• Antonino Germanò, Giovanni Raffa, Alfredo Conti, Patrizia Fiore, Salvatore Massimiliano Cardali, Felice Esposito, Antonino Scibilia, Maria C Quattropani, Sergio Lucio Vinci, Giuseppina Marzano, Stefano Pergolizzi, Marcello Longo, and Filippo Flavio Angileri.
• Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy.
• World Neurosurg. 2019 Nov 1; 131: 371-384.

BackgroundNavigated transcranial magnetic stimulation (nTMS) provides a reliable identification of "eloquent" cortical brain areas. Moreover, it can be used for diffusion tensor imaging fiber tracking of eloquent subcortical tracts. We describe the use of nTMS-based cortical mapping and diffusion tensor imaging fiber tracking for defining the "eloquence" of areas surrounding brain arteriovenous malformations (BAVMs), aiming to improve patient stratification and treatment.MethodsWe collected data of BAVMs suspected to be in eloquent areas treated between 2017 and 2019, and submitted to nTMS-based reconstruction of motor, language, and visual pathways for the definition of the eloquence of the surrounding brain areas. We describe the nTMS-based approach and analyze its impact on patient stratification and allocation to treatment in comparison with the standard assessment of eloquence based on anatomical landmarks.ResultsTen patients were included in the study. Preliminarily, 9 BAVMs were suspected to be located in an eloquent area. After nTMS-based mapping, only 5 BAVMs were confirmed to be close to eloquent structures, thus leading to a change of the score for eloquence and of the final BAVMs grading in 60% of patients. Treatment was customized according to nTMS information, and no cases of neurological worsening were observed. Radiological obliteration was complete in 7 cases microsurgically treated, and accounted for about 70% in the remaining 3 patients 1 year after radiosurgical treatment.ConclusionsThe nTMS-based information allows an accurate stratification and allocation of patients with BAVMs to the most effective treatment according to a modern, customized, neurophysiological identification of the adjacent eloquent brain networks.Copyright © 2019 Elsevier Inc. All rights reserved.

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