The potential of brain stimulation | Sandro Krieg | TEDxTUM

let me give you an example of what I bet

let me give you an example of what I bet you hope will never happen to you this

you hope will never happen to you this

you hope will never happen to you this is a patient who came to our department

is a patient who came to our department

is a patient who came to our department with a new epilepsy this epilepsy was

with a new epilepsy this epilepsy was

with a new epilepsy this epilepsy was due to a brain tumor and the location of

due to a brain tumor and the location of

due to a brain tumor and the location of this tumor is in a very essential region

this tumor is in a very essential region

this tumor is in a very essential region which is called Broca’s area which is

which is called Broca’s area which is

which is called Broca’s area which is known for the production or conception

known for the production or conception

known for the production or conception of language so what brain tumors have in

of language so what brain tumors have in

of language so what brain tumors have in common is that they’re not only consist

common is that they’re not only consist

common is that they’re not only consist of tumor cells but they are highly

of tumor cells but they are highly

of tumor cells but they are highly infiltrative which means that the tumor

infiltrative which means that the tumor

infiltrative which means that the tumor consists of tumor cells but also has

consists of tumor cells but also has

consists of tumor cells but also has incited humor working brain cells and in

incited humor working brain cells and in

incited humor working brain cells and in a lot of cases this brain tissue is

a lot of cases this brain tissue is

a lot of cases this brain tissue is still highly essential for the patient

still highly essential for the patient

still highly essential for the patient itself and for some of his most

itself and for some of his most

itself and for some of his most essential functions so what do you tell

essential functions so what do you tell

essential functions so what do you tell such a patient about the therapeutic

such a patient about the therapeutic

such a patient about the therapeutic options of his tumor should it be

options of his tumor should it be

options of his tumor should it be resected or i afraid just by the

resected or i afraid just by the

resected or i afraid just by the location and you counsel him and tell

location and you counsel him and tell

location and you counsel him and tell him he shouldn’t be operated on so for

him he shouldn’t be operated on so for

him he shouldn’t be operated on so for doctor and for me as a surgeon it’s

doctor and for me as a surgeon it’s

doctor and for me as a surgeon it’s quite hard to tell your patient that you

quite hard to tell your patient that you

quite hard to tell your patient that you can’t help them because you’re not sure

can’t help them because you’re not sure

can’t help them because you’re not sure if there is function or it is not of

if there is function or it is not of

if there is function or it is not of course when we operate on the brain we

course when we operate on the brain we

course when we operate on the brain we roughly know where function is located

roughly know where function is located

roughly know where function is located for instance motor functions look at

for instance motor functions look at

for instance motor functions look at tier two so called precentral gyrus like

tier two so called precentral gyrus like

tier two so called precentral gyrus like for a movement of your body this is the

for a movement of your body this is the

for a movement of your body this is the understanding of language as I told you

understanding of language as I told you

understanding of language as I told you this is Broca’s area for language

this is Broca’s area for language

this is Broca’s area for language production mainly social behavior

production mainly social behavior

production mainly social behavior arithmetic processing which means the

arithmetic processing which means the

arithmetic processing which means the ability to calculate and memory however

ability to calculate and memory however

ability to calculate and memory however this is in the healthy brain we know the

this is in the healthy brain we know the

this is in the healthy brain we know the brain tumors actually impair the

brain tumors actually impair the

brain tumors actually impair the function of the brain and kind of caused

function of the brain and kind of caused

function of the brain and kind of caused a reorganization in some patients and

a reorganization in some patients and

a reorganization in some patients and some it does not

some it does not

some it does not this means that motor function doesn’t

this means that motor function doesn’t

this means that motor function doesn’t need to be here it can also be here the

need to be here it can also be here the

need to be here it can also be here the language doesn’t need

language doesn’t need

language doesn’t need you can also hear so how do you know

you can also hear so how do you know

you can also hear so how do you know before surgery

before surgery

before surgery greatest functions located and what do

greatest functions located and what do

greatest functions located and what do you tell your patient that make search

you tell your patient that make search

you tell your patient that make search reasons at all or not so that’s why in

reasons at all or not so that’s why in

reasons at all or not so that’s why in 2010 we decided to leap forward and

2010 we decided to leap forward and

2010 we decided to leap forward and actually test a brand new application of

actually test a brand new application of

actually test a brand new application of an actually old technique for mapping

an actually old technique for mapping

an actually old technique for mapping brain function which is called a long

brain function which is called a long

brain function which is called a long name navigated transcranial magnetic

name navigated transcranial magnetic

name navigated transcranial magnetic stimulation or short but easier and TMS

stimulation or short but easier and TMS

stimulation or short but easier and TMS and what an TM has does is that it has a

and what an TM has does is that it has a

and what an TM has does is that it has a stimulation coil which is put on the

stimulation coil which is put on the

stimulation coil which is put on the patient’s head it’s handheld and induces

patient’s head it’s handheld and induces

patient’s head it’s handheld and induces a magnetic field which penetrates the

a magnetic field which penetrates the

a magnetic field which penetrates the skull it then hits the brain and where

skull it then hits the brain and where

skull it then hits the brain and where it is in the brain it elicits an

it is in the brain it elicits an

it is in the brain it elicits an electric field and this electric field

electric field and this electric field

electric field and this electric field then stimulates or inhibits neurons and

then stimulates or inhibits neurons and

then stimulates or inhibits neurons and the newest thing is that we can actually

the newest thing is that we can actually

the newest thing is that we can actually navigate in the brain and visualize

navigate in the brain and visualize

navigate in the brain and visualize which point and small area in the brain

which point and small area in the brain

which point and small area in the brain we’re actually stimulating or inhibiting

we’re actually stimulating or inhibiting

we’re actually stimulating or inhibiting is to see here between the red and blue

is to see here between the red and blue

is to see here between the red and blue arrows so we can really see in

arrows so we can really see in

arrows so we can really see in high-resolution MRIs where we stimulate

high-resolution MRIs where we stimulate

high-resolution MRIs where we stimulate the brain and if you then examine the

the brain and if you then examine the

the brain and if you then examine the response of the brain by electrodes of

response of the brain by electrodes of

response of the brain by electrodes of the muscle or by observing the language

the muscle or by observing the language

the muscle or by observing the language of the patient or even the ability to

of the patient or even the ability to

of the patient or even the ability to perform some little and easy calculation

perform some little and easy calculation

perform some little and easy calculation tasks you can make a map of the brain so

tasks you can make a map of the brain so

tasks you can make a map of the brain so it’s quite powerful technique so in the

it’s quite powerful technique so in the

it’s quite powerful technique so in the last six years we learned a lot new

last six years we learned a lot new

last six years we learned a lot new things are about our brain tumor patient

things are about our brain tumor patient

things are about our brain tumor patient and their functional anatomy this is the

