Abstract:
Adjustable devices and methods of adjusting and customizing Transcranial Magnetic Stimulation (TMS) electromagnets to produce an elongated path of induced electrical current along a user-defined trajectory in patients having a variety of different head shapes and curvatures. Existing TMS electromagnets (“coils”) allow only limited adjustment of the current delivery surfaces. The present invention provides means for adjusting the sub-coil loops within a double coil structure. The present design may be powered with the use of a single TMS pulse generator unit.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
       [0001]    This patent application claims priority to provisional patent application No. 61/642,290, filed on May 3, 2012. This provisional patent application is herein incorporated by reference in its entirety. 
       INCORPORATION BY REFERENCE 
       [0002]    All publications and patent applications mentioned in this specification are herein incorporated by reference in their entirety to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference. 
     
    
     FIELD OF THE INVENTION 
       [0003]    Described herein are Transcranial Magnetic Stimulation (TMS) methods, devices and systems. In particular, TMS coils that are adjustable to a patient&#39;s head are described. Systems may include TMS electromagnets with a pair of coils that are adjustable so that the angle between the coils can be changed and held in selected positions. 
       BACKGROUND OF THE INVENTION 
       [0004]    Typical transcranial magnetic stimulation (TMS) electromagnets may include multiple fixed coils forming the body of the magnet. Such TMS coil designs have usually been designed for either high focality or deep penetration, and are not specifically configured either to target a specific brain region of to target this brain region even when applied to different users. 
         [0005]    For example, the TMS coils described in the patent applications listed below are directed to deep brain TMS methods, including electromagnets. These TMS electromagnets include different designs: U.S. patent application Ser. No. 12/669,882, titled “DEVICE AND METHOD FOR TREATING HYPERTENSION VIA NON-INVASIVE NEUROMODULATION,” and filed on Jun. 2, 2010; U.S. patent application Ser. No. 12/671,260, titled “GANTRY AND SWITCHES FOR POSITION-BASED TRIGGERING OF TMS PULSES IN MOVING COILS”, and filed on Jun. 17, 2010; U.S. patent application Ser. No. 12/670,938, titled “FIRING PATTERNS FOR DEEP BRAIN TRANSCRANIAL MAGNETIC STIMULATION,” and filed on Jun. 17, 2010; U.S. patent application Ser. No. 12/677,220, titled “FOCUSED MAGNETIC FIELDS,” and filed on Sep. 16, 2010; U.S. patent application Ser. No. 12/679,960, titled “DISPLAY OF MODELED MAGNETIC FIELDS,” and filed on Sep. 15, 2010; U.S. patent application Ser. No. 12/680,749, titled “INTRA-SESSION CONTROL OF TRANSCRANIAL MAGNETIC STIMULATION,” and filed on Jul. 14, 2010; U.S. patent application Ser. No. 12/680,912, titled “TRANSCRANIAL MAGNETIC STIMULATION WITH PROTECTION OF MAGNET-ADJACENT STRUCTURES,” and filed on Jul. 14, 2010; U.S. patent application Ser. No. 12/324,227, titled “TRANSCRANIAL MAGNETIC STIMULATION OF DEEP BRAIN TARGETS,” and filed on Nov. 26, 2008; U.S. patent application Ser. No. 12/990,235, titled “TRANSCRANIAL MAGNETIC STIMULATION BY ENHANCED MAGNETIC FIELD PERTURBATIONS,” and filed on Nov. 30, 2010; U.S. patent application Ser. No. 12/185,544, titled “MONOPHASIC MULTI-COIL ARRAYS FOR TRANSCRANIAL MAGNETIC STIMULATION,” and filed on Aug. 4, 2008; U.S. patent application Ser. No. 12/701,395, titled “CONTROL AND COORDINATION OF TRANSCRANIAL MAGNETIC STIMULATION ELECTROMAGNETS FOR MODULATION OF DEEP BRAIN TARGETS,” and filed on Feb. 5, 2010; U.S. patent application Ser. No. 13/141,100, titled “SHAPED COILS FOR TRANSCRANIAL MAGNETIC STIMULATION,” and filed on Aug. 1, 2011; U.S. patent application Ser. No. 12/838,299, titled “TRANSCRANIAL MAGNETIC STIMULATION FIELD SHAPING,” and filed on Jul. 16, 2010; U.S. patent application Ser. No. 12/912,650, titled “SUB-MOTOR-THRESHOLD STIMULATION OF DEEP BRAIN TARGETS USING TRANSCRANIAL MAGNETIC STIMULATION,” and filed on Oct. 26, 2010; and U.S. patent application Ser. No. 13/169,967, titled “ENHANCED SPATIAL SUMMATION FOR DEEP-BRAIN TRANSCRANIAL MAGNETIC STIMULATION,” and filed on Jun. 27, 2011. 
