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Background Patient-reported experience measures (PREMs) are a unique measure of experience of patients which can help address the quality of care of the patients.Objective Our aim of the study is to collect quality of care outcomes with our newly navigated transcranial magnetic stimulation patient-reported experience measure (nTMS-PREMs) questionnaire among neurosurgical patients undergoing nTMS.MethodsA single-centre prospective nTMS-PREMs 19-item questionnaire study was performed between February 2018 and December 2018 on patient referred for nTMS at our hospital. The Data was analysed using Likert scale, linear and logistic regression using statistical software (STATA 13.0®).ResultsFifty patient questionnaires were collected (30 males, 20 females, mean age of 47.6 ± 2.1 years) among which 74% of patients underwent both motor and language mapping with a mean duration of 103.3 ± 5.1 min. An overall positive response was noted from the results of the questionnaire, tiredness and anxiety being the common effects noted. Patients with the left-sided disease appreciated more the conditions provided in our laboratory (Q4, p = 0.040) and increasing age was related to less confidence and trust (Q6, p = 0.038) in the staff performing the exam. Younger patients tolerated nTMS better than older patients (> 65 years). PubMed literature search resulted in no relevant articles on the use of PREMs in nTMS patients.ConclusionnTMS is a well-tolerated non-invasive tool and nTMS-PREMS provides a promising role in identifying the unmet needs of the patients and improving the quality of their care.
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Patient-reported experience measures in patients undergoing
navigated transcranial magnetic stimulation (nTMS):
the introduction of nTMS-PREMs
Sabina Patel
&Prajwal Ghimire
&José Pedro Lavrador
&Josephine Jung
&Richard Gullan
&Keyoumars Ashkan
Ranjeev Bhangoo
&Francesco Vergani
Received: 31 October 2019 / Accepted: 17 February 2020
#The Author(s) 2020
Background Patient-reported experience measures (PREMs) are a unique measure of experience of patients which can help
address the quality of care of the patients.
Objective Our aim of the study is to collect quality of care outcomes with our newly navigated transcranial magnetic stimulation
patient-reported experience measure (nTMS-PREMs) questionnaire among neurosurgical patients undergoing nTMS.
Methods A single-centre prospective nTMS-PREMs 19-item questionnaire study was performed between February 2018 and
December 2018 on patient referred for nTMS at our hospital. The Data was analysed using Likert scale, linear and logistic
regression using statistical software (STATA 13.0®).
Results Fifty patient questionnaires were collected (30 males, 20 females, mean age of 47.6 ± 2.1 years) among which 74% of
patients underwent both motor and language mapping with a mean duration of 103.3 ± 5.1 min. An overall positive response was
noted from the results of the questionnaire, tiredness and anxiety being the common effects noted. Patients with the left-sided
disease appreciated more the conditions provided in our laboratory (Q4, p= 0.040) and increasing age was related to less
confidence and trust (Q6, p= 0.038) in the staff performing the exam. Younger patients tolerated nTMS better than older patients
(> 65 years). PubMed literature search resulted in no relevant articles on the use of PREMs in nTMS patients.
Conclusion nTMS is a well-tolerated non-invasive tool and nTMS-PREMS provides a promising role in identifying the unmet
needs of the patients and improving the quality of their care.
Keywords PREMs .nTMS .Unmet needs .Quality of care
Navigated transcranial magnetic stimulation (nTMS) has be-
come in recent years a commonly used tool in the pre-
operative planning for neurosurgical patients [8]. nTMS is
now being widely used as an important pre-operative tool
for motor and speech mapping in eloquent glioma surgery
(awake/asleep), brain metastasis, cavernoma, and vascular
malformations [5,7,14,15,17,20,23,25] and is a useful
adjunct to impact the surgical indications, guide the surgical
approach, and estimate and reduce the risk of inducing post-
surgical deficits [26,27]. It has further been highlighted in
recent studies that the preoperative nTMS motor mapping/
speech mapping provides improved outcome in patients with
glioblastoma [24] and is also useful in language-eloquent tu-
mour surgery in awake-ineligible patients [25]. While a safe
and non-invasive way to map the cerebral cortex, nTMS can
Sabina Patel, Prajwal Ghimire and José Pedro Lavrador contributed
equally to this work.
This article is part of the Topical Collection on Neurosurgery general
A portion of this paper was presented as a poster in the Society of British
Neurosurgeons (SBNS) Spring Meeting 2019 held in Manchester, UK,
on 1922 March 2019 and a poster in EANS Congress 2019, held in
Dublin, Ireland on 2428 September 2019.
Electronic supplementary material The online version of this article
( contains supplementary
material, which is available to authorized users.
*Prajwal Ghimire
Department of Neurosurgery, Kings College Hospital Foundation
Trust, London, UK
/ Published o nline: 25 February 202 0
Acta Neurochirurgica (2020) 162:16731681
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be associated with anxiety or unpleasant experience [14]or
discomfort [28] and can be time-consuming, with motor map-
ping requiring up to 90 min and language mapping requiring
up to 120 min [8]. To date, little is known about the overall
patientsexperience during nTMS, with particular regard to
how well the procedure is tolerated and what additional infor-
mation it gives to patients in their overall healthcare experi-
ence. This is of particular relevance, since patientscollabora-
tion and understanding of nTMS are crucial for the success of
the examination.