and their functional anatomy this is the

and their functional anatomy this is the fusion of the maps of the motor system

fusion of the maps of the motor system

fusion of the maps of the motor system of 100 brain tumor patients you see in

of 100 brain tumor patients you see in

of 100 brain tumor patients you see in light blue the motor area for the arm

light blue the motor area for the arm

light blue the motor area for the arm and the hand and in dark purple for the

and the hand and in dark purple for the

and the hand and in dark purple for the leg and in pink I draw in for you again

leg and in pink I draw in for you again

leg and in pink I draw in for you again the Prasad gyrus which is the

the Prasad gyrus which is the

the Prasad gyrus which is the traditionally thought region for motor

traditionally thought region for motor

traditionally thought region for motor function and as to see here that the

function and as to see here that the

function and as to see here that the actual region in brain tumor patients

actual region in brain tumor patients

actual region in brain tumor patients where motor function can be is far more

where motor function can be is far more

where motor function can be is far more spread so you can’t just buy anatomies

spread so you can’t just buy anatomies

spread so you can’t just buy anatomies tell a patient if you should operate him

tell a patient if you should operate him

tell a patient if you should operate him or not even if you separate these

or not even if you separate these

or not even if you separate these hundred patients in five different

hundred patients in five different

hundred patients in five different groups so that each group only has

groups so that each group only has

groups so that each group only has patients with the tumor in the same

patients with the tumor in the same

patients with the tumor in the same location is to see here you see that the

location is to see here you see that the

location is to see here you see that the region of the motor area is totally

region of the motor area is totally

region of the motor area is totally different depending on the tumor so even

different depending on the tumor so even

different depending on the tumor so even a tumor location then determines in a

a tumor location then determines in a

a tumor location then determines in a way how your motor cortex is reorganized

way how your motor cortex is reorganized

way how your motor cortex is reorganized in the brain

in the brain

in the brain and the same is true for language I

and the same is true for language I

and the same is true for language I showed you earlier the yellow blue

showed you earlier the yellow blue

showed you earlier the yellow blue regions but as you see here in this heat

regions but as you see here in this heat

regions but as you see here in this heat map where that blue means a high rate of

map where that blue means a high rate of

map where that blue means a high rate of patients have motor function inside this

