Joint Brain Research UK - Royal College of Surgeons of England Research Fellowship
Neurosurgical trainee Ahmad Ali was awarded this Fellowship in 2023, to take forward research that aims to improve quality of life for patients with low-grade gliomas.
Whilst surgical resection is key to the treatment of these tumours, increasing survival and delaying progression to high-grade glioma, the surgery itself can cause side-effects, including cognitive impairment.
Transcranial Magnetic Stimulation (TMS) is a non-invasive form of brain stimulation that has been used successfully to treat depression and chronic pain, as well as to reduce cognitive impairments associated with other conditions. During the course of this Fellowship, Ahmad is laying the groundwork for a pilot study trialling the use of TMS to reduce cognitive impairment following surgery for low-grade glioma.
This is our fourth joint fellowship with the Royal College of Surgeons.
Ahmad is a neurosurgical trainee at the Walton Centre in Liverpool, one of the biggest and busiest neurosurgical centres in the UK, and a leading centre for the treatment of brain tumours.
Taking a break from neurosurgical training to work towards a PhD, he has a particular interest in reducing the morbidity associated with neurosurgery – to give patients the best quality of life.
Whilst neurosurgery is central to the treatment of brain tumours, alleviating life-threatening symptoms and extending lives, it can itself carry significant morbidity. The surgery can negatively impact memory, attention and other cognitive function. Ahmad is keen to find ways to reduce this morbidity and improve quality of life for his patients. He is focusing on patients with low-grade gliomas (LGG), a group that he feels is hit particularly hard by cognitive impairment.
"Low-grade glioma is a condition that affects younger patients, often in their forties and fifties. If we can manage to get all of the tumour out, they can live ten, fifteen years, sometimes longer. But they live with cognitive problems that significantly impact their quality of life."
Ahmad is using a technique called Transcranial Magnetic Stimulation (TMS), in which magnetic fields are applied non-invasively to stimulate a part of the brain. If done repetitively to the same part of the brain, TMS can induce long-lasting changes to the wiring of the targeted area. The benefits have been demonstrated in patients with a range of conditions; it is now used routinely to help patients with depression and chronic pain, and trials have demonstrated improved cognition in patients with Alzheimer’s disease, and improvements in upper limb function in glioma patients.
There are many parameters that affect how well TMS works - including, for example, the targeted area of the brain and the method for identifying the target, stimulation frequency and intensity, coil positioning, the timing, and the number of sessions. It is paramount, therefore, that these variables are carefully controlled in any trials of the technique.
Ahmad will spend the year of this joint fellowship laying the groundwork for a pilot study of TMS in LGG patients. One of his first tasks is to carry out a meta-analysis of protocols used in previous TMS studies, to identify the parameters that influence cognitive effects. He will train in MRI analysis and the delivery of TMS, will develop the cognitive assessment protocols, and identify patients to take part in the pilot. He will also consult with patients to get feedback on the design of the trial.
All of this will build the case for a pilot study for a clinical trial to address the main research question - can repetitive TMS reduce post-operative cognitive deficits in LGG patients?
The potential of TMS as a tool to aid repair of the brain is widely recognised, but there are many parameters that affect whether it works. It is paramount, therefore, that these are taken into account.
The work being carried out by Ahmad during this fellowship year will inform the design of a pilot study as the next step towards a clinical trial to establish whether TMS can reduce post-operative cognitive deficits in LGG patients. These cognitive deficits can be enormously debilitating for patients, reducing independence and contributing to a loss of sense of self. Establishing a way to restore cognitive function would have an enormous impact on quality of life. Whilst this work is focused on patients with low grade glioma, the findings will be applicable to patients with other types of brain tumour as well as neurosurgical groups who may be affected by cognitive difficulties.
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