Patient-reported experience measures (PREMs) are in-
creasingly used to assess the effectiveness of clinical care on
a particular patient population (for example, Picker Patient
Experience Questionnaire (PPE-15), Patient Experience
Questionnaire (PEQ), Scottish Inpatient Patient Experience
Survey (SIPES), Norwegian Patient Experience
Questionnaire (NORPEQ), In-Patient Experiences of Health
Care (I-PAHC)) [14,11]. In neurosurgery, studies to evaluate
patientsexperience and satisfaction have been performed, for
example, in patients undergoing awake craniotomy [10,18,
30]. However, no specific PREMs have been reported for the
use of nTMS. In the present paper, we aim to document the
first patient-reported experience measure for nTMS in neuro-
surgery (nTMS-PREMs).
Material and methods
A prospective study was carried out between January and
December 2018 at our hospital. All patients (age 18 years
old) who were referred for TMS at our Institution were in-
volved. Patients were referred for TMS after multidisciplinary
team (MDT) discussions when a lesion in a presumed elo-
quent brain was identified. All patients were instructed about
TMS in person at the time of the first outpatient meeting in the
neuro-oncology clinic and again on the day of the exam. In
addition, patients and their families were supplied with a
booklet explaining the details of the exam. TMS was per-
formed as an outpatient procedure. A T1 post-contrast MRI
for navigation purposes was acquired before or on the day of
the exam. Patients who had the MRI on the same day of TMS
had only a T1 post-gadolinium MRI sequence for navigation
proceeding to TMS. All patients underwent either motor map-
ping alone or a combination of motor and language mapping.
In the latter case, motor and language mapping were per-
formed on the same day as a continuous exam. Motor map-
ping was performed with single pulse stimulation at 105% of
the resting motor threshold (RMT) while language mapping
was performed with repetitive stimulation at 100% of the
RMT. Two authors (S.P. and J.P.L.) performed all the map-
pings. After the mapping, the results were explained and
discussed with patients, with particular regard to the
relationship between positive responses and tumour location.
Details of the nTMS protocol at our institution have been
previously reported [8].
After the exam, all patients were invited to anonymously
fill an ad hoc nTMS-PREMs questionnaire (Supplementary
Material 1). The questionnaire was designed with reference
to the Royal College of Surgeons (RCS) of England survey/
audit indications with domains covering quality of the infor-
mation provided, facilities of the laboratory, the
test/examination, staff evaluation, and discharge information
[19]. The questionnaire evaluated the following domains of
the TMS experience: background (the quality of the informa-
tion provided before the exam, 3 questions); laboratory (the
facilities of the TMS laboratory, 2 questions); staff (evaluating
the examiners performing the procedure, 3 questions); exam
(the experience during the exam itself, 5 questions); discharge
information (the quality and accuracy of the information pro-
vided at discharge, 4 questions); and the overall rating of the
nTMS experience (2 questions). One question within the ex-
amsection was aimed only at patients who had language
mapping alongside the motor mapping. Each question was
rated as a scale from 1 (very poor experience) to 5 (excellent
experience). Each question was addressed individually as well
as part of the 6 domains where the combined score (combined
results of all questions within that domain) was determined. In
order to provide a better global evaluation of each question
and domain, the responses were also combined as follows:
poor, ratings 1 and 2; neutral, rating 3; and good, ratings 4
and 5.
The following variables were analysed against each ques-
tion and domain: age, gender, duration of the exam, and type
of mapping (motor versus motor and language). The laterality
of the disease, location of the disease, and RMT ratio (RMT
disease side/RMT healthy side)pathological (90% < RMT
< 110%) versus non-pathological (all other values)were
assessed against each question in the examdomain. Linear
regression was used for age and duration of the exam. Logistic
regression was used for gender, laterality of the disease, RMT
ratio, and type of mapping. Multinomial logistic regression
was used for location. The combined score analysis was per-
formed using ordered logistic regression analysis. A multivar-
iate analysis was performed for the 6 domains. An adjustment
for age, gender, duration, and type of monitoring was used for
every domain and laterality and RMT ratio for the exam
domain. A subgroup analysis for the older population was
performed. pvalues < 0.05 were considered significant for
all the performed analysis. Statistical software (STATA
13.0®) was used for all the performed analysis. All the anal-
yses were performed after the study was completed.
In addition, a literature search was performed in PubMed to
look for previous papers reporting PREMS related to TMS.
We used MeSH terms related to nTMS and PREMS. There
were no articles in the search that was dedicated to specific
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experience measures in nTMS. The study was registered in the
local audit registry as a service improvement project approved
by the Neurosurgical Department. Informed consent was tak-
en with all the patients in the study for nTMS mapping. The
pre-operative mapping was applied following the standard
nTMS mapping protocol published previously [8].
Patients were referred from both the neuro-oncology and
neurovascular services with a total of 50 questionnaires com-
pleted (30 males, 20 females, mean age of 47.6± 2.1 years)
2 patients did not return the questionnaires. The vast majority
had an underlying brain tumour46 (92.0%). The preferen-
tial location was on the left side (29 patients, 60.4%) with the
frontal (22 cases, 48.9%) and temporal (13 cases, 28.9%)
lobes being more commonly affected. Twenty-one patients
(46.67%) had a pathological RMT ratio (mean RMT ratio,
1.0 ± 0.02). Seventy-four percent of patients underwent both
motor and language mapping with a mean duration of 103.3 ±
5.1 min (motor only, 85.8 ± 6.1 min; motor and speech, 106.9
± 5.9 min; p=0.02,ttest) (Table 1).
