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

Clinical article

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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.


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.


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.


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.



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

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    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).

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    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.



Ahdab RAyache SSBrugières PGoujon CLefaucheur JP: Comparison of “standard” and “navigated” procedures of TMS coil positioning over motor, premotor and prefrontal targets in patients with chronic pain and depression. Neurophysiol Clin 40:27362010


Barker ATJalinous RFreeston IL: Non-invasive magnetic stimulation of human motor cortex. Lancet 1:110611071985


Berger MSOjemann GALettich E: Neurophysiological monitoring during astrocytoma surgery. Neurosurg Clin N Am 1:65801990


Brasil-Neto JPCohen LGPanizza MNilsson JRoth BJHallett M: Optimal focal transcranial magnetic activation of the human motor cortex: effects of coil orientation, shape of the induced current pulse, and stimulus intensity. J Clin Neurophysiol 9:1321361992


Cedzich CTaniguchi MSchäfer SSchramm J: Somatosensory evoked potential phase reversal and direct motor cortex stimulation during surgery in and around the central region. Neurosurgery 38:9629701996


Cohen LGRoth BJNilsson JDang NPanizza MBandinelli S: Effects of coil design on delivery of focal magnetic stimulation. Technical considerations. Electroencephalogr Clin Neurophysiol 75:3503571990


Dum RPStrick PL: Motor areas in the frontal lobe of the primate. Physiol Behav 77:6776822002


Forster MTHattingen ESenft CGasser TSeifert VSzelényi A: Navigated transcranial magnetic stimulation and functional magnetic resonance imaging: advanced adjuncts in preoperative planning for central region tumors. Neurosurgery 68:131713252011


Hastreiter PRezk-Salama CSoza GBauer MGreiner GFahlbusch R: Strategies for brain shift evaluation. Med Image Anal 8:4474642004


Hou BLBradbury MPeck KKPetrovich NMGutin PHHolodny AI: Effect of brain tumor neovasculature defined by rCBV on BOLD fMRI activation volume in the primary motor cortex. Neuroimage 32:4894972006


Ilmoniemi RJRuohonen JKarhu J: Transcranial magnetic stimulation—a new tool for functional imaging of the brain. Crit Rev Biomed Eng 27:2412841999


Kantelhardt SRFadini TFinke MKallenberg KSiemerkus JBockermann V: Robot-assisted image-guided transcranial magnetic stimulation for somatotopic mapping of the motor cortex: a clinical pilot study. Acta Neurochir (Wien) 152:3333432010


Kombos TSuess OFunk TKern BCBrock M: Intra-operative mapping of the motor cortex during surgery in and around the motor cortex. Acta Neurochir (Wien) 142:2632682000


Krings TBuchbinder BRButler WEChiappa KHJiang HJCosgrove GR: Functional magnetic resonance imaging and transcranial magnetic stimulation: complementary approaches in the evaluation of cortical motor function. Neurology 48:140614161997


Krings TBuchbinder BRButler WEChiappa KHJiang HJRosen BR: Stereotactic transcranial magnetic stimulation: correlation with direct electrical cortical stimulation. Neurosurgery 41:131913261997


Krings TChiappa KHFoltys HReinges MHCosgrove GRThron A: Introducing navigated transcranial magnetic stimulation as a refined brain mapping methodology. Neurosurg Rev 24:1711792001


Krings TReinges MHErberich SKemeny SRohde VSpetzger U: Functional MRI for presurgical planning: problems, artefacts, and solution strategies. J Neurol Neurosurg Psychiatry 70:7497602001


Krishnan RRaabe AHattingen ESzelényi AYahya HHermann E: Functional magnetic resonance imaging-integrated neuronavigation: correlation between lesion-to-motor cortex distance and outcome. Neurosurgery 55:9049152004


Laws ER JrTaylor WFClifton MBOkazaki H: Neurosurgical management of low-grade astrocytoma of the cerebral hemispheres. J Neurosurg 61:6656731984


Lefaucheur JPBrugières PMénard-Lefaucheur IWendling SPommier MBellivier F: The value of navigation-guided rTMS for the treatment of depression: an illustrative case. Neurophysiol Clin 37:2652712007