patients have motor function inside this

patients have motor function inside this area it shows you how much more spread

area it shows you how much more spread

area it shows you how much more spread language function can be in brain tumor

language function can be in brain tumor

language function can be in brain tumor patients so coming back to a patient as

patients so coming back to a patient as

patients so coming back to a patient as I showed you at the beginning whom we

I showed you at the beginning whom we

I showed you at the beginning whom we couldn’t tell where function is located

couldn’t tell where function is located

couldn’t tell where function is located because we assume this by location this

because we assume this by location this

because we assume this by location this is a tumor we might not operate and

is a tumor we might not operate and

is a tumor we might not operate and actually that still happens today we’re

actually that still happens today we’re

actually that still happens today we’re able to perform individual maps for each

able to perform individual maps for each

able to perform individual maps for each patient which we actually do a lot of

patient which we actually do a lot of

patient which we actually do a lot of times a week it takes us 2 to 4 hours

times a week it takes us 2 to 4 hours

times a week it takes us 2 to 4 hours for each patient and we can then counsel

for each patient and we can then counsel

for each patient and we can then counsel patients and tell them about the risks

patients and tell them about the risks

patients and tell them about the risks and benefits of surgery if it makes

and benefits of surgery if it makes

and benefits of surgery if it makes sense or not if he has a high risk to

sense or not if he has a high risk to

sense or not if he has a high risk to lose some part of his language or motor

lose some part of his language or motor

lose some part of his language or motor function or not and the same is true for

function or not and the same is true for

function or not and the same is true for children

children

children beginning at age of 2 we’re able to also

beginning at age of 2 we’re able to also

beginning at age of 2 we’re able to also perform naps for them this is actually

perform naps for them this is actually

perform naps for them this is actually the case of a smart kid who has two

the case of a smart kid who has two

the case of a smart kid who has two brain tumors as you see here in orange

brain tumors as you see here in orange

brain tumors as you see here in orange in blue you’ll see again the motor areas

in blue you’ll see again the motor areas

in blue you’ll see again the motor areas and in yellow and blue you see the

and in yellow and blue you see the

and in yellow and blue you see the fibrous which are kind of the cables

fibrous which are kind of the cables

fibrous which are kind of the cables which bring the information down to a

which bring the information down to a

which bring the information down to a spinal cord and as you can imagine on

spinal cord and as you can imagine on

spinal cord and as you can imagine on these slides with such detailed images

these slides with such detailed images

these slides with such detailed images you can tell the parents much easier but

you can tell the parents much easier but

you can tell the parents much easier but the problem of the therapy is

the problem of the therapy is

the problem of the therapy is and if they want to do surgery or truth

and if they want to do surgery or truth

and if they want to do surgery or truth another treatment and you can show them

another treatment and you can show them

another treatment and you can show them in a way that they really understand the

in a way that they really understand the

in a way that they really understand the problem three years ago did a study on

problem three years ago did a study on

problem three years ago did a study on which we analyzed patients who came to

which we analyzed patients who came to

which we analyzed patients who came to our department for a second opinion

our department for a second opinion

our department for a second opinion because they were told they tumors not

because they were told they tumors not

because they were told they tumors not removal or the 51 patients we operated

removal or the 51 patients we operated

removal or the 51 patients we operated on forty-seven seventy-four percent of

on forty-seven seventy-four percent of

on forty-seven seventy-four percent of those had complete tumor resection which

those had complete tumor resection which

those had complete tumor resection which means we resected all tumor you saw an

means we resected all tumor you saw an

means we resected all tumor you saw an MRI scan none of the patients with their

MRI scan none of the patients with their

MRI scan none of the patients with their first brain surgery in our department

first brain surgery in our department

first brain surgery in our department had any new deficit although they were

had any new deficit although they were

had any new deficit although they were told they have high risk and you

