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Brain Topogr. 2018 Nov;31(6):963-971. doi: 10.1007/s10548-018-0660-9. Epub 2018 Jul 3.

Efficient Mapping of the Motor Cortex with Navigated Biphasic Paired-Pulse Transcranial Magnetic Stimulation.

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Department of Clinical Neurophysiology, Kuopio University Hospital, P. O. Box 100, 70029 KYS, Kuopio, Finland.
Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland.
Department of Clinical Neurophysiology, Kuopio University Hospital, P. O. Box 100, 70029 KYS, Kuopio, Finland.
Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland.
Brain Stimulation Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, USA.
Nexstim Plc, Helsinki, Finland.
Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.


Navigated transcranial magnetic stimulation (nTMS) can be applied to locate cortical muscle representations. Usually, single TMS pulses are targeted to the motor cortex with the help of neuronavigation and by measuring motor evoked potential (MEP) amplitudes from the peripheral muscles. The efficacy of single-pulse TMS to induce MEPs has been shown to increase by applying facilitatory paired-pulse TMS (ppTMS). Therefore, the aim was to study whether the facilitatory ppTMS could enable more efficient motor mapping. Biphasic single-pulse TMS and ppTMS with inter-stimulus intervals (ISIs) of 1.4 and 2.8 ms were applied to measure resting motor thresholds (rMTs) as a percentage of the maximal stimulator output and to determine the cortical representation areas of the right first dorsal interosseous muscle in healthy volunteers. The areas, shapes, hotspots, and center of gravities (CoGs) of the representations were calculated. Biphasic ppTMS with ISI of 1.4 ms resulted in lower rMTs than those obtained with the other protocols (p = 0.001). With ISI of 2.8 ms, rMT was lower than with single-pulse TMS (p = 0.032). The ppTMS mapping was thus performed with lower intensity than when using single-pulse TMS. The areas, shapes, hotspots, and CoGs of the muscle representations were in agreement. Hence, biphasic ppTMS has potential in the mapping of cortical hand representations in healthy individuals as an alternative for single-pulses, but with lower stimulation intensity by utilizing cortical facilitatory mechanism. This could improve application of nTMS in subjects with low motor tract excitability.


Motor cortex; Motor evoked potential; Motor mapping; Navigated transcranial magnetic stimulation; Short-interval intracortical facilitation

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