Utility of presurgical navigated transcranial magnetic brain stimulation for the resection of tumors in eloquent motor areas

Clinical article

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Object

Navigated transcranial magnetic stimulation (nTMS) is a newly evolving technique. Despite its supposed purpose (for example, preoperative central region mapping), little is known about its accuracy compared with established modalities like direct cortical stimulation (DCS) and functional MR (fMR) imaging. Against this background, the authors performed the current study to compare the accuracy of nTMS with DCS and fMR imaging.

Methods

Fourteen patients with tumors in or close to the precentral gyrus were examined using nTMS for motor cortex mapping, as were 12 patients with lesions in the subcortical white matter motor tract. Moreover, preoperative fMR imaging and intraoperative mapping of the motor cortex were performed via DCS, and the outlining of the motor cortex was compared.

Results

In the 14 cases of lesions affecting the precentral gyrus, the primary motor cortex as outlined by nTMS correlated well with that delineated by intraoperative DCS mapping, with a deviation of 4.4 ± 3.4 mm between the two methods. In comparing nTMS with fMR imaging, the deviation between the two methods was much larger: 9.8 ± 8.5 mm for the upper extremity and 14.7 ± 12.4 mm for the lower extremity. In 13 of 14 cases, the surgeon admitted easier identification of the central region because of nTMS. The procedure had a subjectively positive influence on the operative results in 5 cases and was responsible for a changed resection strategy in 2 cases. One of 26 patients experienced nTMS as unpleasant; none found it painful.

Conclusions

Navigated TMS correlates well with DCS as a gold standard despite factors that are supposed to contribute to the inaccuracy of nTMS. Moreover, surgeons have found nTMS to be an additional and helpful modality during the resection of tumors affecting eloquent motor areas, as well as during preoperative planning.

Abbreviations used in this paper:AED = antiepilepsy drug; APB = abductor pollicis brevis; BOLD = blood oxygen level–dependent; CMAP = compound muscle action potential; DCS = direct cortical stimulation; DICOM = Digital Imaging and Communications in Medicine; EMG = electromyography; fMR = functional magnetic resonance; MEP = motor evoked potential; nTMS = navigated transcranial magnetic stimulation; rMT = resting motor threshold; SENSE = sensitivity encoding.

Article Information

Address correspondence to: Florian Ringel, M.D., Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675 Munich, Germany. email: Florian.Ringel@lrz.tum.de.

Please include this information when citing this paper: published online February 3, 2012; DOI: 10.3171/2011.12.JNS111524.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Bar graph showing rMT in relation to AED use. No significant difference was observed.

  • View in gallery

    Deviation of nTMS compared with DCS and fMR imaging. Bar graph showing that nTMS data correlate quite well with DCS data (4.4 ± 3.4 mm), whereas delineation of the primary motor cortex via fMR imaging differs significantly from nTMS, depending on whether the extremity is upper (9.8 ± 8.5 mm) or lower (14.7 ± 12.4 mm; p < 0.05).

  • View in gallery

    Bar graph showing nTMS data had a significant impact on the course of the operation, surgeon confidence, and operative results.

  • View in gallery

    Illustrative case demonstrating severe deviation between nTMS and fMR imaging data. Functional MR image (A) showing the primary motor cortex of the hand is dorsolateral to the metastasis. An nTMS map (B) showing this region to be ventromedial to the tumor. Green indicates the nTMS mapping at peeling levels of 15, 20, and 25 mm; yellow indicates fiber tracking. Navigated TMS data significantly influenced the approach for resection and was intraoperatively confirmed by DCS mapping.

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