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Alternative Stimulation Intensities for Mapping Cortical Motor Area with Navigated TMS

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Abstract

Navigated transcranial magnetic stimulation (nTMS) is becoming a popular tool in pre-operative mapping of functional motor areas. The stimulation intensities used in the mapping are commonly suprathreshold intensities with respect to the patient’s resting motor threshold (rMT). There is no consensus on which suprathreshold intensity should be used nor on the optimal criteria for selecting the appropriate stimulation intensity (SI). In this study, the left motor cortices of 12 right-handed volunteers (8 males, age 24–61 years) were mapped using motor evoked potentials with an SI of 110 and 120 % of rMT and with an upper threshold (UT) estimated by the Mills–Nithi algorithm. The UT was significantly lower than 120 % of rMT (p < 0.001), while no significant difference was observed between UT and 110 % of rMT (p = 0.112). The representation sizes followed a similar trend, i.e. areas computed based on UT (5.9 cm2) and 110 % of rMT (5.0 cm2) being smaller than that of 120 % of rMT (8.8 cm2) (p ≤ 0.001). There was no difference in representation sizes between 110 % of rMT and UT. The variance in representation size was found to be significantly lower with UT compared to 120 % of rMT (p = 0.048, uncorrected), while there was no difference between 110 % of rMT and UT or 120 % of rMT. Indications of lowest inter-individual variation in representation size were observed with UT; this is possibly due to the fact that it takes into account the individual input–output characteristics of the motor cortex. Therefore, the UT seems to be a good option for SI in motor mapping applications to outline functional motor areas with nTMS and it could potentially reduce the inter-individual variation caused by the selection of SI in motor mapping in pre-surgical applications and radiosurgery planning.

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Acknowledgments

The authors thank biostatistician Tuomas Selander, Kuopio University Hospital, for helping us to implement the statistical analyses. The study was funded by the Kaute Foundation, Helsinki, Finland, The Finnish Brain Research and Rehabilitation Center Neuron, Kuopio, Finland, Finnish Concordia Fund, Helsinki, Finland and The Paulo Foundation, Helsinki, Finland. In addition, the authors acknowledge the Research Committee of the Kuopio University Hospital Catchment Area for the State Research Funding (project 5041730, Kuopio, Finland).

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Authors and Affiliations

  1. Department of Clinical Neurophysiology, Kuopio University Hospital, P.O. Box 100, 70029, Kuopio, Finland

    Elisa Kallioniemi & Petro Julkunen

  2. Department of Applied Physics, University of Eastern Finland, Kuopio, Finland

    Elisa Kallioniemi & Petro Julkunen

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  1. Elisa Kallioniemi
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  2. Petro Julkunen
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Correspondence to Elisa Kallioniemi.

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Conflicts of interest

Petro Julkunen has received unrelated consulting pay from Nexstim Plc, manufacturer of the nTMS devices. Elisa Kallioniemi declares that she has no conflicts of interest.

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All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional research committee (ethical permission 1/2014) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Kallioniemi, E., Julkunen, P. Alternative Stimulation Intensities for Mapping Cortical Motor Area with Navigated TMS. Brain Topogr 29, 395–404 (2016). https://doi.org/10.1007/s10548-016-0470-x

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