EB Neuro Training Course 2014

Florence, Italy

STM9000 Family
Overview

Edoardo Dal Pra, MEng.

International Sales Department
EB Neuro S.p.A.
 Market Requests

TMS/rTMS

EB Neuro Positioning

HW Solutions

Coils

Software

Main Competitors

Conclusions
Neurophysiologists
Physiatrists/Physiotherapists
Rehabilitation Medicine
Rheumatologists
Sport Medicine
Psychologists
The first experiments with the magnetic stimulation
were made by Arsonval in 1896. Positioning the head
of the patient inside an induction coil, they were
detected some fosfene (ocular glows) and dizziness
and, in some cases, a syncope. Later, many scientists
informed about the phenomenon of the magneto-
fosfene, the visual sensations caused by the stimulation
of the retina due to the magnetic fields. The magnetic
stimulation was then resumed many years later, in
particular with the studies on the frog made by Kolin,
others made in 1959 and afterwards on the human
peripheral optical nerve by Bickford and by Fremming in
1965.
It isn’t invasive.
It isn’t necessary to prepare the patient in
any particular way before proceeding with
the stimulation.
The application can be easily repeated.
The effects got with this technique on the
cerebral cortex are reversible.
It’s painless.
For these reasons it’s unanimously
considered not invasive, and it is used in
the diagnostic, therapeutic and research
fields.
 Clinical Diagnosis Therapy Rehabilitation
& Research
Transcranial Magnetic Repetitive Transcranial Functional Magnetic
Stimulation (TMS) and Motor Magnetic Stimulation (rTMS) Stimulation (fMS)
Evoked Potential (MEP) Low/High Stimulation frequency Muscle-skeletal stimulation
Mag Stimulator + EMG High power High frequency, low power

Potential customers Potential customers Potential customers

Neurologists Psychiatrists Neurologist
Neurophysiologists Neurologists Rehabilitation/Rheumatologists
Psychiatrists ……….. Sport Medicine/Physiotherapists
Neuro-Rehabilitation doctors Pneumologists

Applications Applications Applications

MEP, CMCT (Clinical Diagn.) Depression Stroke, Pain, ALS, MS
Cortical Silent Period Schizophrenia Distonia, Spastic diseases
Brain Mapping Bipolarism Neuro-Muscular diseases
Connectivity, Inhibition, Alimentary troubles COPD (chronic obstructive
Facilitations ……… pulmonary disease)
TFT 8,4” Interactive Color Display
Control Console with Knob and 5 Multifunction Keys
Up to 100Hz of Stimulation Frequency
Double Stimulation Function (BI Option)
Many Available Coils (including cooled and placebo)
Magnetic Field up to 4.2 Tesla (depending on the specific
used coil)
Two Channels MEP Module (Option)
TTL IN/OUT Trigger
Footswitch Trigger Input
Dimensions 500x420x340mm
Weight 30Kg
Dedicated Trolley with Coil’s Arm Support, Retractile
Draw and Printer Shelf (Option)
Monophasic and Biphasic Morphology
Sinusoidal Morphology (Option)
Up to 100Hz of Stimulation Frequency
Double Stimulation Function (BI Option)
Burst and Theta Burst Capabilities
Dedicated Patient Protocols
Full Screen MEP Visualization
PC Interface for Protocol Management
Easy Upgrade with USB Stick
Characteristics
Monophasic and Biphasic waveforms
Stimulation frequency up to 10Hz
Upgrade capability to superior versions Standard, Fast and Ultrafast
Circular Coil 90mm included

Applications
Clinical Neurophysiology Exams
Rest and Activated Motor Threshold
Motor Evoked Potentials (MEP)
Cortical Silent Period (CSP)
Motor Mapping
Central Conduction Time (CCT)
Triple Stimulation Technique (TST)
Characteristics
Monophasic and Biphasic waveforms
Stimulation Frequency up to 30Hz
Burst and Theta Burst Stimulation
Double Stimulation Function (BI Option)
Upgrade Capability to Superior Versions Fast and Ultrafast
2 Channels MEP Module Included

Applications
Cognitive Neuroscience Studies
Therapy
Long and Short Cortical Excitability Studies (with BI Option)
Characteristics
Monophasic and Biphasic waveforms
Stimulation frequency up to 50Hz
Burst and Theta Burst Stimulation
Double Stimulation Function (BI Option)
Upgrade Capability to Ultrafast Version
2 Channels MEP Module Included

Applications
Psychiatry and Psychology Applications
Characteristics
Monophasic, Biphasic and Sinusoidal
Waveforms
Stimulation Frequency up to 100Hz
Burst and Theta Burst Stimulation
Double Stimulation Function (BI Option)
2 Channels MEP Module Included

Applications
Motor and Linguistic Rehabilitation
Advanced Research Applications
Only one unit model

Extremely easy to use

Easily upgradable

Start model (STM9000 Basic) with:

Biphasic and Monophasic waveforms
Color display
MEP capabilities
 Ergonomic Grip with:
Right and Left Power Control Buttons
Right and Left Enabling Button
Charge Visualization Display

Large or Small Coils?