A breakdown of responses to the questionnaire is reported
in Table 2. In general, patients reported a positive experience
with nTMS, with 94% positive responses for the overall
nTMS experience. Seven hundred ninety-two (85%) of the
responses provided about our service were rated as good,
and 648 (69%) rated with the maximum score. Taking into
account the individual domains of the questionnaire, 89% of
patients reported a positive score for the backgrounddo-
main, with a good understanding of TMS and availability of
information prior to TMS taking place with only 7% rating
this section poorly. The combined score for the laboratory
domain was good in 85% of responses with 75% reporting no
technical problems during the exam. The staffsection had
the highest positive rating, with 95% good responses, indicat-
ing confidence in the staff performing the investigation (95%),
presence of knowledge (92%), and support from staff (96%).
The examdomain had the lowest positive rating (70% as
good) with a poor experience due to anxiety and pain reported
by 26% and 24% of patients, respectively. In addition, 16% of
patients reported tiredness during/after the exam and difficul-
ties in concentration. Reassuringly, 94% of patients felt the
exam duration met their expectations and was acceptable.
The quality of the discharge informationprovided was well
rated by the patients (84% rated as good) with 88% of patients
feeling they had a better understanding of the relationship
between their lesion and the eloquent areas of the brain and
70% of patients clearly understood the importance of nTMS in
the context of the surgical treatment they were about to
The significant results from the univariate statistical analy-
sis are reported in Table 3(the complete table of results is
provided in Supplementary Table 2). An increased duration
of the exam was related to increased pain felt during the exam
(Q13, p= 0.004) and a poorer understanding of the signifi-
cance of the results for the surgical treatment (Q14, p=
0.031). Increasing age was related to less confidence and trust
(Q6, p= 0.038) and less ability to recognize knowledge and
experience (Q7, p= 0.003) in the staff performing the exam
(Table 3).
The univariate analysis was also repeated against each do-
main of the questionnaire. This revealed that longer exams
were related to a poorer rate of the laboratory conditions
(p= 0.017). Increasing age was related to a poorer rate of staff
performance (p= 0.001). Concerning the exam, the patients
who had only motor mapping had a better experience than
the ones who had both motor and language mapping (p=
0.020). Patients who had frontal lesions and longer mapping
reported worse experiences (p= 0.028 and p= 0.003). The
quality of the information provided at discharge was better
in patients who had motor mapping only (p=0.001) and
Table 1 Demographic characteristics of the study population
nTMS (n=50)
Age 47.6 ± 2.1
Male 30 (60.0%)
Female 20 (40.0%)
Oncology 46 (92.0%)
Vascular 4 (8.0%)
Type of mapping
Motor only 13 (26.0%)
Speech and motor 37 (74.0%)
Right 19(39.6%)
Left 29 (60.4%)
Location (lobe)
Insula 3 (6.7%)
Frontal 22 (48.9%)
Parietal 7 (15.6%)
Temporal 13 (28.9%)
Ipsilateral to the disease (%) 41.1 ± 1.7
Contralateral to the disease (%) 40.5 ± 1.5
RMT ratio 1.0 ± 0.02
Pathological RMT (patients) 21 (46.64%)
Duration (min) 103.3 ± 5.1
Motor only 85.8 ± 6.1
Speech and motor 106.9 ± 5.9
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Table 2 Results of the nTMS-PREMs questionnaire
Rating Classification Overall
Questions 1 2 3 4 5 NA Poor Neutral Good Poor Neutral Good
Intro 1. How much information has been given
to you about TMS?
2 (4%) 1 (2%) 2 (4%) 11 (22%) 34 (68%) 3 (6%) 2 (4%) 45 (90%) 11 (7%) 5 (3%) 133 (89%)
2. How much understanding you had
about the importance and role of TMS in
the treatment of your disease?
1 (2%) 3 (6%) 2 (4%) 10 (20%) 34 (68%) 4 (8%) 2 (4%) 44 (88%)
3. Have you been given enough time and
2 (4%) 2 (4%) 1 (2%) 6 (12%) 38 (76%) 1 (2%) 4 (8%) 1 (2%) 44 (88%)
Lab 4. Was the laboratory quiet so you could
concentrate and collaborate during
the exam?
1(2%) 2 (4%) 7 (14%) 40 (80%) 1 (2%) 2 (4%) 47 (94%) 7 (7%) 6 (6%) 85 (85%)
5. Was there any technical problem
during the course of the exam?
5 (10%) 1 (2%) 4 (8%) 12 (24%) 26 (52%) 2 (4%) 6 (12%) 4 (8%) 38 (76%)
Staff 6. Did you have confidence and trust
in the staff performing the exam?
1(2%) ––4 (8%) 45 (90%) 1(2%) 49 (98%) 6 (4%) 1 (0.6%) 143 (95%)
7. Did you recognize knowledge and
experience about your condition in the
members of the staff?
2 (4%) 1 (2%) 1 (2%) 5 (10%) 41 (82%) 3 /6%) 1 (2%) 46 (92%)
8. Did the members of staff provide you
support during the exam?
2(4%) ––4 (8%) 44 (88%) 2(4%) 48 (96%)
Exam 9. Do you think the exam duration was in
line with your expectations and acceptable?
