Theta burst stimulation in neglect after stroke: functional outcome and response variability origins

Nyffeler, Thomas; Vanbellingen, Tim; Kaufmann, Brigitte C.; Pflugshaupt, Tobias; Bauer, Daniel; Frey, Julia; Chechlacz, Magdalena; Bohlhalter, Stephan; Müri, René M.; Nef, Tobias; Cazzoli, Dario (2019). Theta burst stimulation in neglect after stroke: functional outcome and response variability origins. Brain, 142(4), pp. 992-1008. Oxford Academic 10.1093/brain/awz029

awz029.pdf - Published Version
Available under License Publisher holds Copyright.

Download (1MB) | Preview
Nyffeler_2019_cTBS_functional_outcome_BRAIN.pdf - Accepted Version
Available under License Publisher holds Copyright.

Download (5MB) | Preview

Spatial neglect is a strong and negative predictor of general functional outcome after stroke, and its therapy remains a challenge. Whereas inhibitory non-invasive brain stimulation over the contralesional, intact hemisphere has generally been shown to ameliorate neglect on a group level, a conspicuous variability of the effects at the individual level is typically observed. We aimed to assess the characteristics and determinants of the effects of inhibitory non-invasive brain stimulation in neglect, identifying which patients would respond to this therapeutic approach and which not. To this end, we prospectively included 60 patients with a subacute right-hemispheric stroke. In 30 patients with spatial neglect, continuous theta burst stimulation (cTBS) was applied over the left posterior parietal cortex in a randomized clinical trial, either in eight or 16 trains, or as sham stimulation. Thirty patients without neglect served as a control group. Neglect severity was measured with a neuropsychological test battery and the Catherine Bergego Scale, at admission to and at discharge from inpatient neurorehabilitation, as well as at 3 months follow-up. General functional outcome was assessed by means of the Functional Independence Measure (FIM) and the Lucerne ICF-based Multidisciplinary Observation Scale (LIMOS). The impact of clinical and demographic factors was evaluated, and the influence of lesion location and extension was assessed by means of voxel-based lesion-symptom mapping. On a group level, both cTBS protocols (i.e. eight and 16 trains) significantly reduced neglect severity in both the Catherine Bergego Scale and the neuropsychological tests, at discharge and 3 months later. Furthermore, cTBS significantly improved general functional outcome. On an individual level, hierarchical cluster and voxel-based lesion-symptom mapping analyses revealed that the variability in the responses to cTBS is determined by the integrity of interhemispheric connections within the corpus callosum, in particular parieto-parietal connections. In cTBS responders, in whom neglect and general functional outcome were significantly improved, the corpus callosum was intact, whereas this was not the case in cTBS non-responders. Moreover, analyses based on the proportional recovery rule and the Maugeri predictive stroke recovery model showed that the recovery of neglect and of the activities of daily living (ADL) was accelerated only in cTBS responders. Furthermore, the level of ADL recovery of these neglect patients was brought close to the one of right-hemispheric control patients without neglect. Hence, in neglect patients with intact interhemispheric connectivity, cTBS over the contralesional posterior parietal cortex significantly improves and accelerates neglect recovery and, associated with it, general functional outcome.

Item Type:

Journal Article (Original Article)


04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology
04 Faculty of Medicine > Pre-clinic Human Medicine > BioMedical Research (DBMR) > DCR Unit Sahli Building > Forschungsgruppe Neurologie
10 Strategic Research Centers > ARTORG Center for Biomedical Engineering Research > ARTORG Center - Gerontechnology and Rehabilitation

Graduate School:

Graduate School for Health Sciences (GHS)

UniBE Contributor:

Nyffeler, Thomas, Vanbellingen, Tim, Bohlhalter, Stephan, Müri, René Martin, Nef, Tobias, Cazzoli, Dario


600 Technology > 610 Medicine & health




Oxford Academic




Angela Amira Botros

Date Deposited:

31 May 2019 15:33

Last Modified:

05 Dec 2022 15:26

Publisher DOI:


PubMed ID:





Actions (login required)

Edit item Edit item
Provide Feedback