• Philipp Hendrix, Yvonne Dzierma, Benedikt W Burkhardt, Andreas Simgen, Gudrun Wagenpfeil, Christoph J Griessenauer, Sebastian Senger, and Joachim Oertel.
• Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.
• Neurosurgery. 2021 Feb 16; 88 (3): 627-636.

BackgroundNavigated transcranial magnetic stimulation (nTMS) is an established, noninvasive tool to preoperatively map the motor cortex. Despite encouraging reports from few academic centers with vast nTMS experience, its value for motor-eloquent brain surgery still requires further exploration.ObjectiveTo further elucidate the role of preoperative nTMS in motor-eloquent brain surgery.MethodsPatients who underwent surgery for a motor-eloquent supratentorial glioma or metastasis guided by preoperative nTMS were retrospectively reviewed. The nTMS group (n = 105) was pair-matched to controls (non-nTMS group, n = 105). Gross total resection (GTR) and motor outcome were evaluated. Subgroup analyses including survival analysis for WHO III/IV glioma were performed.ResultsGTR was significantly more frequently achieved in the entire nTMS group compared to the non-nTMS group (P = .02). Motor outcome did not differ (P = .344). Bootstrap analysis confirmed these findings. In the metastases subgroup, GTR rates and motor outcomes were equal. In the WHO III/IV glioma subgroup, however, GTR was achieved more frequently in the nTMS group (72.3%) compared to non-nTMS group (53.2%) (P = .049), whereas motor outcomes did not differ (P = .521). In multivariable Cox-regression analysis, prolonged survival in WHO III/IV glioma was significantly associated with achievement of GTR and younger patient age but not nTMS mapping.ConclusionPreoperative nTMS improves GTR rates without jeopardizing neurological function. In WHO III/IV glioma surgery, nTMS increases GTR rates that might translate into a beneficial overall survival. The value of nTMS in the setting of a potential survival benefit remains to be determined.Copyright © 2020 by the Congress of Neurological Surgeons.

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