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NTMS mapping of non-primary motor areas in brain tumour patients and healthy volunteers

  • Original Article - Brain Tumors
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Abstract

Objective

Navigated transcranial magnetic stimulation (nTMS) has been increasingly used for presurgical cortical mapping of the primary motor cortex (M1) but remains controversial for the evaluation of non-primary motor areas (NPMA). This study investigates clinical and neurophysiological parameters in brain tumour patients and healthy volunteers to decide whether single-pulse biphasic nTMS allows to reliably elicite MEP outside from M1 or not.

Materials and methods

Twelve brain tumour patients and six healthy volunteers underwent M1 nTMS mapping. NPMA nTMS mapping followed using 120% and 150% M1 resting motor threshold (RMT) stimulation intensity. Spearman’s correlation analysis tested the association of clinical and neurophysiological parameters between M1 and NPMA mapping.

Results

A total of 88.81% of nTMS stimulations in NPMA in patients/83.87% in healthy volunteers in patients/83.87% in healthy volunteers did not result in MEPs ≥ 50 μV. Positive nTMS mapping in NPMA correlated with higher stimulation intensity and larger M1 areas in patients (120% M1 RMT SI p = 0.005/150% M1 RMT SI p = 0.198).

Conclusion

Our findings indicate that in case of positive nTMS mapping in NPMA, MEPs originate mostly from M1. For future studies, MEP parameters and TMS coil rotation should be studied closely to assess the risk for postoperative motor deterioration.

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Abbreviations

FDI:

First dorsal interosseous muscle

FT:

Finger tapping

KPSS:

Karnofsky Performance Status Scale

MEP:

Motor evoked potentials

MRC:

Medical Research Council

M1:

Primary motor cortex

NHPT:

Nine-Hole Peg Test

NPMA:

Non-primary motor areas

nTMS:

Navigated transcranial magnetic stimulation

PMC:

Premotor cortex

RMT:

Resting motor threshold

SMA:

Supplementary motor area

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Funding

Matters of Activity. Image Space Material. An Interdisciplinary Laboratory Cluster of Excellence at the Humboldt-Universität zu Berlin (sponsor number EXC 2025/1) with financial support from the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) supported the research. The sponsor had no role in the design or conduct of this research.

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Authors and Affiliations

  1. Department of Neurosurgery, Charité University Medicine, Charitéplatz 1, Berlin, Germany

    Andia Mirbagheri, Heike Schneider, Anna Zdunczyk, Peter Vajkoczy & Thomas Picht

Authors
  1. Andia Mirbagheri
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  2. Heike Schneider
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  3. Anna Zdunczyk
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  4. Peter Vajkoczy
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  5. Thomas Picht
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Corresponding author

Correspondence to Andia Mirbagheri.

Ethics declarations

Data collection was conducted in accordance with the ethical standards set forth by the ethics commission of the Charité University Hospital in Berlin (EA 2/135/14), local ethics committees, and the Declaration of Helsinki.

Conflict of interest

Thomas Picht has served as a speaker for a TMS manufacturer (Nexstim Oy) but is not a contracted consultant. All other authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethics Commission of the Charité University Hospital and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

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

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Comments

Navigated TMS is increasingly used as a preoperative tool to map cortical areas involved in motor and speech functions. It has long been postulated, and recently also shown, that pathological processes, such as intra-axial tumours and epileptogenic lesions within eloquent cortex, may induce plastic changes resulting in transfer of function away from the original sites to nearby, less affected cortical regions. While intraoperative direct cortical stimulation remains the gold standard method for mapping the functional cortex, we and others have found nTMS as a very useful tool in predicting the most likely positive stimulation sites, thereby facilitating both the planning of the surgery and the actual intraoperative mapping. It is certainly comforting for the neurosurgeon to be prepared to expect positive stimulation sites in regions that might be unexpected based only on classical anatomical landmarks, and avoiding unnecessary confusion in the operating room also saves valuable time during surgery.

This work from a very experienced nTMS research team is important in describing a potential source of error during nTMS mapping - without care, one might interpret the results as plastic changes in a situation where there is none! Studies like this are very important to advance our understanding and applicability of nTMS as a preoperative mapping technique.

Aki Laakso and Pantelis Lioumis

Helsinki, Finland

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This article is part of the Topical Collection on Brain Tumors

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Mirbagheri, A., Schneider, H., Zdunczyk, A. et al. NTMS mapping of non-primary motor areas in brain tumour patients and healthy volunteers. Acta Neurochir 162, 407–416 (2020). https://doi.org/10.1007/s00701-019-04086-x

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