TMS Safety Checklist
Purpose
To provide information and rationale for completing the TMS Safety Checklist in consultation with the patient, their family, and the patient’s clinical notes.
Overview
It is important to screen patients for absolute contraindications and safety considerations before TMS testing. A TMS Safety Checklist should be completed by a trained staff member and signed off by the patient’s physician before TMS testing takes place.
The TMS Safety Checklist obtains vital information regarding absolute contraindications and safety considerations for TMS. The latest TMS Safety Checklist is based on the 2021 guidelines from the International Federation of Clinical Neurophysiology. The responses collected from an interview with the patient, their family, and the patient’s clinical notes, allow you and the patient’s physician to determine if a patient can have TMS or not.
Once the NIHSS score is obtained, you will know which two predictions are possible after TMS testing: Good or Limited for people with an NIHSS score less than 7, and Good or Poor for people with an NIHSS score of 7 or more. It can be very helpful to discuss the possible outcomes of the TMS test at the time you complete the TMS safety checklist with the patient. This gives you the chance to prepare the patient and their family for whatever prediction they will hear once the test is complete.
Once you’ve described the possible predictions, it’s a good idea to ask whether they would like to hear their prediction straight after the TMS test, or would they rather wait if they’re not feeling ready for that discussion. This gives patients and their family the chance to manage the flow of information so they’re not overwhelmed. The prediction can be recorded in the notes and held until the patient and their family are ready for the discussion.
The checklist has a patient preference section that allows you to record whether the patient would like to know the results of testing. The checklist also has a therapist section so you can document who completed the checklist, and a physician’s section so you can document their decision.
Present condition
Outline the patient’s current medical condition, for example the location and day of the stroke and what current impairments the patient is experiencing. Any other current medical issues should also be noted. This information helps the physician evaluate suitability for TMS.
Past medical history
Outline the past medical history as described in the notes and by the patient. This allows the physician to review any additional information that may need to be considered when evaluating suitability for TMS.
Current medications
For PREP2, the patient’s physician who reviews the checklist should have the expertise to review the list of patient’s medications, including dose information, to evaluate whether TMS is appropriate.
Patient preference
The TMS Safety Checklist prompts you to ask if the patient and their family wish to know the results of the TMS testing. It’s important to discuss this with the patient and their family at the time of TMS safety screening. Occasionally, patients don’t feel ready to hear their prediction straight away. If they would rather wait, then their prediction can be recorded in their clinical notes, ready for when the patient and their family ask for it.
TMS Safety Checklist Questions
ABSOLUTE CONTRAINDICATIONS
TMS is contraindicated if the answer to any of the below questions is YES.
- Does the patient have a cochlear implant?
- Does the patient have a cortical stimulator?
- Does the patient have a deep brain stimulator?
- Does the patient have a ventriculoperitoneal shunt?
- Does the patient have a skull defect related to their current admission?
- Has the patient experienced a prior TMS-related serious adverse event?
- Has the patient had a seizure in the last 12 months while taking anti-epilepsy medication?
- Has the patient experienced seizures related to their current admission?
There can be uncertainty about whether a seizure has occurred, consult physician if in doubt
TMS SAFETY CONSIDERATIONS
These are not necessarily contraindications to TMS but questions with a YES answer should be discussed with the team physician.
- Does the patient have a history of epilepsy?
- Does the patient have intracranial implants, such as clips or stents, or skull plates?
- Does the patient have any implanted electronics?
- Has the patient ever had a skull fracture or brain surgery?
- Is the patient pregnant?
- Does the patient experience recurring headaches?
- Does the patient experience tinnitus or hyperacusis?
Therapist’s section
The therapist section at the end of the checklist allows documentation of whether additional measures are needed during the assessment. One potential measure is the use of spacers for people with implanted electronics. Spacers act as a visual cue to ensure the TMS coil is discharged only on the participant’s scalp and not closer to the location of the implanted device. They also prevent the coil from being physically close enough to the implanted device to be able to affect its functioning. Examples of spacers include pillows or a rolled up towel can be seen below. Ear plugs should also be offered to people with tinnitus or hyperacusis as hearing protection.
Physician’s section
The physician section allows clear documentation of whether TMS testing is approved for the patient or not.
Resources
FAQs
How is the information for the TMS Safety Checklist collected?
A TMS Safety Checklist is completed by a trained staff member in consultation with the patient, their family, and a review of the patient’s clinical notes. Obtaining information from all these sources reduces the risk of missing essential information.
Who needs to approve the TMS Safety Checklist?
The completed TMS Safety Checklist should be signed off by the patient’s physician before TMS testing is commenced.