1(2%) 2 (4%) 7 (14%) 40 (80%) 1 (2%) 2 (4%) 47 (94%) 40 (17%) 30 (13%) 165 (70%)
10. Did you feel tired during the exam?
(1 very tired, 5 not tired at all)
3 (6%) 5 (10%) 8 (16%) 15 (30%) 18 (36%) 1 (2%) 8 (16%) 8 (16%) 33 (66%)
11. Were you able to concentrate during the
exam? (Speech mapping only)
4 (11%) 2 (5%) 6 (16%) 8 (22%) 17 (46%) 6 (16%) 6 (16%) 25 (68%)
12. Were you anxious during the exam?
(1 very anxious, 5 not anxious at all)
12 (24%) 1 (2%) 6 (12%) 4 (8%) 26 (52%) 1 (2%) 13 (26%) 6 (12%) 30 (60%)
13. Did you feel pain during
the exam? (1 very painful,
5 not painful at all)
6 (12%) 6 (12%) 8 (16%) 8 (16%) 22 (44%) 12 (24%) 8 (16%) 30 (60%)
Discharge 14. Were the explanations of the results
important for your understanding
of the operation?
2 (4%) 1 (2%) 4 (8%) 8 (16%) 32 (64%) 3 (6%) 3 (6%) 4 (8%) 35 (70%) 11 (6%) 9 (4%) 167 (84%)
15. Did TMS help you to
understand the relationship
between the lesion and the
brain areas that control function?
3(6%) 2 (4%) 9 (18%) 35 (70%) 1 (2%) 3 (6%) 2 (4%) 44 (88%)
16. Have your concerns been
supported and answered by
the team staff?
2(4%) 1 (2%) 7 (14%) 38 (76%) 2 (4%) 2 (4%) 1 (2%) 45 (90%)
17. Has the post-exam instructions / follow-up
plan been explained to you satisfactorily
at the end of the exam?
3(6%) 2 (4%) 10 (20%) 33 (66%) 2 (4%) 3 (6%) 2 (4%) 43 (86%)
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worse in patients who had longer mappings (p=0.002).None
of the studied variables seemed to influence the way patients
rated their overall experience of nTMS (all p> 0.05) (Table 4).
The multivariate analysis confirmed age (p= 0.01) and du-
ration of the exam (p= 0.05) as two major factors influencing
the rating of the TMS exam. Increasing age was related to a
poorer rating in almost all domains with exception of the
laboratory conditions and increased duration of the exam
was related to the poor rating of laboratory conditions (p=
0.03) and worse discharge information (p=0.003) (Table 5
and Supplemental Table 3)
PREMs play an important role in evaluating the experience of
patients to an intervention that leads to the evaluation of pa-
tientssatisfaction and is useful for research, quality improve-
ment projects, clinician performance evaluation, audit, and
economic evaluation [1,11]. In recent years, generic- and
intervention-specific PREMs have been developed and used
in different areas of clinical medicine and surgical practice,
stressing the relevance of patient satisfaction to a patient-
centred approach in modern medicine [1,3,4,11]. Well-
established surgical PREMs have already been developed
for specific surgical interventions, like hernia repair or hip
replacement and these have been approved for use in the UK
and worldwide [2]. In neurosurgery, intervention-specific
PREMs will act as an important indicator of the quality of
care of neurosurgical patients and enhance research, quality
governance, and economic evaluation/cost-effectiveness of
the overall treatment/surgical decision-making and execution.
Over the last decade, nTMS has been used by neurosur-
geons to map functional areas of the brain for surgical plan-
ning in neuro-oncology [5,22], AVM resection [7,9,16], and
epilepsy [13]. A successful nTMS depends largely on patient
cooperation, with a long duration of the exam and fatigue or
discomfort potentially affecting the results of the mapping.
PREMs specifically designed to assess the nTMS experience
can give a valuable insight into patient counselling, experi-
ence during the procedure, side effects, duration of the test,
and how the results of the mapping are understood and per-
ceived by patients. The information provided can in turn be
used as a feedback for the nTMS team to allow self-
assessment and service improvement. Our literature search
through PubMed showed that there are currently no PREMs
specifically designed for TMS. Previous papers looked at pa-
tient experience during repetitive TMS for therapeutic appli-
cation [12]. Singh et al. [28] looked at experience and attitudes
in patients undergoing repetitive TMS for psychiatric condi-
tions in North India over a 3-month period. They noted an
overall positive experience in the context of repetitive TMS
for treatment of depression, with a majority agreeing they
Tab l e 2 (continued)
Rating Classification Overall
Questions 1 2 3 4 5 NA Poor Neutral Good Poor Neutral Good
End 18. Do you think after completing this
exam that TMS is an important
part of your treatment plan?
1(2%) 1 (2%) 5 (10%) 42 (84%) 1 (2%) 1 (2%) 1 (2%) 47 (94%) 3 (3%) 2 (2%) 94 (94%)
19. How would you rate your overall
TMS experience? Would you have
TMS mapping again?
2(4%) 1 (2%) 4 (8%) 43 (86%) 2 (4%) 1 (2%) 47 (94%)
Total 55 (7%) 23 (2%) 53 (6%) 144 (15%) 648 (69%) 14 (1%) 78 (9%) 53 (6%) 792 (85%)
13 patients were excludedmotor
mapping only
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would recommend TMS to others. A similar result was report-
ed by an earlier study carried out in Tasmania in 2001, again in
the context of rTMS for depression [6]. In neurosurgery, re-
cent studies [14,23,28,29] focused on the occurrence of pain,
discomfort, and seizures during pre-surgical brain mapping.
