Paired-pulse navigated TMS is more effective than single-pulse navigated TMS for mapping upper extremity muscles in brain tumor patients

Nico Sollmann, Haosu Zhang, Anna Kelm, Axel Schröder, Bernhard Meyer, Minna Pitkänen, Petro Julkunen, Sandro M. Krieg

Research output: Contribution to journalArticlepeer-review

13 Scopus citations


Objective: Single-pulse navigated transcranial magnetic stimulation (sp-nTMS) is used for presurgical motor mapping in patients with motor-eloquent lesions. However, recently introduced paired-pulse nTMS (pp-nTMS) with biphasic pulses could improve motor mapping. Methods: Thirty-four patients (mean age: 56.0 ± 12.7 years, 53.0% high-grade glioma) with motor-eloquent lesions underwent motor mapping of upper extremity representations and nTMS-based tractography of the corticospinal tract (CST) by both sp-nTMS and pp-nTMS with biphasic pulses for the tumor-affected hemisphere before resection. Results: In three patients (8.8%), conventional sp-nTMS did not provide motor-positive points, in contrast to pp-nTMS that was capable of generating motor maps in all patients. Good concordance between pp-nTMS and sp-nTMS in the spatial location of motor hotspots and center of gravity (CoG) as well as for CST tracking was observed, with pp-nTMS leading to similar motor map volumes (585.0 ± 667.8 vs. 586.8 ± 204.2 mm3, p = 0.9889) with considerably lower resting motor thresholds (35.0 ± 8.8 vs. 32.8 ± 7.6% of stimulator output, p = 0.0004). Conclusions: Pp-nTMS with biphasic pulses may provide motor maps even in highly demanding cases with tumor-affected motor structures or edema, using lower stimulation intensity compared to sp-nTMS. Significance: Pp-nTMS with biphasic pulses could replace standardly used sp-nTMS for motor mapping and may be safer due to lower stimulation intensity.

Original languageEnglish
Pages (from-to)2887-2898
Number of pages12
JournalClinical Neurophysiology
Issue number12
StatePublished - Dec 2020
Externally publishedYes


  • Brain tumor
  • Corticospinal excitability
  • Motor cortex
  • Navigated transcranial magnetic stimulation
  • Paired-pulse stimulation


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