• Pedro H C Ferreira-Pinto, Flavio Nigri, Egas M Caparelli-Daquer, Dutra do Souto Antonio Aversa AA National Cancer Institute, Rio de Janeiro, RJ, Brazil., and de Miranda Chaves Christiani Márcio M National Cancer Institute, Rio de Janeiro, RJ, Brazil..
• Division of Neurosurgery, Department of Surgical Specialties, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil; LabEEL-Laboratório de Estimulação Elétrica do Sistema Nervoso, Division of Neurosurgery, Department of Surgical Specialties, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil. Electronic address: pedrohcfp@gmail.com.
• World Neurosurg. 2020 Jan 1; 133: 42-48.

BackgroundNavigated transcranial magnetic stimulation (nTMS) is being used for different purposes in patients with brain tumors. However, the procedure requires a positive electrophysiological response. For patients with negative response in rest conditions, active motor threshold (AMT) may be used. However, sometimes it is difficult to obtain AMT measures owing to inability of the patient to sustain steady muscle contraction. Herein, we describe a simple method by using a hand dynamometer to obtain AMT measures during nTMS session.Case DescriptionA woman aged 68 years underwent total removal of a right frontal lobe oligodendroglioma World Health Organization grade II 15 years ago. Cranial magnetic resonance imaging during follow-up revealed local recurrence. In the postoperative period, she developed left upper limb paresis. A postoperative nTMS session was performed for motor electrophysiological evaluation. However, using the standard technique for AMT measurement, the patient was unable to perform sustained muscle contraction as required. A hand dynamometer was used. It allowed sustained muscle contraction for AMT measurement. A counter force for the index finger flexion, the hand support to stabilize hand joints, and a numerical screen serving for both the examiner and the patient as a feedback parameter may explain the success obtained with this simple device.ConclusionsAlthough more studies are necessary to validate the method, the hand dynamometer should be considered for patients unable to sustain muscle contraction during AMT measurement.Copyright © 2019 Elsevier Inc. All rights reserved.

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