The authors concluded that nTMS is safe and generally well
tolerated. Despite giving useful information on the safety and
tolerability of nTMS, this study did not report PREMs ad-
dressing the whole patient experience.
In the present paper, we report the first specific nTMS-
PREMs. To this effect, we designed a patient questionnaire
following the indications of the Royal College of Surgeon in
auditing patient experience and satisfaction and the published
literature review on commonly developed PREMs [1,19]. As
a result, six domains were identified and evaluated: back-
ground information, laboratory, staff, exam experience, dis-
charge information, and overall rating of the nTMS experi-
ence. Our results show that nTMS is largely well-tolerated
and patients have an overall good experience with nTMS at
different time points of the mapping. In all domains, there was
a majority of positive responses, with 94% of positive re-
sponses for the overall nTMS assessment. However, approx-
imately one in four patients reported the occurrence of anxiety
and pain during the exam. Both univariate analysis and mul-
tivariate analysis confirmed the age and duration of exam as
two major factors that influence patientsexperience during
the TMS procedure. The univariate analysis clarified that lon-
ger durationof mapping and language mapping are related to a
poorer experience. The poorer experience with language map-
ping can be explained on the basis of the longer duration of the
test and on the discomfort/pain induced by repetitive stimula-
tion involving the temporalis muscle [2729]. Similarly, an
increased duration of the exam was related to a poorer under-
standing of the discharge information, with particular regard
to the role of TMS in planning the surgical treatment. We
speculate that this is due to the difficulty of patients to
maintain attention and retain information due to fatigue after
a long mapping session. Elderly patients tended to give a
poorer assessment of the staff performing nTMS. This result
may be explained on the basis that only very few negative
responses were reported concerning the staff (with a possible
influence on the statistical result). However, we acknowledge
that nTMS was performed by relatively junior members with-
in the neuro-oncology team and therefore, we cannot exclude
that a perceived generational gapbetween patients and
healthcare professionals may have played a role [21,31].
The information gathered from the PREMs recorded in this
study can be used to improve clinical practice. The poor ex-
perience reported with long duration of mapping can be mit-
igated by ensuring patients can take appropriate rest. It has
now become customary at our institution to offer patients a
break in between motor and language mapping, so that they
can be more relaxed and focused during the language testing.
In addition, on top of providing patients with a booklet con-
taining all the information about nTMS before the testing, we
make sure to spend enough time to explain the results of
mapping, showing patients their nTMS-generated maps.
After nTMS, the majority of patients reported a good under-
standing of the relationship between the tumour and function-
al areas of the brain. This is relevant, as nTMS results can be
used for better patient counselling at the time of consenting for
an operation. It is now a routine at our institution to include
nTMS-generated maps, when available, as part of the infor-
mation presented to patients and relatives when describing the
challenges and risks of a specific neurosurgical intervention in
This is a single-centre pilot study in a limited number of pa-
tients. Further multicentric, international studies are warranted
Table 3 Summary of the positive findings in the univariate analysis for nTMS-PREMs questionnaire
Coef. 95% confidence interval pvalue
Q4. Was the laboratory quiet so you could concentrate and collaborate during the exam?
Laterality (left side) 1.400 [0.0642.737] 0.040
Q6. Did you have confidence and trust in the staff performing the exam?
Age 7.055 [13.708 to 0.408] 0.038
Q7. Did you recognize knowledge and experience about your condition in the members of the staff?
Age 6.313 [10.411 to 2.214] 0.003
Q13. Did you feel pain during the exam? (1 very painful, 5 not painful at all)
Duration 9.501 [15.793 to 3.209] 0.004
Q14. Were the explanations of the results important for your understanding of the operation?
Duration 9.023 [17.189 to 0.857] 0.031
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to further validate our questionnaire and confirm the
generalisability of our results across different countries and
patient populations. Our pilot, single-centre experience will
serve as the necessary basis for such studies.