         [0006]    The inventors herein suggest, based on ongoing experimental data, that there may be clinical efficacy in deliberately steering the direction of induced current to a particular brain region, and in particular, directing induced current across a distance that may traverse two or more structures involved in a targeted brain circuit. 
         [0007]    However, the fixed-coil TMS electromagnets currently available are not configured to produce an elongated path of induced electrical current along a pre-defined trajectory while adapting to differences in the curvature of each patient&#39;s head. For example, even the more physically flexible, large-coil designs currently available stimulate too much brain tissue lateral to the targeted strip, and thereby raise safety concerns. Thus, there is a need for TMS electromagnets (“coils”) that stimulate along an extended linear trajectory while conforming to the unique curvature of each patient&#39;s head. 
         [0008]    Described herein are TMS electromagnets and methods of using them to treat patients that may address the concerns raised above. 
       SUMMARY OF THE INVENTION 
       [0009]    In general, described herein are TMS electromagnets that are configured to target specifically and exclusively a predefined target brain region, even when applied to patients having different head shapes. Thus, the TMS electromagnets may be configured to adjust to different patient head geometries, while targeting the same specific brain region (and not substantially targeting other brain regions. Also described herein are methods of using such TMS electromagnetic devices. 
         [0010]    For example, described herein are TMS electromagnet device(s) that are configured to provide transcranial magnetic stimulation to a specified area of the brain, wherein the specific area of the brain is a longitudinal strip extending from the left dorsolateral prefrontal cortex to the medial frontal cortex overlying the dorsal anterior cingulate gyrus; these TMS electromagnets may target this same region a variety of head sizes and shapes using the same coil apparatus. This TMS electromagnet (coil apparatus) may therefore be adjustable to different head sizes while maintaining the same brain target region(s). 
         [0011]    In some variations a Transcranial Magnetic Stimulation (TMS) electromagnet device may include: an adjustable head frame that is configured to be worn on the patient&#39;s head and holds at least one TMS electromagnet that is (or can be) oriented to stimulate a predetermined target brain region without substantially stimulating more laterally positioned regions; and a TMS electromagnet that is adjustably connected to the adjustable head frame, wherein the TMS electromagnet comprises a first TMS coil and a second TMS coil that are adjustably and electrically connected to each other so that the angle between the first and second TMS coils may be adjusted. 
         [0012]    In general, a TMS electromagnet device as described herein may also include a second (or third, fourth, fifth, etc.) TMS electromagnet that is adjustably connected to the adjustable head frame, wherein the second TMS electromagnet comprises a third TMS coil and a fourth TMS coil that are adjustably and electrically connected to each other so that the angle between the third and fourth TMS coils may be adjusted. Each of the pair of TMS coils may include multiple windings of a material used to form the TMS electromagnet, and the two coils may be connected so that the windings of each are electrically connected (and continuous), so that the TMS electromagnet functions as a unit. As shown and descried in greater detail herein, these TMS electromagnets (which may be referred, for convenience, as “hinged TMS electromagnets” or “angle adjustable TMS electromagnets”) typically include a region between each coil that permits the two coils to be adjusted relative to each other. For example, the first coil may be bent, twisted, rotated, angled, etc. The adjustment may be along a line (e.g., hinged motion) or a point (e.g., pivoting), so that the planes of each coil move relative to each other. 
         [0013]    For example, the TMS electromagnet may be configured so that the angle between the plane of the first TMS coil and the plane of the second TMS coil may be adjusted from a hinge region between the first TMS coil and the second TMS coil. In some variations, the TMS electromagnet is configured so that the angle between the plane of the first TMS coil and the plane of the second TMS coil may be adjusted from a pivot point between the first TMS coil and the second TMS coil. 
         [0014]    In some variations, the TMS device includes a lock, holder, or other securement that is configured to hold the angle between the first TMS coil and the second TMS coil of the TMS electromagnet once it has been adjusted. The lock/holder may be released and re-secured, or in some variations it may be permanent. The lock may be secured by screwing, or otherwise engaging a member, pin, clasp, etc. 