Large coils provide a high penetration depth, but cannot be very focused at the same time. The small
coils, however, are more focused, but have a relatively feeble penetration depth.

Circular Coils
The induced current in the tissue occurs under the windings, when applying the circular coil. A fairly
large area of body tissue will be stimulated. The circular coil may be positioned conveniently over many
parts of the body, and usually serves well as a “general purpose coil”.

Butterfly Coils
The Butterfly coils are more focused in comparison with the circular coils. The two windings are placed
side-by-side, enabling the coil to stimulate structures with focus right under its center.
The butterfly coil is useful in focused stimulation of deep structures.
Standard Coils
Circular Coil 70mm-90mm
Butterfly Coil 70mm
Special Coils
Butterfly 70mm with 90°
90 Handle
Butterfly 90mm 120° Angled
Butterfly 70mm Placebo
Cooled Coils
Circular 70mm Air Cooled
Butterfly 70mm Air Cooled
Butterfly 70mm Air Cooled Placebo
Device
Model
Normal - Single, Double or Repetitive stimulation
Burst - For the use in Burst or Theta Burst
Stimulation (TBS) mode
Protoc. - To manage Burst/TBS stimulation
protocols
Setup - For the setting of trigger, language and
other options
Service - To set the functions related to the
technical service and for software/firmware upgrade
 Wave forms availability depends from STM9000 system configuration.

Current in the coil Electric field induced

Biphasic
Typically needed when an high level power is
required using a low level of stimulation.
Application fields: MEP, rTMS e fMS.
Good focalization.

Monophasic
Used in clinical evaluation and research.
A big quantity of energy is “lost” in the coil, this
is the reason why the coil become rapidly warm
and the number of stimulus are limited.
Very well focalization.

Sinus
Used when a big quantity of energy is required in
a short time. Not very focal, big response.
 Coil
Section
Status
Bar

Setup MEP
Menu Preview

Function Keys
 There are three different stimulation modalities:
Single – Single Shot Stimulation
Double – Single Shot with Double Stimuli (BI Stim Option). It’s possible to set the ISI
time between the two stimuli
Frequency – Repetitive Stimulation. It’s possible to set the stimulation frequency and the
number of stimuli (max 10Hz)

How to use:
Select the Mode
Set all Parameters
Arm the Coil with “Arm” button (Coil Energy bacome orange)
Stimulate the patient

If Double is active there will be two

different Coil’s Energy bars
2ch for EMG/MEP
16 bit A/D conversion
Touch-proof FMM 1.5mm
To activate MEP function
Burst Stimulation
This function allows to stimulate by sequential trains of stimuli, specifying
the stimulation frequency and setting the total number of trains and the
waiting time between them.

Theta Burst Stimulation (TBS)

This function allows to perform trains of bursts, which are smaller groups of
stimuli. A TBS is fully specified by the burst internal frequency, the burst
repetition time, the number of bursts in a train, the pause between the
trains and the number of trains.
 Status Coil
Bar Section

Burst
Preview
Setup
Menu Threshold
Level
Protocol
Name

Progress
Bar

Function Keys
 First of all “Thresh.” button has to be used in order to find the
motor threshold of the patient. Motor threshold is the minimum
stimulation power that grants a response of minimum 50µV in at
least 5 of 10 stimulations.

To find the motor threshold the MEP module (or an external electromyographic
system) is needed in order to record the answer and measure it.
Once the threshold has been found, press Accept button.
 Burst Train
Burst freq.
1Hz
Wait time
1s 2.30s 1s 2.30s 3s

6.30s 6.30s
Burst duration

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Pulses num. 16
With a dedicated PC program is possible to connect the STM9000 to a
normal Windows PC. In this way all protocol management will be
performed directly on the PC and then tranferred with LAN (or USB) to the
stimulator.
Once a protocol is created, it could be renamed with patient’s name in
order to easily assign it to the patient. Then, with Add button, is possible
to transfer it directly to the stimulator with LAN connection or USB stick.
 Brand Country Model

MagVenture Denmark Compact, R30, R100, X100

MagStim UK 2002, BiStim2, Rapid2

Mag & More Germany PowerMAG 30, PowerMAG 100

Neurosoft Russia Neuro-MS, Neuro-MS 2010

Daymed Czech DuoMAG rTMS

• Only one unit model, the external box is always the same

• Extremely easy to use, either for unexperienced people

• Easily upgradable, no new units needed

• Start model (Basic) with Monophasic Waveform

Unique
• Start model (Basic) with Color Display features
• Start model (Basic) with MEP Capabilities
Thanks