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Focused high frequency repetitive transcranial magnetic stimulation for localisation of the unexposed primary motor cortex during brain tumour surgery
  1. V Rohde1,
  2. L Mayfrank1,
  3. M Weinzierl1,
  4. T Krings2,
  5. J M Gilsbach1
  1. 1Department of Neurosurgery, Aachen University, Germany
  2. 2Department of Neuroradiology, Aachen University
  1. Correspondence to:
 Dr V Rohde, Department of Neurogurgery, University of Technology (RWTH) Aachen, Pauwelsstrasse 30, D-52057 Aachen, Germany; 


Objectives: To investigate if intraoperative focused high frequency repetitive transcranial magnetic stimulation (rTMS) can localise the primary motor cortex without exposure of the cortical surface.

Methods: A high frequency train (357 Hz) of four suprathreshold magnetic stimuli was delivered transcranially to the region of the rolandic area during brain tumour operations in 12 patients. To induce a focal magnetoelectric field, the flat figure of eight coil (outer diameter of each loop 7 cm) was used. Motor evoked potentials (MEP) were recorded in eight muscles of the upper and lower contralateral extremities. The first stimulation site was 2.5 cm behind the bregma, the second site 2 cm, and the third site 4 cm dorsal to the first stimulation site. If no MEP were obtainable, stimulation was repeated in anteroposterior direction at more laterally located sites. Using neuronavigation, each positive stimulation site was correlated with the underlying cortical anatomy.

Results: Stimulation was performed at a total of 42 sites (in two patients, maximum stimulation at the three initial sites failed to evoke a motor response). In four patients, MEP were obtained only from one stimulation site. This site exactly overlayed the primary motor cortex. In eight patients, MEP could be elicited from more than one stimulation site. In seven of the eight patients, the site from which MEP with peak amplitudes were elicited, corresponded to the primary motor cortex. In total, the primary motor cortex was correctly identified on the basis of electrophysiological findings in 11 of 12 patients (92 %). In two patients, only the more lateral stimulation sites permitted MEP recording.

Conclusion: Intraoperative focused rTMS is highly sensitive for localisation of the primary motor cortex. Focused rTMS as a localising instrument alleviates the need of motor cortex exposure and, thereby, can contribute to minimise the surgical approach to brain tumours in the rolandic area.

  • high frequency repetitive stimulation
  • motor evoked potentials
  • transcranial magnetic stimulation
  • rTMS, repetitive transcranial magnetic stimulation
  • MEP, motor evoked potentials

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  • Funding: the work was supported by grants of the Stiftung Tumorforschung Kopf-Hals given to the first author.

  • Competing interests: none declared.