What happens if the patient’s condition or medications change between sign-off and TMS testing?
Notes should be added to the TMS Checklist to outline any changes and the physician that signed off the original checklist should be consulted to determine whether TMS testing is still appropriate.
What details are relevant when recording a patient’s medications?
For all current medications the drug name and dosage should be recorded. Dosage information should consist of the dose, form, and frequency of the medication.
Case Examples
Below is information for four example patients. Detail is given for any question that the patient answered ‘YES’ to, and the reasoning behind the physician’s decision to include or exclude each person is provided.
Mr Greenwald (35 y)
Present condition: Left hemisphere PCA stroke 6 days ago. Patient had clot retrieval 2
days ago, report showing a Solitaire 6 x 20 stent deployed.
Past medical history: None.
Current medications: Zopliclone 7.5mg PRN, Aspirin 100 mg daily, Clopidogrel 75 mg daily
Considerations Q4: Does the patient have intracranial implants, such as clips or stents, or skull plates? YES
If the implant is MRI compatible then it is safe for TMS.
Details for Q4: Patient had clot retrieval 2 days ago, report showing a Solitaire 6 x 20 stent deployed. Clot successfully retrieved. Stent is made of non-ferrous materials.
Decision: INCLUDE
The physician approved this patient for TMS. The clot retrieval and stent insertion was identified as a consideration, but as this stent is made of non-ferrous material the physician determined the patient was able to be included.
Mrs Ngata (60 y)
Present condition: Right hemisphere MCA stroke 4 days ago.
Past medical history: AF, gout, cochlear implant inserted at age 10 on left side.
Current medications: Diltiazem 120mg morning and evening, Aspirin 100 mg daily,
Zopliclone 7.5mg PRN
Contraindications Q1: Does the patient have a cochlear implant? YES
Decision: EXCLUDE
The physician did not approve this patient for TMS because cochlear implants are an absolute contraindication.
Mx Lin (72 y)
Present condition: Left hemisphere basal ganglia stroke 7 days ago
Past medical history: Hypertension, dyslipidaemia, Type II diabetes, cardiac pacemaker
implanted 5 years ago.
Current medications: Metformin 500mg morning and evening, Clopidogrel 75m daily,
Atorvastatin 40mg daily, Metoprolol CR 47.5mg daily
Considerations Q3: Does the patient have any implanted electronics? YES
If yes use spacers during TMS testing.
Practice notes:
TMS with figure-8-coils is considered safe in individuals with cardiac pacemakers, vagus nerve stimulation systems, and spinal cord stimulators if the TMS coil is not activated close to (< 10 cm) electronic components such as the implanted pulse generator located in the neck or torso. TMS can also be conducted safely in patients with implanted electrodes in the central and peripheral nervous system that are not connected to a stimulator.
Details for Q3: Cardiac pacemaker implanted 5 years ago. No issues with it to date.
Decision: INCLUDE
The physician approved this patient because TMS is considered safe in individuals with cardiac pacemakers so long as the TMS coil is not discharged within 10 cm of the implanted device. Spacers should be used such as rolled up towels laid over the patient’s shoulders or a pillow placed over the patient’s chest as a reminder to the TMS operators to only discharge the coil on top of the participant’s head during TMS testing.
Mr Siakam (55 y)
Present condition: Left hemisphere MCA stroke 6 days ago
Past medical history: Hypertension, chronic left knee pain, head injury (see Q4)
Current medications: Paracetamol 500 – 1000mg up to every 6 hours as required,
Clopidogrel 75mg daily, Metoprolol CR 23.75mg daily
Considerations Q4: Has the patient ever had a skull fracture or brain surgery? YES
Burr holes and other openings in the skull do not affect the field generated by TMS.
Practice notes:
Past skull fracture or brain surgery are not absolute contraindications, but ought to be considered by the physician and TMS operator.
Details for Q4: Assaulted 5 years ago. Lost consciousness for about 5 minutes. Admitted to hospital for a week. Discharge summary showed right parietal skull fracture, with extradural haematoma. Does not suffer any ongoing issues related to this incident.
Decision: INCLUDE
The physician approved this patient for TMS because they were no longer experiencing ongoing problems related to their skull fracture.
Quiz
Click here for a practice quiz to assess your learning on the TMS Safety Checklist section.
Once the practice quiz has been completed with at least 70% correct you will be emailed a link to the final quiz for this section.
If you pass the final quiz with at least 80% correct you will be emailed a certificate of completion for the TMS Safety Checklist section. There is no limit to the number of attempts for the practice or final quiz.