetamine, amantadine, and trials with two MAOI’s. She underwent 30 sessions of deep TMS with a Brainsway device using 1 Hz slow stimulation to the right dorsolateral prefrontal cortex (DLPFC) followed by intermittent theta burst stimulation (iTBS) to the midline prefrontal cortex. She also underwent an additional 34 treatments at another TMS treatment center using a Neurostar figure8 coil with fast 10 Hz stimulation over the left DLPFC and slow 1 Hz stimulation over the right DLPFC. The patient tolerated deep TMS without complications (her longstanding migraine headaches worsened initially but then markedly improved by week 4 of deep TMS). Her BDI-II score dropped from 39 to 16, her PHQ-9 score dropped from 27 to 13, and her Beck Anxiety Inventory (BAI) score dropped from 20 to 7. The patient showed additional improvement on the PHQ-9 after 34

中文翻译：

---

颅内动脉瘤夹患者的深部经颅磁刺激：病例报告和临床医生指南

虽然一些专家认为颅内动脉瘤夹是 TMS 的禁忌症 [1]，但其他人认为，如果夹子由非铁磁性钛制成 [2]，则此类夹子可能是治疗的可克服障碍。我们介绍了一个用深部 TMS 成功治疗的严重难治性重性抑郁症，然后是常规 TMS，在患者状态下，脑动脉瘤破裂后用钛动脉瘤夹治疗。我们总结了 MRI 文献中支持在钛动脉瘤夹患者中使用 TMS 的指南。尽管谨慎是必要的，但 TMS 患者动脉瘤夹的绝对禁忌症可能会通过抢占可能从 TMS 治疗中受益的患者获得 TMS 来弊大于利。Saxby Pridmore 和 Fiona Lawson 证明，非铁磁性动脉瘤夹在受到来自 figure8 线圈的脉冲时不会显着移动，即使保持在不切实际的近距离 [3]。我们使用 Brainsway H-1 线圈装置进行了类似的试验，结果相似。此外，使用非铁磁性颅内动脉瘤夹的患者几十年来一直在安全地接受 MRI 检查。即使是深 TMS 线圈的场强也大致相当于当前的 MRI 机器，TMS 在非铁磁性动脉瘤夹患者中应该是安全的。我们治疗了一位 73 岁的女性，她在 53 岁时动脉瘤破裂，并用钛动脉瘤夹治疗。在她的动脉瘤之后，持续的平衡、记忆和执行功能障碍，以及难以治疗的抑郁症。先前不成功的药物试验包括 5 种 SSRI 和 2 种 TCA，增加了 4 种非典型抗精神病药、三碘甲状腺原氨酸、丁螺环酮、锂、安非他酮、拉莫三嗪、普拉克索、哌醋甲酯、混合苯丙胺盐、托莫西汀、右旋苯丙胺、金刚烷胺，以及两种 MAOI 的试验。她使用 Brainsway 设备进行了 30 次深度 TMS，对右侧背外侧前额叶皮层 (DLPFC) 进行 1 Hz 慢速刺激，然后对中线前额叶皮层进行间歇性 theta 爆发刺激 (iTBS)。她还在另一个 TMS 治疗中心接受了额外的 34 次治疗，使用 Neurostar figure8 线圈，在左侧 DLPFC 上进行快速 10 Hz 刺激，在右侧 DLPFC 上进行慢速 1 Hz 刺激。患者耐受深部 TMS 没有并发症（她长期的偏头痛最初恶化，但到深部 TMS 的第 4 周时明显改善）。她的 BDI-II 评分从 39 分下降到 16 分，她的 PHQ-9 评分从 27 分下降到 13 分，她的贝克焦虑量表 (BAI) 评分从 20 分下降到 7 分。患者在 34 岁后表现出对 PHQ-9 的进一步改善