Language mapping with navigated transcranial magnetic stimulation in pediatric and adult patients undergoing epilepsy surgery: Comparison with extraoperative direct cortical stimulation

Henri Lehtinen, Jyrki P Mäkelä, Teemu Mäkelä, Pantelis Lioumis, Liisa Metsähonkala, Laura Hokkanen, Juha Wilenius, Eija Gaily, Henri Lehtinen, Jyrki P Mäkelä, Teemu Mäkelä, Pantelis Lioumis, Liisa Metsähonkala, Laura Hokkanen, Juha Wilenius, Eija Gaily

Abstract

Objective: Navigated transcranial magnetic stimulation (nTMS) is becoming increasingly popular in noninvasive preoperative language mapping, as its results correlate well enough with those obtained by direct cortical stimulation (DCS) during awake surgery in adult patients with tumor. Reports in the context of epilepsy surgery or extraoperative DCS in adults are, however, sparse, and validation of nTMS with DCS in children is lacking. Furthermore, little is known about the risk of inducing epileptic seizures with nTMS in pediatric epilepsy patients. We provide the largest validation study to date in an epilepsy surgery population.

Methods: We compared language mapping with nTMS and extraoperative DCS in 20 epilepsy surgery patients (age range 9-32 years; 14 children and adolescents).

Results: In comparison with DCS, sensitivity of nTMS was 68%, specificity 76%, positive predictive value 27%, and negative predictive value 95%. Age, location of ictal-onset zone near or within DCS-mapped language areas or severity of cognitive deficits had no significant effect on these values. None of our patients had seizures during nTMS.

Significance: Our study suggests that nTMS language mapping is clinically useful and safe in epilepsy surgery patients, including school-aged children and patients with extensive cognitive dysfunction. Similar to in tumor surgery, mapping results in the frontal region are most reliable. False negative findings may be slightly more likely in epilepsy than in tumor surgery patients. Mapping results should always be verified by other methods in individual patients.

Keywords: Direct cortical stimulation; Epilepsy surgery; Language mapping; Navigated transcranial magnetic stimulation; Pediatric.

Figures

Figure 1
Figure 1
Navigated transcranial magnetic stimulation (nTMS) and direct cortical stimulation (DCS) mapping results in the left hemisphere of Patient 3. DCS (large circles, diameter 1 cm) found 2 language sites (pink), 5 motor sites (blue), the frontal eye field (brown), and 1 sensory site for the tongue (green) or no effects (white). nTMS (small dots) elicited anomias (red), hesitations (orange), semantic paraphasias (yellow), 1 phonological paraphasia (blue), or no effects (black). nTMS elicited hesitations in 1 language site (true positive) but not the other (false negative). nTMS in the tongue sensory site produced several errors (false positive). nTMS did not elicit errors in most silent or motor DCS sites (true negatives). There are large areas covered only by DCS (anteriorly) or only by nTMS (especially posteriorly).
Figure 2
Figure 2
Numbers of patients with overlapping sites mapped for language and language‐positive findings by direct cortical stimulation (DCS) and navigated transcranial magnetic stimulation (nTMS) in cortical parcellation system (CPS) parcels. In each parcel, the first digit indicates the number of patients with overlapping sites within the parcel, the second 1 the number of patients with language‐positive DCS findings, and the third 1 the number of patients with language‐positive nTMS findings (figure modified after30).

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Source: PubMed

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