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Review
. 2020 May-Jun;13(3):717-750.
doi: 10.1016/j.brs.2020.02.019. Epub 2020 Feb 23.

Electrical stimulation of cranial nerves in cognition and disease

Affiliations
Review

Electrical stimulation of cranial nerves in cognition and disease

Devin Adair et al. Brain Stimul. 2020 May-Jun.

Abstract

The cranial nerves are the pathways through which environmental information (sensation) is directly communicated to the brain, leading to perception, and giving rise to higher cognition. Because cranial nerves determine and modulate brain function, invasive and non-invasive cranial nerve electrical stimulation methods have applications in the clinical, behavioral, and cognitive domains. Among other neuromodulation approaches such as peripheral, transcranial and deep brain stimulation, cranial nerve stimulation is unique in allowing axon pathway-specific engagement of brain circuits, including thalamo-cortical networks. In this review we amalgamate relevant knowledge of 1) cranial nerve anatomy and biophysics; 2) evidence of the modulatory effects of cranial nerves on cognition; 3) clinical and behavioral outcomes of cranial nerve stimulation; and 4) biomarkers of nerve target engagement including physiology, electroencephalography, neuroimaging, and behavioral metrics. Existing non-invasive stimulation methods cannot feasibly activate the axons of only individual cranial nerves. Even with invasive stimulation methods, selective targeting of one nerve fiber type requires nuance since each nerve is composed of functionally distinct axon-types that differentially branch and can anastomose onto other nerves. None-the-less, precisely controlling stimulation parameters can aid in affecting distinct sets of axons, thus supporting specific actions on cognition and behavior. To this end, a rubric for reproducible dose-response stimulation parameters is defined here. Given that afferent cranial nerve axons project directly to the brain, targeting structures (e.g. thalamus, cortex) that are critical nodes in higher order brain networks, potent effects on cognition are plausible. We propose an intervention design framework based on driving cranial nerve pathways in targeted brain circuits, which are in turn linked to specific higher cognitive processes. State-of-the-art current flow models that are used to explain and design cranial-nerve-activating stimulation technology require multi-scale detail that includes: gross anatomy; skull foramina and superficial tissue layers; and precise nerve morphology. Detailed simulations also predict that some non-invasive electrical or magnetic stimulation approaches that do not intend to modulate cranial nerves per se, such as transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS), may also modulate activity of specific cranial nerves. Much prior cranial nerve stimulation work was conceptually limited to the production of sensory perception, with individual titration of intensity based on the level of perception and tolerability. However, disregarding sensory emulation allows consideration of temporal stimulation patterns (axon recruitment) that modulate the tone of cortical networks independent of sensory cortices, without necessarily titrating perception. For example, leveraging the role of the thalamus as a gatekeeper for information to the cerebral cortex, preventing or enhancing the passage of specific information depending on the behavioral state. We show that properly parameterized computational models at multiple scales are needed to rationally optimize neuromodulation that target sets of cranial nerves, determining which and how specific brain circuitries are modulated, which can in turn influence cognition in a designed manner.

Keywords: Cranial nerve; Olfactory; Optic; Stimulation; Trigeminal; Vagus; Vestibulocochlear.

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Conflict of interest statement

Declaration of competing interest The City University of New York has inventions on tES with MB as inventor. MB has equity in Soterix Medical and serves on the scientific advisory boards or has grants from Mecta, Halo Neuroscience, Boston Scientific and GlaxoSmithKline. BWB is an inventor on tES patents and patent applications, has equity in Bodhi NeuroTech and serves as a consultant to eQuility. Vitaly Napadow has a financial interest in Cala Health which is licensing taVNS technology from Massachusetts General Hospital, and his interest was reviewed and managed by the Massachusetts General Hospital and Partners HealthCare in accordance with their institutional policies. JDB has research grant support from ElectroCore, Inc. The rest of co-authors have nothing to disclose.