nTMS is an overall well-tolerated procedure, with positive
feedback reported by the vast majority of patients. Poorer
experience has been identified in elderly patients and in pa-
tients undergoing long mapping, with particular regard to pain
Table 4 Univariate analysis for the 6 domains of the nTMS-PREMs
Coef. 95% Confidence Interval pvalue
Age 0.015 [0.0370.014] 0.378
Gender 0.324 [1.0420.394] 0.377
Laterality 0.424 [0.2881.135] 0.244
Frontal 0.589 [0.0701.108] 0.026
Parietal 0.611 [0.0481.271] 0.069
Temporal 0.438 [0.0910.966] 0.104
RMT ratio 0.240 [0.4790.960] 0.512
Duration 0.011 [0.0240.003] 0.121
Type of mapping 0.901 [0.00031.802] 0.050
Age 0.003 [0.0270.032] 0.866
Gender 0.832 [1.7300.066] 0.069
Laterality 1.308 [0.4282.188] 0.004
Frontal 0.074 [0.6000.748] 0.830
Parietal 0.459 [0.4721.390] 0.334
Temporal 0.190 [0.5370.916] 0.609
RMT ratio 0.045 [0.9000.810] 0.917
Duration 0.019 [0.035 to 0.003] 0.017
Type of mapping 0.390 [1.3040.524] 0.402
Age 0.076 [.122 to 0.030] 0.001
Gender 0.806 [1.8750.262] 0.139
Laterality 0.074 [0.8891.037] 0.880
Frontal 13.414 [1510.3281483.499] 0.986
Parietal 13.303 [1510.2181483.61] 0.986
Temporal 13.037 [1509.951483.877] 0.986
RMT ratio 0.351 [0.6121.315] 0.475
Duration 0.012 [0.0280.004] 0.155
Type of mapping 1.259 [0.2512.768] 0.102
Age 0.008 [0.0250.009] 0.331
Gender 0.428 [0.9290.073] 0.094
Laterality 0.166 [0.3330.665] 0.513
Frontal 1.375 [2.602 to 0.147] 0.028
Parietal 0.985 [2.2110.295] 0.134
Temporal 1.162 [2.3950.070] 0.065
RMT ratio 0.027 [0.5300.476] 0.916
Duration 0.014 [0.023 to 0.005] 0.003
Type of mapping 0.748 [0.1181.378] 0.020
Discharge information
Age 0.17 [0.0400.006] 0.139
Gender 0.423 [1.0670.221] 0.198
Laterality 0.407 [0.2311.044] 0.212
Tabl e 4 (continued)
Coef. 95% Confidence Interval pvalue
Frontal 0.302 [1.0600.457] 0.436
Parietal 0.201 [0.7411.143] 0.676
Temporal 0.189 [0.9710.592] 0.635
RMT ratio 0.080 [0.7180.557] 0.804
Duration 0.020 [0.033 to 0.008] 0.002
Type of mapping 2.037 [0.8193.254] 0.001
Age 0.013 [0.0570.030] 0.542
Gender 0.674 [1.9080.560] 0.285
Laterality 0.185 [0.9601.331] 0.751
Frontal 0.216 [0.5831.015] 0.597
Parietal 0.230 [0.7331.193] 0.639
Temporal 0.392 [0.5511.335] 0.415
RMT ratio 0.083 [1.2211.054] 0.886
Duration 0.010 [0.0330.012] 0.372
Type of mapping 1.708 [0.37803.794] 0.109
Table 5 Positive findings of multivariate analysis for the 6 domains of
the nTMS-PREMs questionnaire
Coef. 95% confidence interval pvalue
Age 0.034 [0.064 to 0.003] 0.030
0.0181 [0.0.4 to 0.0014] 0.034
0.351 [0.669 to 0.0329] 0.031
0.028 [0.050 to 0.007] 0.01
Discharge information
Age 0.044 [0.071 to 0.017] 0.002
Duration 0.020 [0.034 to 0.007] 0.003
0.089 [0.159 to 0.019] 0.013
Acta Neurochir (2020) 162:16731681 1679
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and understanding of nTMS results. This information can help
in tailoring the nTMS experience to individual patientsneeds.
Acknowledgements The authors would like to acknowledge the
Department of Neurosurgery at Kings College Hospital, London, for
support during the study.
Authorscontributions PG, SP, and JPL drafted the manuscript. SP car-
ried out the collection of the data. PG, JPL and FV participated in the
design of the study. SP, JJ, and JPL contributed in draftingdiscussion. FV,
RB, RG, and KA conceived of the study and participated in its design and
coordination and helped to draft the manuscript. All authors read and
approved the final manuscript.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
Informed consent All patients involved in the study voluntarily com-
pleted the questionnaire after informed consent regarding the study.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as
long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article
are included in the article's Creative Commons licence, unless indicated
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article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
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The authors report on patient reported experience measures (PREMs) for
navigated transcranial magnetic stimulation (nTMS). They argue that
while nTMS provides safe and non-invasive cortical mapping the exam-
ination is often long and associated with anxiety and discomfort.
Although patient collaboration is essential for a successful examination,
PREMs specific to nTMS have not been reported before. The authors use
a new questionnaire designed in house, on guidelines from the Royal
College of Surgeons, and review outcomes on 50 adult patients with
eloquent brain lesions (tumours in 92%), recruited between January and
December 2018, who go on to have surgery. The examination is carried
out as an out-patient procedure; patients are given an explanatory booklet
before the test and a discussion on the results is carried out on completion.
Patients were then given the questionnaire to complete; only two out of 50
were not returned. Responses were overall good, but anxiety and pain
were identified frequently in the Exam domain of the questionnaire. This
is an interesting study that addresses the impact and patient perception of
nTMS. The authors acknowledge a major limitation related to the single-
centre nature of this study - its use in other centres and its external vali-
dation is an important subsequent step to this work.
Kristian Aquilina
London, UK
Publishersnote Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
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Background: Measuring the quality and performance of health care is a major challenge in improving the efficiency of a health system. Patient experience is one important measure of the quality of health care, and the use of patient-reported experience measures (PREMs) is recommended. The aims of this project are 1) to develop item banks of PREMs that assess the quality of health care for adult patients with psychiatric disorders (schizophrenia, bipolar disorder, and depression) and to validate computerized adaptive testing (CAT) to support the routine use of PREMs; and 2) to analyze the implementation and acceptability of the CAT among patients, professionals, and health authorities. Methods: This multicenter and cross-sectional study is based on a mixed method approach, integrating qualitative and quantitative methodologies in two main phases: 1) item bank and CAT development based on a standardized procedure, including conceptual work and definition of the domain mapping, item selection, calibration of the item bank and CAT simulations to elaborate the administration algorithm, and CAT validation; and 2) a qualitative study exploring the implementation and acceptability of the CAT among patients, professionals, and health authorities. Discussion: The development of a set of PREMs on quality of care in mental health that overcomes the limitations of previous works (ie, allowing national comparisons regardless of the characteristics of patients and care and based on modern testing using item banks and CAT) could help health care professionals and health system policymakers to identify strategies to improve the quality and efficiency of mental health care. Trial registration: NCT02491866.