         [0015]    The adjustable head frame devices may be configured to target any appropriate brain region. For example, the devices may be configured to aim TMS at a predetermined brain region such as the left dorsolateral prefrontal cortex to medial frontal cortex overlapping the dorsal anterior cingulate gyrus. The adjustable head frame may include an adjustable headband. The 
         [0016]    TMS electromagnets may be held to the adjustable head frame by one or more holders that retain the TMS electromagnet(s) on the head frame, but allows it to be adjusted so that the shape of the TMS electromagnets may be conformed to the subject&#39;s head. The holder(s) may be configured so that they generally aim the TMS electromagnets to a predetermined target, but allow just enough movement of the TMS electromagnets so that they can conform to the head. 
         [0017]    Thus also generally described herein are adjustable Transcranial Magnetic Stimulation (TMS) electromagnets (adjustable TMS electromagnet devices), that may include: a first TMS coil comprising multiple coil windings; a second TMS coil comprising multiple coil windings; an adjustable connecting region between the first TMS coil and the second TMS coil, wherein the adjustable connecting region is configured so that the angle between the first and second TMS coils may be adjusted; and a lock configured to hold the adjustable connecting region in a predetermined position, wherein the first TMS coil and the second TMS coil are electrically connected through the adjustable connecting region so that current flows between the first TMS coil and the second TMS coil. Although TMS electromagnets having two coils are described and shown herein, it should be understood that these devices may include three, four, or more coils; these coils may be connected at a single connecting region or multiple adjustable connecting regions may be included. 
         [0018]    As mentioned, any of these devices may include a hold or lock configured to lock the angle between the coils (e.g., the first TMS coil and the second TMS coil) of the TMS electromagnet once it has been adjusted. 
         [0019]    In some variations, the adjustable connecting region may comprise a hinge region configured so that the angle between a plane of the first TMS coil and a plane of the second TMS coil may be adjusted from the hinge region. In some variations, the adjustable connecting region comprises a pivot region (which may be a pivot point) configured, e.g., so that the angle between the plane of the first TMS coil and the plane of the second TMS coil may be adjusted from the pivot region. 
         [0020]    Also described herein are coil devices for Transcranial Magnetic Stimulation (TMS), the device comprising: a curved undersurface configured to approximate the curvature of a human skull; an outwardly extending portion for either drawing or returning current to/from the curved undersurface; an inwardly extending region for either drawing or returning current to/from curved undersurface. In some variations the inwardly and outwardly portions are joined in electrical contact. In some variations, the curved undersurface comprises a flexible conductive material that conforms to the shape of patient&#39;s skull when in the specified position. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0021]      FIG. 1  illustrates a set of two coils of a TMS electromagnet with a hinge apparatus retaining the two in proximity, and with underlying hemi-pads keeping the coils at an appropriate tilt, such that the main direction of primary electrical current within both coils is aligned diagonally from the left prefrontal cortex to the midline over the dorsal cingulate. 
           [0022]      FIG. 2  illustrates multi-axis hinge mechanisms that permit a pair of coils to contact the scalp of varying head shapes and sizes, only along those portions of the coil circumference that induce current in the desired direction. 
           [0023]      FIG. 3  details the hemi-padding arrangement that places one portion of each coil surface closer to the scalp than the other portions of each coil surface. 
           [0024]      FIG. 4A  illustrates an arrangement in which each of the two coils are physically bent, thereby placing one portion of each coil surface closer to the brain than the other portions of each coil surface, without the requirements for pads. 
           [0025]      FIG. 4B  illustrates an exemplary electrical wiring approach for the two coils, whereby they are powered in parallel by electrical pulses discharged between the positive and negative terminals of a single standard TMS pulse generator. 
           [0026]      FIG. 4C  illustrates the two tiltable hemi-padded coils powered by a single TMS pulse generator, with an arrow indicating the principal direction of the primary electrical current within the coils on the portions of the coil which are placed closest to the brain. 
           [0027]      FIG. 5  illustrates a hinged coil pair attached to a suspension apparatus, in which multiple axes of positioning movement are enabled. 
           [0028]      FIG. 6  illustrates a ball and socket mechanism for allowing relative positioning of the two circular coil elements. 
           [0029]      FIG. 7  illustrates a cross wire “x-wire” mechanism for allowing relative positioning of the two circular coil elements. 
