Implementation of a TMS-fMRI system: A primer

Transcranial magnetic stimulation (TMS) is a non-invasive and non-pharmacological intervention, approved for the treatment of individuals diagnosed with treatment-resistant depression. This well-tolerated approach uses magnetic pulses to stimulate specific brain regions and induce changes in brain networks at multiple levels of human functioning. Combining TMS with other neuroimaging techniques, such as functional magnetic resonance imaging (fMRI), offers new insights into brain functioning, and allows to map out the causal alterations brought on by TMS interventions on neural network connectivity and behaviour. However, the implemention of concurrent TMS-fMRI brings on a number of technical challenges that must be overcome to ensure good quality of functional images. The goal of this study was thus to investigate the impact of TMS pulses in an MR-environment on the quality of BRAINO phantom images, in terms of the signal of the images, the temporal fluctuation noise, the spatial noise and the signal to fluctuation noise ratio, at the University of British Columbia (UBC) Neuroimaging facility. The results of our analyses replicated those of previous sites, and showed that the present set-up for concurrent TMS-fMRI ensures minimal noise artefact on functional images obtained through this multimodal approach. This step was a key stepping stone for future clinical trials at UBC. ### Competing Interest Statement FVR receives research support from CIHR, Brain Canada, Michael Smith Foundation for Health Research, Vancouver Coastal Health Research Institute, and Weston Brain Institute for investigator-initiated research. Philanthropic support from Seedlings Foundation. In-kind equipment support for this investigator-initiated trial from MagVenture. He has received honoraria for participation in advisory board for Janssen.