Lehéricy SDuffau HCornu PCapelle LPidoux BCarpentier A: Correspondence between functional magnetic resonance imaging somatotopy and individual brain anatomy of the central region: comparison with intraoperative stimulation in patients with brain tumors. J Neurosurg 92:5895982000


Levy WJAmassian VESchmid UDJungreis C: Mapping of motor cortex gyral sites non-invasively by transcranial magnetic stimulation in normal subjects and patients. Electroencephalogr Clin Neurophysiol Suppl 43:51751991


Mills KRMurray NMHess CW: Magnetic and electrical transcranial brain stimulation: physiological mechanisms and clinical applications. Neurosurgery 20:1641681987


Neuloh GPechstein UCedzich CSchramm J: Motor evoked potential monitoring with supratentorial surgery. Neurosurgery 61:1 Suppl3373482007


Neuloh GSchramm J: Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurosurg 100:3893992004


Penfield WBoldrey E: Somatic motor and sensory representation in the cerebral cortex of man as studied by electrical stimulation. Brain 60:3894431937


Picht TMularski SKuehn BVajkoczy PKombos TSuess O: Navigated transcranial magnetic stimulation for preoperative functional diagnostics in brain tumor surgery. Neurosurgery 65:6 Suppl93992009


Picht TSchmidt SBrandt SFrey DHannula HNeuvonen T: Preoperative functional mapping for rolandic brain tumor surgery: comparison of navigated transcranial magnetic stimulation to direct cortical stimulation. Neurosurgery 69:5815882011


Plewnia CReimold MNajib AReischl GPlontke SKGerloff C: Moderate therapeutic efficacy of positron emission tomography-navigated repetitive transcranial magnetic stimulation for chronic tinnitus: a randomised, controlled pilot study. J Neurol Neurosurg Psychiatry 78:1521562007


Pouratian NBookheimer SY: The reliability of neuroanatomy as a predictor of eloquence: a review. Neurosurg Focus 28:2E32010


Ruohonen JIlmoniemi RJ: Modeling of the stimulating field generation in TMS. Electroencephalogr Clin Neurophysiol Suppl 51:30401999


Ruohonen JKarhu J: Navigated transcranial magnetic stimulation. Neurophysiol Clin 40:7172010


Rutten GJRamsey NF: The role of functional magnetic resonance imaging in brain surgery. Neurosurg Focus 28:2E42010


Säisänen LJulkunen PNiskanen EDanner NHukkanen TLohioja T: Motor potentials evoked by navigated transcranial magnetic stimulation in healthy subjects. J Clin Neurophysiol 25:3673722008


Sanai NBerger MS: Intraoperative stimulation techniques for functional pathway preservation and glioma resection. Neurosurg Focus 28:2E12010


Sanai NBerger MS: Mapping the horizon: techniques to optimize tumor resection before and during surgery. Clin Neurosurg 55:14192008


Stummer WReulen HJMeinel TPichlmeier USchumacher WTonn JC: Extent of resection and survival in glioblastoma multiforme: identification of and adjustment for bias. Neurosurgery 62:5645762008


Suess OSuess SBrock MKombos T: Intraoperative electrocortical stimulation of Brodman area 4: a 10-year analysis of 255 cases. Head Face Med 2:202006


Suess OSuess SMularski SKühn BPicht TSchönherr S: [Evaluation of a DC pulsed magnetic tracking system in neurosurgical navigation: technique, accuracies, and influencing factors.]. Biomed Tech (Berl) 52:2232332007. (Ger)


Taniguchi MCedzich CSchramm J: Modification of cortical stimulation for motor evoked potentials under general anesthesia: technical description. Neurosurgery 32:2192261993


Teitti SMäättä SSäisänen LKönönen MVanninen RHannula H: Non-primary motor areas in the human frontal lobe are connected directly to hand muscles. Neuroimage 40:124312502008


Vaalto SSäisänen LKönönen MJulkunen PHukkanen TMäättä S: Corticospinal output and cortical excitation-inhibition balance in distal hand muscle representations in nonprimary motor area. Hum Brain Mapp 32:169217032011


Yetkin FZMueller WMMorris GLMcAuliffe TLUlmer JLCox RW: Functional MR activation correlated with intraoperative cortical mapping. AJNR Am J Neuroradiol 18:131113151997




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