           [0030]      FIG. 8  illustrates a trolley-in-rail mechanism for allowing relative positioning of the two circular coil elements. 
           [0031]      FIG. 9  illustrates a flexible “sock”-like fitting that joins the two coils, allowing relative positioning. 
           [0032]      FIG. 10A  represents a “D-shaped” coil design with a curved undersurface and specified placement in which a concentrically wound single coil powered by a single TMS pulse source. Space between coil windings is exaggerated for illustrative purposes. 
           [0033]      FIG. 10B  specifies the location and direction of primary electrical current within the coil at the scalp-contacting curved undersurface of the coil, as related to head positions defined in accordance with the EEG 10-20 convention. Induced current within the brain moves in a direction opposite that of the primary electrical current in the coil. 
           [0034]      FIG. 10C  illustrates a lateral projection of a patient&#39;s head with the D-coil in place, with one end over the left dorsolateral prefrontal cortex, turning posteriorly at a diagonal, and the other end over midline above dorsal anterior cingulate. 
           [0035]      FIG. 10D  illustrates an anterior-posterior projection of a patient&#39;s head with the D-coil in place, with one end over the left dorsolateral prefrontal cortex, turning posteriorly at a diagonal, and the other end over midline above dorsal anterior cingulate. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0036]    In general, the devices described herein include one or more TMS electromagnets that are configured to be worn on a patients head to induce current in a specific target region of the patient&#39;s brain (e.g., the left dorsolateral prefrontal cortex overlaying the dorsal anterior cingulate gyrus). The devices maybe configured to stimulate this region specifically (and without substantially stimulating non-target regions) in a variety of head sizes and shapes using the same device. 
         [0037]    In some variations this device includes a head mount holding the TMS electromagnet, which may be configured as a hat, helmet, headband, or the like. The position or orientation of the TMS electromagnets (which may include two or more TMS electromagnets or coils) may be fixed, while various subcomponents of the TMS electromagnets may be adjustable. 
         [0038]    For example,  FIG. 1  illustrates a set of two coils with a hinge apparatus retaining the two in proximity, and with underlying hemi-pads keeping the coils at an appropriate tilt, such that the main direction of primary electrical current within both coils is aligned diagonally from the left prefrontal cortex to the midline over the dorsal cingulate. In this example, the patient&#39;s head  100  is shown, the patient is wearing a headband  120 , to which a top coil portion  110  and a left coil portion  115  are attached, separated by a coil hinge  105 . The device or system shown in this embodiment is specifically arranged to be worn so that the direction of primary current within the coils at the scalp-contacting surface of the coil ( 113  and  114 ) is oriented to specifically and narrowly stimulate the left dorsolateral prefrontal cortex overlaying the dorsal anterior cingulate gyrus. The figure also illustrates displacement hemi-pads  115 ,  116 , and  117  on the headband  120 ; the headband  120  also includes one or more adjustable controls (ratchet  125 ) that may be used to tighten/loosen the headband on the head. In this example, the direction of primary current in coil section  111  and  112  is indicated by the curving arrows. 
         [0039]    Another device example is shown in  FIG. 2 , which illustrates a multi-axis hinge mechanisms that permit a pair of coils to contact the scalp of varying head shapes and sizes, only along those portions of the coil circumference that induce current in the desired direction. In this example the TMS electromagnets shown may be used with any appropriate holder or head mount, such as the headband shown in  FIG. 1 .  FIG. 2  shows: a first coil  201  and  221 , a second coil  202  and  222 , a coil roll hinge  203 , a pitch hinge  211  and  210 , and a hinge ratchet lock  214  and  235 .  FIG. 2  also illustrates the direction of pitch  211  and  230 , direction of roll  204  and  233 , and shows pivot portions  212  and  213 . The angle and orientation of the TMS electromagnets (coils) may be adjusted as indicated; the angle between each of the two coil regions (e.g.,  201  and  222 ) may be separately adjusted. 
         [0040]      FIGS. 3 through 9  illustrate other variations of similarly adjustable TMS electromagnets. 
         [0041]    For example,  FIG. 3  details a hemi-padding arrangement that places one portion of each coil surface closer to the scalp than the other portions of each coil surface. In this example, the Figure shows: a first coil  301 , a second coil  302 , a first hemi-pad  305 , a second hemi-pad  306 , and a hinge  303 . The lower right portion of the figure shows a lateral view of coil  320 , including a lateral view of hemi-pad  321 , and a patient-contacting surface  322 . 