told they have high risk and you

told they have high risk and you shouldn’t operate the tumor in another

shouldn’t operate the tumor in another

shouldn’t operate the tumor in another study we compared tations were operated

study we compared tations were operated

study we compared tations were operated on without preoperative TMS data and

on without preoperative TMS data and

on without preoperative TMS data and those with TMS data and we saw that the

those with TMS data and we saw that the

those with TMS data and we saw that the rate of complete tumor removal increased

rate of complete tumor removal increased

rate of complete tumor removal increased from 58 to 78% however there’s actually

from 58 to 78% however there’s actually

from 58 to 78% however there’s actually just the beginning of using TMS in the

just the beginning of using TMS in the

just the beginning of using TMS in the surgery there are some specialties who

surgery there are some specialties who

surgery there are some specialties who already used TMS also non levitated

already used TMS also non levitated

already used TMS also non levitated since decades for pain tinnitus a

since decades for pain tinnitus a

since decades for pain tinnitus a depression but also a stroke and what

depression but also a stroke and what

depression but also a stroke and what patients with stroke have has main

patients with stroke have has main

patients with stroke have has main problem in many cases is that they’ll

problem in many cases is that they’ll

problem in many cases is that they’ll suffer from a weakness of one side of

suffer from a weakness of one side of

suffer from a weakness of one side of the body and we know today that if you

the body and we know today that if you

the body and we know today that if you have a injured half of the brain half of

have a injured half of the brain half of

have a injured half of the brain half of the brains called hemisphere so if you

the brains called hemisphere so if you

the brains called hemisphere so if you have an intern hemisphere the healthy

have an intern hemisphere the healthy

have an intern hemisphere the healthy hemisphere has inhibitory pathways which

hemisphere has inhibitory pathways which

hemisphere has inhibitory pathways which even makes the hell injured hemisphere

even makes the hell injured hemisphere

even makes the hell injured hemisphere even worse so it inhibits the inert

even worse so it inhibits the inert

even worse so it inhibits the inert atmosphere what we can do with TMS is

atmosphere what we can do with TMS is

atmosphere what we can do with TMS is that we apply inhibitory pulses which is

that we apply inhibitory pulses which is

that we apply inhibitory pulses which is kind of an overstimulation so the

kind of an overstimulation so the

kind of an overstimulation so the healthy hemisphere and avoid that makes

healthy hemisphere and avoid that makes

healthy hemisphere and avoid that makes the injured one universe and it works

the injured one universe and it works

the injured one universe and it works actually well most drug patients and a

actually well most drug patients and a

actually well most drug patients and a lot of studies and we actually do that

lot of studies and we actually do that

lot of studies and we actually do that study now on our brain tumor patients

study now on our brain tumor patients

study now on our brain tumor patients which is ongoing who suffer actually

which is ongoing who suffer actually

which is ongoing who suffer actually after surgery from a problem with moving

after surgery from a problem with moving

after surgery from a problem with moving arm or leg

arm or leg

arm or leg and we have really amazing cases some of

and we have really amazing cases some of

and we have really amazing cases some of them matriz we don’t all a patient who

them matriz we don’t all a patient who

them matriz we don’t all a patient who could move his right arm and hand for

could move his right arm and hand for

could move his right arm and hand for five weeks after surgery and then we did

five weeks after surgery and then we did

five weeks after surgery and then we did treatment on hand with TMS and after

treatment on hand with TMS and after

treatment on hand with TMS and after some sessions his talent or show moved

some sessions his talent or show moved

some sessions his talent or show moved in his hand in another case we had a

in his hand in another case we had a

in his hand in another case we had a young woman who could write the day

young woman who could write the day

young woman who could write the day after surgery not move her left side of

after surgery not move her left side of

after surgery not move her left side of the body and at the seventh day of

the body and at the seventh day of

the body and at the seventh day of treatment she actually walked to the

treatment she actually walked to the

treatment she actually walked to the treatment room so it’s what not only for

treatment room so it’s what not only for

treatment room so it’s what not only for us especially for the family it was kind