Full-text available
Introduction The impact of patient centredness (PC) in healthcare has grown over the years. However, conceptualisations of PC are heterogeneous. Existing patient-reported measures of PC have shown inconsistencies and shortcomings. This impedes the comparison of results across studies. To foster PC, it is important to know which dimensions matter most to patients and to be able to measure its current extent from the patients’ perspective. This study aims (1) to assess relevance of dimensions of PC from the patients’ perspective, (2) to develop and psychometrically test a core set of patient-reported experience measures (PREMs) assessing PC and (3) to investigate the feasibility of implementation of this core set in routine healthcare. Methods and analysis A mixed-methods approach will be used. In phase 1, 200 patients will assess the relevance of the dimensions of PC in a Delphi study using a plain language description. In phase 2, the core set of PREMs will be developed through literature reviews, focus groups, key informant interviews and content validity ratings. The core set will be tested psychometrically in a cross-sectional study with 2000 inpatient and outpatients with different chronic conditions (ie, cancer, cardiovascular diseases, mental disorders and musculoskeletal disorders). In phase 3, the feasibility of implementation of the core set will be assessed through semistructured interviews with healthcare practitioners after piloting in routine care. Furthermore, an expert workshop will be held on how to foster implementation. Ethics and dissemination The study will be carried out in accordance to the latest version of the Helsinki Declaration of the World Medical Association and principles of good scientific practice. The study was approved by the Ethics Committee of the Medical Association Hamburg, Germany (study ID: PV5724). The study results will be disseminated in scientific journals and through collaboration partners and plain language press releases.
Full-text available
Background Awake surgery to preserve language function in young children is challenging, therefore reliable non-invasive work-up of language functional anatomy is needed to preserve language function at any cost. Furthermore, there are obvious limitations of an awake craniotomy with direct stimulation on a child. Case report A 6-year-old boy with a low-grade glioma of the left temporal lobe suffering from epileptic seizures underwent surgery, guided by preoperative transcranial magnetic stimulation (TMS) language mapping and consecutive DTI fiber tracking. Discussion and conclusion We report successful surgery of a language eloquent brain tumor in a young child based on TMS mapping and DTI fiber tracking alone. Surgical treatment of left-sided perisylvian tumors in children is discussed.
Full-text available
Background: The treatment of brain arteriovenous malformations (BAVMs) is still contrarily discussed. Despite the debatable results of the ARUBA trial, most BAVMs still require treatment depending on the Spetzler-Martin (SM) grading. Since size is measurable and venous drainage is visible, the determination of eloquence is comparably crucial but not fully objective. The present bicentric cohort study aims to examine the influence of preoperative navigated transcranial magnetic stimulation (nTMS) motor and language mapping data on decision-making for or against surgical treatment of BAVMs. Methods: The influence of data from nTMS on decision-making for or against treatment of BAVMs was examined by confirming/falsifying presumed motor or language eloquence. Results: The results of nTMS mappings changed the SM grading in nine cases. In six cases, the SM grading changed to a lower grade (= falsified eloquence); in three cases, the SM grading changed to a higher grade due to nTMS mappings (= unexpected eloquence). Out of all 34 cases, indication for surgery was supported by nTMS mappings in 15 cases (7 motors, 8 languages). In six cases, the decision against surgery was made based on nTMS mappings (three motors, three languages). Conclusion: In 21 of 34 cases (62%), nTMS was a supportive argument. We could show that nTMS motor and language data can be used for a more objective decision-making regarding the treatment of BAVMs and for a more detailed SM grading regarding the rating of eloquence.
Full-text available
Background Navigated transcranial magnetic stimulation (nTMS) is a non-invasive mapping tool to locate functional areas of the brain. While gaining importance in the preoperative planning process in motor eloquent regions, its usefulness for reliably identifying language areas is still being discussed. The aim of this study was to identify biometric factors which might influence and therefore bias the results of repetitive nTMS (rnTMS) over cortex areas relevant for language. Method We included data of 101 patients with language eloquent brain lesions who underwent preoperative rnTMS examination bihemispherically. Prior to rnTMS mapping, all patients performed two to three baseline runs of a picture-naming paradigm without stimulation, and only promptly and correctly named objects were retained for TMS mapping. Nine biometric factors (age, gender, baseline dataset, cognitive performance score, aphasia score, histology of lesion, affected hemisphere, location of lesion on the hemisphere, pain caused by examination) were included in the statistical analysis measuring their correlation with the incidence of errors during baseline naming as well as during rnTMS mapping. ResultsThe incidence of baseline errors correlated with aphasia (p < 0.0001) and cognitive impairment (p < 0.0001). No significant correlation was observed between most biometric factors and errors during rnTMS mapping. Factors significantly affecting the incidence of errors during rnTMS mapping were again aphasia (p < 0.023) and cognitive impairment (p < 0.038). Patients affected by those factors showed a significantly higher baseline error rate, starting at 28% error rate. Conclusions Patients with pre-existing aphasia or severe cognitive impairment did still make significantly more mistakes during rnTMS mapping than non-aphasic patients despite baseline stratification, rendering the question of whether the procedure is reliable in those patient groups. Baseline testing revealed a cut-off point at 28% error rate. Interestingly, age or pain (caused by the examination) did not bias the results.