         [0042]      FIG. 4A  illustrates an arrangement in which each of the two coils of the TMS electromagnet are physically bent, thereby placing one portion of each coil surface closer to the brain than the other portions of each coil surface, without the requirements for pads. The first bent coil section  406 , second bent coil section  407 , first patient-contacting surface of coil  405 , and second patient-contacting surface of coil  408  are shown, along with the direction of primary current in coils at contacting surface  409 . 
         [0043]      FIG. 4B  illustrates an exemplary electrical wiring approach for the two coils, whereby they are powered in parallel by electrical pulses discharged between the positive and negative terminals of a single standard TMS pulse generator. In this example, negative pulse generator terminal  427 , positive pulse generator terminal  426  contact the first coil  428  and second coil  425  at positive lead of first coil  424  and negative lead of first coil  423 . The direction of primary current in coils  429  is also illustrated by the large arrow. 
         [0044]      FIG. 4C  illustrates the two tiltable hemi-padded coils powered by a single TMS pulse generator, with an arrow indicating the principal direction of the primary electrical current within the coils on the portions of the coil that are placed closest to the brain. In  FIG. 4C , the negative pulse generator terminal  438 , positive pulse generator terminal  437 , first coil  431 , second coil  432 , first hemi-pad  435 , and second hemi-pad  436  are all illustrated. The primary direction of current in first coil  433  as well as the direction of primary current in second coil  434  and direction of primary current of both coils at patient contacting surface  439  are shown. 
         [0045]      FIG. 5  illustrates a hinged coil pair attached to a suspension apparatus, in which multiple axes of positioning movement are enabled. In this example, the following elements are shown in their relative relationships: ratcheted hinge  501 , ratchet lock knob  510 , first coil  502 , second coil  503 , ball in socket  503 , extension shaft  504 , second ball in socket  505 , fixation knob  512 , and cantilevered arm  506 . 
         [0046]    In  FIGS. 6-9 , various mechanisms illustrate ways to allow relative positioning of the two circular coil elements. Space between first and second coil shown is exaggerated for concept illustration purposes. Hinge mechanisms may also be of larger sturdier dimension, but are shown here in small scale for better visibility in the context of the whole diagram. It is intended that these illustrative mechanisms be combined with sturdy mechanical fixation means that prevents unintended loss of their affixed position with patient movement and coil pulsing. Such fixation means may include ratcheting, friction-based fixation, motorized stepping, and pin and hole locks. 
         [0047]    For example,  FIG. 6  illustrates a ball and socket mechanism for allowing relative positioning of the two circular coil elements. In this example, the first coil enclosure  605 , second coil enclosure  610 , ball  615 , and socket  620 . The inset region in the lower right shows a close up of ball  622  and a close up of socket  621 . 
         [0048]      FIG. 7  illustrates a cross wire “x-wire” mechanism for allowing relative positioning of the two circular coil elements, including a first coil enclosure  705 , second coil enclosure  710 , first cross-wire  720 , and second cross-wire  725 . The inset region in the lower left corner shows a close up of first coil enclosure  706 , a close up of second coil enclosure  711 , a close up of first cross-wire  721 , a close up of second cross-wire  726 , an attachment of second cross-wire to second coil enclosure  727 , and an attachment of first-cross wire to second coil enclosure  722 . 
         [0049]      FIG. 8  illustrates a trolley-in-rail mechanism for allowing relative positioning of the two circular coil elements. In this example the TMS electromagnet includes a first coil enclosure  805 , a second coil enclosure  810 , a trolley  815 , a track  820 , and in the lower right inset region, a close up of trolley  816 , a close up of track  821 . 
         [0050]      FIG. 9  illustrates a flexible “sock”-like fitting that joins the two coils, allowing relative positioning. In  FIG. 9 , a first coil exterior  905 , second coil exterior  910 , first portion of flexible sock  906 , and a second portion of flexible sock  907  as well as an intermediate portion of flexible sock  920  are shown. 
         [0051]      FIG. 10A  shows a represents a “D-shaped” coil design with a curved undersurface and specified placement in which a concentrically wound single coil powered by a single TMS pulse source.  FIG. 6A  shows the general orientation of the insulated conductive members, with exaggerated space between the coil windings for illustrative purposes: in reality these concentric conductive members are intended to be as tightly wound as possible for inductive efficiency. Curved undersurface  1005  may be made of either rigid material such as copper and potting material, or may be made of flexible material such as stranded copper or silver cable. This portion may also be constructed with Litz wire or similar flexible conductive material. (Expand detailing each item numbered in the figure). 
