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

Clinical article

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  • 1 Department of Neurosurgery and
  • 2 Section of Neuroradiology, Department of Radiology, Klinikum rechts der Isar, Technische Universität München, Germany
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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.

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Contributor Notes

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.

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