Figures

Figure 1.
Figure 1.
MRI-derived finite element models of electrode montages typically used in transcranial electrical stimulation (tES) studies. Surrounding tissue were segmented using automatic and manual techniques, referencing prior atlases. Each electrode montage is referenced in accordance with the International 10/20 System of Electrode Placement or other superficial anatomical marker Top row: current streamlines (purple/yellow) during electrical stimulation montages using exemplary electrode montages. Bottom row: cranial nerves overlaid with tDCS montages (trigeminal: orange, vagus: green, vestibular: green, optic: blue, glossopharyngeal: purple, intermediate branch of the facial nerve: pink). a) cerebellar stimulation with a cheek “reference” b) “right DLPFC” stimulation anode over F4 and cathode over the right mastoid (P10) c) M1-SO montage with anode over C3 and cathode over the right supra-orbital area (Fp2). These simulations show the diffuse current pattern produced by tES / tDCS electrode montages will overlap with the anatomical distribution of specific cranial nerves.
Figure 2.
Figure 2.
MRI-derived finite element models of non-invasive electrical stimulation. Surrounding tissue were segmented using automatic and manual techniques, referencing prior atlases. Each montage is referenced in accordance with the International 10/20 System of Electrode Placement or other superficial landmarks. Top row: current streamlines (purple/yellow) during electrical stimulation using exemplary electrode montages. Bottom row: Cranial nerves overlaid with cranial nerve stimulation montages (trigeminal: orange, vagus: green, vestibular: green, optic: blue, glossopharyngeal: purple, intermediate branch of the facial nerve: pink) a) galvanic vestibular stimulation, electrodes placed over the mastoids (P10/P9) b) transcutaneous auricular vagus nerve stimulation, electrode place on the tragus c) trigeminal nerve stimulation, electrodes roughly over Fp1 and Fp2
Figure 3.
Figure 3.
Uniform formula of stimulation waveform including as used in cranial electrical nerve stimulation. a-c address waveforms composed of rectangular pulses with expanding temporal scale, while d shows additional waveform types. a) The pulse shape includes the frequency, pulse width, amplitude, and interphase delay where applicable b) The burst stimulation pattern includes the repetition time and number of pulses or cycles per burst – if no burst pattern is reported than the stimulation pattern is continuous. c) The on/off period describes the time the stimulation pattern — continuous or burst—is active/inactive and is typically in the scale of minutes d) Direct current has a fixed amplitude but may include an on/off ramp and is, by definition, monophasic. Unless otherwise indicated, sinusoidal stimulation has a single frequency and symmetric biphasic (no DC offset). There are various types of noise-based stimulation, conventionally with no DC offset. Unless otherwise indicated, a square wave is monophasic. e) Monophasic pulse example. f) Burst example.
Figure 4.
Figure 4.
Anatomy and major axon sub-type of cranial nerves containing a major afferent component. Cranial nerve color key: olfactory tract: yellow, optic: dark blue, trigeminal: green, intermediate branch of the facial nerve: pink, vestibular: teal, glossopharyngeal: purple, vagus: orange. OB: Olfactory Bulb; LGN: Lateral Geniculate Nucleus; TN: Trigeminal Nuclei; NTS: Nucleus Tractus Solitarus; VN – Vestibular Nuclei. IAM: Internal acoustic meatus. Touch fibers (mechano-, chemo-, thermo- receptor and nociceptor) - Aβ: myelinated discriminatory touch fibers; Aβ: myelinated nociceptive thermal and mechanical fiber; C: unmyelinated mechanical, thermal, metabolic fiber.
Figure 5.
Figure 5.
Anatomical map of connections from the cranial nerve (far left), to the brain stem nuclei (middle), to the cerebral cortex (far right). Specifically, the anatomical connections indicated provide pathways from specific cranial nerves to cortical region involved in higher order cognition as well as deep node structures involved in gating of information processing. Colors represent the sensory modality conveyed by the connection, however we propose that approaches to alter cognition can engage these pathways without necessarily inducing percepts. In this sense, sensory modalities are indicated here to illustrate functional circuit connections for neuromodulation. As explained in this review, cranial nerves offer a unique target for electrical stimulation of the brain circuits of cognition.

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