         [0052]      FIG. 10A  shows a TMS electromagnet coupled or coupleable to a positive terminal of pulse generator  1001 , a negative terminal of pulse generator  1002 . The TMS electromagnet includes a “D” coil  1000  having a free transverse portion  1008 , upwardly extending portion  1007 , downwardly extending portion  1009 , and a patient contacting surface  1005 .  FIG. 10A  also shows the direction of primary current in patient-contacting surface  1006 . 
         [0053]      FIG. 10B  specifies the location and direction of primary electrical current within the coil at the scalp-contacting curved undersurface of the coil, as related to head positions defined in accordance with the EEG 10-20 convention. Induced current within the brain moves in a direction opposite that of the primary electrical current in the coil. Preferred placement for the coils described herein (including the D-shaped coil of  FIG. 10A ) is with a posterior slanted diagonal from the left side of the head near F 3 , to the top of the head anterior to C 7  ( 1015 ), but posterior to F 2  ( 1016 ). In this manner, conventional electrical current flows within curved undersurface  1005  from the left side of the head at a posterior slanted diagonal to the top of the head overlying medial frontal cortex, and dorsal anterior cingulate below it. 
         [0054]    In  FIG. 10B , the schematic of EEG 10-20 layout of a head  1010  includes a point F 2   1016 , CZ  1015 , and indicates the footprint of the “D” coil on patient&#39;s head  1012 , spanning the point F 3   1013 . The direction of primary current in “D” coil at patient-contacting surface is indicated by the arrow  1011 . 
         [0055]    The positive side  1052  of curved undersurface  1005  is placed approximately over the F 3  (EEG 10-20 nomenclature), or the left dorsolateral prefrontal cortex, Brodmann&#39;s Area 9/46. The negative side  1054  of curved undersurface  1005  is placed over medial frontal cortex, anterior to C 7  ( 1015 ), but posterior to F 2  ( 1016 ). In this manner, conventional electrical current flows within the curved undersurface  605  from the left side of the head. 
         [0056]      FIG. 10C  illustrates a lateral projection of a patient&#39;s head with the D-coil in place, with one end over the left dorsolateral prefrontal cortex, turning posteriorly at a diagonal, and the other end over midline above dorsal anterior cingulate. Preferred placement for this coil is with the positive side  1052  of curved undersurface  1005  is placed approximately over the F 3  (EEG 10-20 nomenclature), or the left dorsolateral prefrontal cortex, Brodmann&#39;s Area 9/46. The negative side  1054  of curved undersurface  1005  is placed over medial frontal cortex, anterior to C 7  ( 615 ), but posterior to F 2  ( 616 ). In this manner, conventional electrical current flows within the curved undersurface  1005  from the left side of the head in the desired region. In this example, the patient  1050  is shown wearing the “D” coil  1051 . The “D” coil includes an inferior margin of “D” coil  1052 , a superior margin of “D” coil  1054 . The top of head, anterior  2  CZ  1055 , F 3   1053  are shown. The direction of primary current in coil at patient-contacting surface  1057  is also illustrated. 
         [0057]      FIG. 10D  illustrates an anterior-posterior projection of a patient&#39;s head with the D-coil in place, with one end over the left dorsolateral prefrontal cortex, turning posteriorly at a diagonal, and the other end over midline above dorsal anterior cingulate. Similar to  FIG. 10C ,  FIG. 10D  shows a patient  1060  wearing a “D” coil  1061  and include an inferior margin of “D” coil  1062 . Region F 3   1063 , the superior margin of “D” coil  1064 , and the top of head anterior to CZ  1065  are all show. In this example, the direction of primary current in coil at patient-contacting surface  1067  is also shown. 
         [0058]    Although the description above is broken into parts and includes specific examples of variations of suture passers, any of the features or elements described in any particular example or section may be incorporated into any of the other embodiments. Although the foregoing invention has been described in some detail by way of illustration and example for purposes of clarity of understanding, it is readily apparent to those of ordinary skill in the art in light of the teachings of this invention that certain changes and modifications may be made thereto without departing from the spirit or scope of the appended claims.