One patient experienced nTMS mapping as unpleasant, whereas no patient actually stated nTMS mapping was painful. Preoperative motor cortex mapping was compared to intraoperative DCS with a navigated DCS electrode. Borders between positive and negative stimulation points of both modalities were then compared on axial slices

by recalibrating screenshots and BrainLAB iPlan® Net Cranial 3.0.1. A difference of 4.5 ± 3.5 mm (range 1.9–9.2 mm) between nTMS and intraoperative DCS has been determined for the borders of the mapped primary motor cortex without observing any systematic monodirectional deviation (Figure 2 and Figure 3). Compared to nTMS data, determination of the primary motor cortex using BOLD data differed strongly between the upper and lower extremities. For the upper extremity, the deviation INK 128 clinical trial of nTMS and fMRI was 9.6 ± 7.9 mm (range 5.3–39.7 mm) (Fig. 3).

For the lower extremity, this difference was 15.0 ± 12.8 mm (range 8.4–33.5 mm) (Figure 2 and Figure 3). Again, no monodirectional systematic deviation could be observed. When using nTMS as the seed region for DTI-FT, we observed significantly this website less fibers within the tracked CST (nTMS: 916.0 ± 986.0 fibers; standard: 1297.9 ± 1278.7 fibers; p < 0.01; Fig. 4), fewer aberrant tracts (nTMS: 0.33 ± 0.47 aberrant tracts/tracked CST; standard: 0.57 ± 0.5 aberrant tracts/tracked CST; p < 0.001; Fig. 5), and less interobserver variability compared to standard tracking. Interobserver variability

was evaluated and visualized by a Bland–Altman plot ( Fig. 6) [14]. In both modalities, we were not able to show any significant differences between the two measurements of each observer for any examined item (data not shown). Today, the only widely used and applicable method for preoperative functional brain mapping is fMRI. But, as repeatedly shown, fMRI is insufficient for reliable delineation of functional motor areas [6] and [15]. We moreover confirmed the discrepancy between metabolic and electrophysiological (i.e., true functional) mapping (Fig. 3). Especially in cases when tumors with pathologic vasculature compromise the central region, mapping of the primary motor cortex by metabolic measures was demonstrated to be an unreliable method [15], only [16], [17] and [18]. Moreover, metabolically activated brain parenchyma does not have to be essential for motor function. Another disadvantage of fMRI is its frequent affection by the patient’s cooperation or claustrophobia as confirmed in our work. Taking standard deviation into account, spatial deviation of DCS and nTMS ranges within the calculated accuracy of the used nTMS system (eXimia 3.2, Nexstim, Helsinki, Finland), which is 5.73 mm [19]. Such precision was already reported in previous reports on nTMS accuracy stating that a spatial resolution of 5 mm is obtainable [20] and [21].