Full-text available
Introduction: Navigated transcranial magnetic stimulation (nTMS) is increasingly used for preoperative mapping of motor function, and clinical evidence for its benefit for brain tumor patients is accumulating. In respect to language mapping with repetitive nTMS, literature reports have yielded variable results, and it is currently not routinely performed for presurgical language localization. The aim of this project is to define a common protocol for nTMS motor and language mapping to standardize its neurosurgical application and increase its clinical value. Methods: The nTMS workshop group, consisting of highly experienced nTMS users with experience of more than 1500 preoperative nTMS examinations, met in Helsinki in January 2016 for thorough discussions of current evidence and personal experiences with the goal to recommend a standardized protocol for neurosurgical applications. Results: nTMS motor mapping is a reliable and clinically validated tool to identify functional areas belonging to both normal and lesioned primary motor cortex. In contrast, this is less clear for language-eloquent cortical areas identified by nTMS. The user group agreed on a core protocol, which enables comparison of results between centers and has an excellent safety profile. Recommendations for nTMS motor and language mapping protocols and their optimal clinical integration are presented here. Conclusion: At present, the expert panel recommends nTMS motor mapping in routine neurosurgical practice, as it has a sufficient level of evidence supporting its reliability. The panel recommends that nTMS language mapping be used in the framework of clinical studies to continue refinement of its protocol and increase reliability.
Background: Surgery for lesions in eloquent brain areas remains challenging owing to the risk of permanent neurological deficits. To date, direct electrical stimulation (DES) and intraoperative neuromonitoring represent the reference standard. Recently, navigated transcranial magnetic stimulation (nTMS) has emerged as a mapping tool to optimize surgical planning. Our aim was to correlate nTMS with the intraoperative findings and assess its effects on surgical decision-making. Methods: We retrospectively reviewed our series of patients who had undergone craniotomy for removal of a brain tumor at our institution with preoperative nTMS, intraoperative neuromonitoring, and DES from February 2017 to February 2018. Demographic data, tumor entity and location, extent of resection, change in surgical approach, and neurological outcome were collected. Results: Of 35 patients, 24 (68.6%) had undergone preoperative motor mapping and 11 (31.4%) had undergone mapping for language. Histopathological examination demonstrated glioma in 88.6% (high grade, n = 24; low grade, n = 6), metastasis (n = 2), epidermoid cyst (n = 1), and cavernoma (n = 1). nTMS resulted in change in the surgical strategy in 31.5% (craniotomy size, n = 7; access pathway, n = 3; surgical indication, n = 1). The specificity of nTMS for language was 66.7%, with a negative predictive value of 74.1%. nTMS motor mapping correlated with DES in all cases, with a mean abductor pollicis brevis hotspot distance of 3.50 ± 0.66 mm (n = 9). Conclusions: nTMS is a safe, noninvasive adjunctive tool for preoperative mapping of brain tumors in eloquent areas. Furthermore, nTMS can influence the surgical decisions in up to one third of patients in our experience.
Objectives: Awake surgery and intraoperative monitoring represent the gold standard for surgery of brain tumors located in the perisylvian region of the dominant hemisphere due to their ability to map and preserve the language network during surgery. Nevertheless, in some cases awake surgery is not feasible. This could increase the risk of postoperative language deficit. Navigated transcranial magnetic stimulation (nTMS) and nTMS-based DTI fiber tracking (DTI-FT) provide a preoperative mapping and reconstruction of the cortico-subcortical language network. This can be used to plan and guide the surgical strategy to preserve the language function. The objective if this study is to describe the impact of a non-invasive preoperative protocol for mapping the language network through the nTMS and nTMS-based DTI-FT in patients not eligible for awake surgery and thereby operated under general anesthesia for suspected language-eloquent brain tumors. Patients and methods: We reviewed clinical data of patients not eligible for awake surgery and operated under general anaesthesia between 2015 and 2016. All patients underwent nTMS language cortical mapping and nTMS-based DTI-FT of subcortical language fascicles. The nTMS findings were used to plan and guide the maximal safe resection of the tumor. The impact on postoperative language outcome and the accuracy of the nTMS-based mapping in predicting language deficits were evaluated. Results: Twenty patients were enrolled in the study. The nTMS-based reconstruction of the language network was successful in all patients. Interestingly, we observed a significant association between tumor localization and the cortical distribution of the nTMS errors (p = 0.004), thereby suggesting an intra-hemispheric plasticity of language cortical areas, probably induced by the tumor itself. The nTMS mapping disclosed the true-eloquence of lesions in 12 (60%) of all suspected cases. In the remaining 8 cases (40%) the suspected eloquence of the lesion was disproved. The nTMS-based findings guided the planning and surgery through the visual feedback of navigation. This resulted in a slight reduction of the postoperative language performance at discharge that was completely recovered after one month from surgery. The accuracy of the nTMS-based protocol in predicting postoperative permanent deficits was significantly high, especially for false-eloquent lesions (p = 0.04; sensitivity 100%, specificity 57.14%, negative predictive value 100%, positive predicitive value 50%). Conclusions: The nTMS-based preoperative mapping allows for a reliable visualization of the language network, being also able to identify an intra-hemispheric tumor-induced cortical plasticity. It allows for a customized surgical strategy that could preserve post-operative language function. This approach should be considered as a support for neurosurgeons whenever approaching patients affected by suspected language-eloquent tumors but not eligible for awake surgery.