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Applicability of nTMS in locating the motor cortical representation areas in patients with epilepsy

  • Clinical Article-Functional
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Abstract

Background

Transcranial magnetic stimulation (TMS) is increasingly used for non-invasive functional mapping in preoperative evaluation for brain surgery, and the reliability of navigated TMS (nTMS) motor representation maps has been studied in the healthy population and in brain tumor patients. The lesions behind intractable epilepsy differ from typical brain tumors, ranging from developmental cortical malformations to injuries early in development, and may influence the functional organization of the cortical areas. Moreover, the interictal cortical epileptic activity and antiepileptic medication may affect the nTMS motor threshold. The reliability of the nTMS motor representation localization in epilepsy patients has not been addressed.

Methods

We compared the nTMS motor cortical representation maps of hand and arm muscles with the results of invasive electrical cortical stimulation (ECS) in 13 patients with focal epilepsy. The nTMS maps were projected to the cortical surface segmented from preoperative magnetic resonance images (MRI), and the positions of the subdural electrodes were extracted from the postoperative low-dose computed tomography (CT) images registered with preoperative MRI.

Results

The 3D distance between the average nTMS site and average ECS electrode location was 11 ± 4 mm for the hand and 16 ± 7 mm for arm muscle representation areas. In all patients the representation areas defined with nTMS and ECS were located on the same gyrus, also in patients with abundant interictal epileptic activity on the motor gyrus.

Conclusions

nTMS can reliably locate the hand motor cortical representation area with the accuracy needed for pre-surgical evaluation in patients with epilepsy.

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Abbreviations

APB:

Abductor pollicis brevis

ADM:

Abductor digiti minimi

BB:

Biceps brachii

CT:

Computed tomography

DCS:

Direct cortical stimulation

ECS:

Electrical cortical stimulation

ECSCOG :

The weighted mean of the ECS map (arithmetic mean weighted by the inverse of the stimulating current)

ECSE :

Individual ECS electrode location

ECSG :

The average ECS site (arithmetic mean of the coordinates of the electrodes centers)

ECSMIN :

The center of the electrode eliciting motor response with the lowest current

EDC:

Extensor digitorum communis

EEG:

Electroencephalography

EMG:

Electromyography

FCD:

Focal cortical dysplasia

FCR:

Flexor carpi radialis

MEP:

Motor-evoked potential

MRI:

Magnetic resonance imaging

nTMS:

Navigated transcranial magnetic stimulation

nTMSG :

The average stimulation site (arithmetic mean of the stimulation site coordinates) projected to the brain surface of a given muscle group motor representation area in the nTMS

RMT:

Resting motor threshold

SD:

Standard deviation

SP:

Silent period

TMS:

Transcranial magnetic stimulation

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Acknowledgments

We would like to thank the staff contributing to the pre- and postoperative studies, diagnostics and data collection. Phil.Lic. Anne-Mari Vitikainen received a grant from the Finnish Cultural Foundation during the preparation of this manuscript. Ph.D. Pantelis Lioumis was supported by Helsinki University Central Hospital (EVO research funding) and the SalWe Research Program for Mind and Body (Tekes,the Finnish Funding Agency for Technology and Innovation, grant 1104/10).

Conflicts of interest

Dr. Eero Salli discloses a consultation fee from Nexstim in 2009 before the initiation of this study. Ph.D. Pantelis Lioumis dicloses a consultation fee from Nexstim in 2011. Dr. Jyrki P. Mäkelä, Dr. Liisa Metsähonkala, and Phil.Lic. Anne-Mari Vitikainen report no financial interest or potential conflicts of interest.

Author information

Authors and Affiliations

  1. Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, P.O. Box 340, 00029, Helsinki, Finland

    Anne-Mari Vitikainen & Eero Salli

  2. Department of Physics, University of Helsinki, P.O. Box 64, 00014, Helsinki, Finland

    Anne-Mari Vitikainen

  3. BioMag Laboratory, HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, P.O. Box 340, 00029, Helsinki, Finland

    Anne-Mari Vitikainen, Pantelis Lioumis & Jyrki P. Mäkelä

  4. Epilepsy Unit, Department of Gynaecology and Pediatrics, Helsinki University Central Hospital and University of Helsinki, P.O. Box 280, 00029, Helsinki, Finland

    Liisa Metsähonkala

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  1. Anne-Mari Vitikainen
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  2. Eero Salli
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  4. Jyrki P. Mäkelä
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Corresponding author

Correspondence to Anne-Mari Vitikainen.

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Table A

Details of the electrode grids and the stimulated electrodes evoking positive motor responses for each patient. REF refers to reference electrode not evoking a response in monopolar arrangement. (XLS 52.5 KB)

Table B

Hand and arm muscle group results for maps done with monophasic stimulating pulses with motor-evoked potential (MEP) responses in navigated transcranial magnetic stimulation (nTMS) for the distance parameters dist(nTMSG,ECSCOG) and dist(nTMSG,ECSMIN). The mean, standard deviation (SD) and ranges are given. nTMSG refers to the average stimulation site in nTMS, ECSCOG to the weighted average of the corresponding electrode locations, ECSMIN to the location of the electrode evoking motor response with the minimum current and n/a to not available. (XLS 44 kb)

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Vitikainen, AM., Salli, E., Lioumis, P. et al. Applicability of nTMS in locating the motor cortical representation areas in patients with epilepsy. Acta Neurochir 155, 507–518 (2013). https://doi.org/10.1007/s00701-012-1609-5

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  • DOI: https://doi.org/10.1007/s00701-012-1609-5

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