The impact of nTMS mapping on treatment of brain AVMs
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.
KeywordsBrain AVM Motor and language mapping nTMS Spetzler-Martin grading
brain arteriovenous malformations
direct cortical stimulation
digital subtraction angiography
- DTI FT
diffusion tensor imaging fiber tracking
functional magnetic resonance imaging
motor evoked potential
navigated transcranial magnetic stimulation
resting motor threshold
somatosensory evoked potential
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.
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 was obtained from all patients included in the study.
- 8.Giussani C, Roux FE, Ojemann J, Sganzerla EP, Pirillo D, Papagno C (2010) Is preoperative functional magnetic resonance imaging reliable for language areas mapping in brain tumor surgery? Review of language functional magnetic resonance imaging and direct cortical stimulation correlation studies. Neurosurgery 66:113–120CrossRefPubMedGoogle Scholar
- 10.Ille S, Sollmann N, Hauck T, Maurer S, Tanigawa N, Obermueller T, Negwer C, Droese D, Boeckh-Behrens T, Meyer B, Ringel F, Krieg SM (2015) Impairment of preoperative language mapping by lesion location: a functional magnetic resonance imaging, navigated transcranial magnetic stimulation, and direct cortical stimulation study. J Neurosurg 123:314–324CrossRefPubMedGoogle Scholar
- 13.Krieg SM, Lioumis P, Makela JP, Wilenius J, Karhu J, Hannula H, Savolainen P, Lucas CW, Seidel K, Laakso A, Islam M, Vaalto S, Lehtinen H, Vitikainen AM, Tarapore PE, Picht T (2017) Protocol for motor and language mapping by navigated TMS in patients and healthy volunteers; workshop report. Acta Neurochir 159:1187–1195CrossRefPubMedGoogle Scholar
- 15.Krieg SM, Tarapore PE, Picht T, Tanigawa N, Houde J, Sollmann N, Meyer B, Vajkoczy P, Berger MS, Ringel F, Nagarajan S (2014) Optimal timing of pulse onset for language mapping with navigated repetitive transcranial magnetic stimulation. NeuroimageGoogle Scholar
- 20.Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ, International Ai (2014) Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 383:614–621CrossRefPubMedGoogle Scholar
- 21.Ogilvy CS, Stieg PE, Awad I, Brown RD Jr, Kondziolka D, Rosenwasser R, Young WL, Hademenos G, Stroke Council ASA (2001) Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the stroke council, American Stroke Association. Circulation 103:2644–2657CrossRefPubMedGoogle Scholar
- 22.Picht T, Krieg SM, Sollmann N, Rosler J, Niraula B, Neuvonen T, Savolainen P, Lioumis P, Makela JP, Deletis V, Meyer B, Vajkoczy P, Ringel F (2013) A comparison of language mapping by preoperative navigated transcranial magnetic stimulation and direct cortical stimulation during awake surgery. Neurosurgery 72:808–819CrossRefPubMedGoogle Scholar
- 24.Rossini PM, Burke D, Chen R, Cohen LG, Daskalakis Z, Di Iorio R, Di Lazzaro V, Ferreri F, Fitzgerald PB, George MS, Hallett M, Lefaucheur JP, Langguth B, Matsumoto H, Miniussi C, Nitsche MA, Pascual-Leone A, Paulus W, Rossi S, Rothwell JC, Siebner HR, Ugawa Y, Walsh V, Ziemann U (2015) Non-invasive electrical and magnetic stimulation of the brain, spinal cord, roots and peripheral nerves: basic principles and procedures for routine clinical and research application. An updated report from an I.F.C.N. Committee. Clin Neurophysiol 126:1071–1107CrossRefPubMedGoogle Scholar
- 28.Sollmann N, Ille S, Hauck T, Maurer S, Negwer C, Zimmer C, Ringel F, Meyer B, Krieg SM (2015) The impact of preoperative language mapping by repetitive navigated transcranial magnetic stimulation on the clinical course of brain tumor patients. BMC Cancer 15:261CrossRefPubMedPubMedCentralGoogle Scholar
- 29.Sollmann N, Kubitscheck A, Maurer S, Ille S, Hauck T, Kirschke JS, Ringel F, Meyer B, Krieg SM (2016) Preoperative language mapping by repetitive navigated transcranial magnetic stimulation and diffusion tensor imaging fiber tracking and their comparison to intraoperative stimulation. Neuroradiology 58:807–818CrossRefPubMedGoogle Scholar
- 37.Tarapore PE, Tate MC, Findlay AM, Honma SM, Mizuiri D, Berger MS, Nagarajan SS (2012) Preoperative multimodal motor mapping: a comparison of magnetoencephalography imaging, navigated transcranial magnetic stimulation, and direct cortical stimulation. J Neurosurg 117:354–362CrossRefPubMedPubMedCentralGoogle Scholar