Operative Neurosurgery 29:62–70, 2025
Navigated transcranial magnetic stimulation (nTMS) and DTI tractography enable precise preoperative risk stratification in insular glioma surgery, identifying patients at higher risk for postoperative motor deficits by assessing resting motor threshold, tumor proximity to the corticospinal tract, and fiber tract integrity, thus improving surgical planning and outcomes.
• Navigated transcranial magnetic stimulation (nTMS) and nTMS-based DTI tractography were evaluated for preoperative risk stratification in insular glioma surgery.
• Thirty-two patients with insular gliomas underwent preoperative nTMS mapping and DTI tractography to assess motor cortex and corticospinal tract (CST) involvement.
• Higher resting motor threshold (RMT) ratios, CST-tumor distances <3 mm, and decreased peritumoral fractional anisotropy (pFA) ratios were significantly associated with new postoperative motor deficits.
• All patients with new postoperative motor deficits had a CST-tumor distance below 3 mm; lower pFA ratios also correlated with deficits.
• One-third of patients with intraoperative ischemic events developed permanent motor deficits, suggesting additional mediating factors such as CST integrity and cortical excitability.
• A risk model combining RMT ratio, CST distance <3 mm, and low pFA ratio predicted an 82% risk for new motor deficits.
• Preoperative nTMS-based DTI tractography may improve individual risk stratification and surgical planning for insular glioma patients.
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