Acta Neurochirurgica

, Volume 160, Issue 3, pp 567–578 | Cite as

The impact of nTMS mapping on treatment of brain AVMs

  • Sebastian Ille
  • Thomas Picht
  • Ehab Shiban
  • Bernhard Meyer
  • Peter Vajkoczy
  • Sandro M. Krieg
Original Article - Vascular



The treatment of brain arteriovenous malformations (BAVMs) is still contrarily discussed. Despite the debatable results of the ARUBA trial, most BAVMs still require treatment depending on the Spetzler-Martin (SM) grading. Since size is measurable and venous drainage is visible, the determination of eloquence is comparably crucial but not fully objective. The present bicentric cohort study aims to examine the influence of preoperative navigated transcranial magnetic stimulation (nTMS) motor and language mapping data on decision-making for or against surgical treatment of BAVMs.


The influence of data from nTMS on decision-making for or against treatment of BAVMs was examined by confirming/falsifying presumed motor or language eloquence.


The results of nTMS mappings changed the SM grading in nine cases. In six cases, the SM grading changed to a lower grade (= falsified eloquence); in three cases, the SM grading changed to a higher grade due to nTMS mappings (= unexpected eloquence). Out of all 34 cases, indication for surgery was supported by nTMS mappings in 15 cases (7 motors, 8 languages). In six cases, the decision against surgery was made based on nTMS mappings (three motors, three languages).


In 21 of 34 cases (62%), nTMS was a supportive argument. We could show that nTMS motor and language data can be used for a more objective decision-making regarding the treatment of BAVMs and for a more detailed SM grading regarding the rating of eloquence.


Brain AVM Motor and language mapping nTMS Spetzler-Martin grading 





brain arteriovenous malformations


direct cortical stimulation


digital subtraction angiography


diffusion tensor imaging fiber tracking


display time


functional magnetic resonance imaging


intraoperative neuromonitoring


interpicture interval




motor evoked potential


navigated transcranial magnetic stimulation


picture-to-trigger interval


resting motor threshold


repetitive nTMS




stereotactic radiosurgery


somatosensory evoked potential


repetition time


echo time


Funding information

The study was financed by institutional grants from the Departments of Neurosurgery and the Sections of Neuroradiology of the Klinikum rechts der Isar, Technische Universität München, Munich, and Charité-Universitätsmedizin Berlin.

Compliance with ethical standards

Conflict of interest

TP, BM, PV, and SK are consultants for Brainlab AG (Munich, Germany). TP and SK are consultants for Nexstim Plc (Helsinki, Finland). All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in the study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all patients included in the study.


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Sebastian Ille
    • 1
    • 2
  • Thomas Picht
    • 3
  • Ehab Shiban
    • 1
  • Bernhard Meyer
    • 1
  • Peter Vajkoczy
    • 3
  • Sandro M. Krieg
    • 1
    • 2
  1. 1.Department of Neurosurgery, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
  2. 2.TUM-Neuroimaging Center, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
  3. 3.Department of NeurosurgeryCharité-Universitätsmedizin BerlinBerlinGermany

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