Accelerated rTMS for Post-Stroke Apathy

This pilot study will investigate the safety, feasibility, tolerability, and preliminary efficacy of accelerated high-dose repetitive transcranial magnetic stimulation (rTMS) targeting the medial prefrontal cortex (mPFC) to address apathy symptoms in individuals with chronic stroke.

Inclusion Criteria: 1. 40 years old or greater 2. Right- or left-hemisphere ischemic or hemorrhagic stroke with at least 6 months chronicity 3. Symptomatic apathy as confirmed by (A) total score on the Apathy Evaluation Scale (AES) of ≥39 as rated by the participant or caregiver informant 4. Intact cortex under the coil at the stimulation target site confirmed by neuroimaging 5. Ability to participate in psychometric testing and cognitive tasks Exclusion Criteria: 1. Primary extra-axial hemorrhage (subdural or subarachnoid) without ischemic stroke or intraparenchymal hemorrhage 2. Concomitant neurological disorders affecting motor or cognitive function (e.g. dementia) 3. Moderate or severe global aphasia 4. Visual impairment precluding completion of cognitive tasks 5. Presence of contraindications to MRI or TMS including electrically, magnetically or mechanically activated metal or nonmetal implants such as cardiac pacemakers, intracerebral vascular clips, or any other electrically sensitive support system; 6. Pregnancy (to be later confirmed by UPT in any premenopausal female participants) 7. History of a seizure disorder 8. Preexisting scalp lesion, wound, bone defect, or hemicraniectomy 9. Claustrophobia precluding the ability to undergo an MRI 10. Active substance use disorder 11. Psychotic disorders 12. Bipolar 1 Disorder 13. Acute suicidality as assessed by the Columbia Suicide Severity Rating Scale (C-SSRS) or suicide attempt in the previous year