Repetitive transcranial magnetic stimulation for post-stroke depression: Associations between neural damage and treatment response

Repetitive transcranial magnetic stimulation (rTMS) shows promise for treating post-stroke depression, yet whether lesion characteristics are associated with treatment response is unclear. Nineteen adults with history of stroke and depression completed a two-week high frequency rTMS protocol targeting the left dorsolateral prefrontal cortex. Depression (Beck Depression Inventory, BDI; Patient Health Questionnaire-9, PHQ-9) and self-efficacy (Stroke Self-Efficacy Questionnaire; SSEQ) were assessed pre- and post-intervention. Baseline neuroimaging included structural MRI, diffusion-weighted imaging and resting-state functional MRI. Bayesian linear mixed effects models quantified exploratory associations between baseline characteristics and rTMS response. Response rate (>50% improvement) on the BDI was 53%, with 84% exceeding the threshold for a clinically meaningful improvements in depression symptoms. There was an also an observed increase in PHQ-9 and SSEQ scores post rTMS, with males demonstrating greater PHQ-9 improvements than females (pd = 98.25%, 0.23% in ROPE). Participants with right hemisphere lesions demonstrated lower baseline self-efficacy but a trend towards greater observed improvement on the SSEQ and PHQ-9 compared to those with left hemisphere lesions (pd > 92%). Baseline neuroimaging metrics, including lesion volume, white matter integrity, and default mode network connectivity, did not reveal clear association with observed depression symptom improvement following rTMS in this small sample. rTMS was associated with observed improvements in depressive symptoms across individuals with diverse lesion characteristics. Sex and lesion hemisphere may influence response magnitude but require further investigation.