Despite the good agreement between nTMS and DCS (Fig. 3), we have to be aware that these results strongly rely on many parameters, such as definition of resting motor threshold (rMT), the voltage at which CMAP is considered significant, registration

errors, navigation SKI606 errors of both systems, and brain shift after durotomy [23] and [24]. Therefore, it seems to be unlikely that nTMS is capable to completely replace intraoperative neuromonitoring (IOM). Yet, when the rolandic region is compromised by tumor growth, it is highly valuable to have another modality at hand, which confirms the results of DCS mapping. Compared to fMRI, nTMS is also less affected by the patient’s cooperation or claustrophobia. Further newly evolved possibilities of nTMS are to decide whether or not DCS is mandatory or not and it enhances IOM by guiding the DCS probe, thus accelerating DCS mapping significantly. The adaptation of nTMS motor mapping data for outlining functionally crucial seed regions was simple, and compatibility between the Nexstim eXimia 3.2 and iPlan® Cranial 3.0.1 using iPlan® Net was given by the DICOM standard and remained trouble-free when changing to iPlan® Cranial Unlimited (BrainLAB AG, Feldkirchen,

Germany). Traditional outlining of the primary motor cortex can be quite challenging when tumors affect the rolandic region. Mostly due to mass effects and edema. Such structural alteration NVP-AUY922 datasheet with impairment of the anatomy causes an imprecise outlining of the cortical Arachidonate 15-lipoxygenase seed region with the manual technique. Thus, even tracts from accidently included non-eloquent regions are incorporated and lead to a broader and therefore less specific definition of the CST. Furthermore, tumors within the CST or the precentral

gyrus can cause cerebral plasticity so that functionally important motor areas do not have to coincide anymore with standard anatomical landmarks, which are also regularly hard to identify [17], [25], [26] and [27]. Especially due to this matter, only nTMS data and not anatomical landmarks can reliably identify functionally crucial motor regions prior to surgery. Because our technique, shown in this work, is based on functional and not structural anatomy, it should provide a more accurate white matter fiber reconstruction. Nonetheless, we have to keep in mind that in large volume lesions or largely infiltrating tumors, nTMS might not be able to elicit MEPs in all fibers of the CST due to impairment of these fibers by tumor or edema. Therefore the tract might appear more compact than observed with traditional tractography. In most cases, these missing fibers are located around the tumor in the upper part of the tract in standard tractography, which seem to be missing in the nTMS-designed tracts.