us especially for the family it was kind

us especially for the family it was kind of a miracle for effort was also like a

of a miracle for effort was also like a

of a miracle for effort was also like a very strong treatment effect at thinking

very strong treatment effect at thinking

very strong treatment effect at thinking even one step further this is a PET scan

even one step further this is a PET scan

even one step further this is a PET scan a PET scan shows you biological activity

a PET scan shows you biological activity

a PET scan shows you biological activity of tissue which means it shows you where

of tissue which means it shows you where

of tissue which means it shows you where the tissue is most highly active and

the tissue is most highly active and

the tissue is most highly active and also where the tumor is highly active

also where the tumor is highly active

also where the tumor is highly active and this is again a two men so called

and this is again a two men so called

and this is again a two men so called Broca’s area and I told you before we

Broca’s area and I told you before we

Broca’s area and I told you before we don’t know where language is usually so

don’t know where language is usually so

don’t know where language is usually so we did a mapping on him and

we did a mapping on him and

we did a mapping on him and unfortunately the mapping showed us

unfortunately the mapping showed us

unfortunately the mapping showed us right inside the tumor this is actually

right inside the tumor this is actually

right inside the tumor this is actually a tree lingual patient it showed us for

a tree lingual patient it showed us for

a tree lingual patient it showed us for every of his three languages that he has

every of his three languages that he has

every of his three languages that he has essential language function inside a

essential language function inside a

essential language function inside a tumor so what do you do with such a

tumor so what do you do with such a

tumor so what do you do with such a patient do you tell them well we won’t

patient do you tell them well we won’t

patient do you tell them well we won’t operate at all do we tell him why we

operate at all do we tell him why we

operate at all do we tell him why we remove some part of it we try to remove

remove some part of it we try to remove

remove some part of it we try to remove everything and can happen that you

everything and can happen that you

everything and can happen that you cannot speak anymore after surgery we

cannot speak anymore after surgery we

cannot speak anymore after surgery we can then try some tumors treatment it

can then try some tumors treatment it

can then try some tumors treatment it might work might not or you think one

might work might not or you think one

might work might not or you think one step further and you apply to these

step further and you apply to these

step further and you apply to these highly essential brain areas inside the

highly essential brain areas inside the

highly essential brain areas inside the tumor you apply inhibitory TMS treatment

tumor you apply inhibitory TMS treatment

tumor you apply inhibitory TMS treatment and make it much harder for the brain to

and make it much harder for the brain to

and make it much harder for the brain to actually produce language and then you

actually produce language and then you

actually produce language and then you force the brain to find new solutions

force the brain to find new solutions

force the brain to find new solutions and reprogram itself

so finally coming back to our knowledge

so finally coming back to our knowledge about the functional anatomy of brain

about the functional anatomy of brain

about the functional anatomy of brain tumor patients we know that this

tumor patients we know that this

tumor patients we know that this different from healthy people so we

different from healthy people so we

different from healthy people so we shouldn’t treat them like they have a

shouldn’t treat them like they have a

shouldn’t treat them like they have a normal function atomy but we also do not

normal function atomy but we also do not

normal function atomy but we also do not have to because today we’re able to

have to because today we’re able to

have to because today we’re able to perform individual Maps we actually do

perform individual Maps we actually do

perform individual Maps we actually do that on a routine basis in our

that on a routine basis in our

that on a routine basis in our department several times a week and we

department several times a week and we

department several times a week and we do that with a powerful help of brain

do that with a powerful help of brain

do that with a powerful help of brain stimulation and as I showed you today

stimulation and as I showed you today

stimulation and as I showed you today this is just the beginning of this

this is just the beginning of this

this is just the beginning of this technique thank you very much

technique thank you very much

technique thank you very much [Applause]