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Motor and language mapping with Nexstim nTMS Preserving what is essential

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Now deemed an essential technique in neurosurgery1, Nexstim nTMS (navigated transcranial magnetic stimulation) enables preoperative, noninvasive mapping of brain areas that are closely linked with motor and language functions. Combined with Brainlab Elements for neurosurgical planning, nTMS offers surgeons the chance to improve outcomes and patients’ quality of life.2 

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Make informed decisions before surgery

nTMS data is the foundation for comprehensive preoperative evaluation and helps the entire team involved in determining the treatment strategy. nTMS empowers precise planning and enables more patients to be eligible for surgical resection.3 

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Increase resection rates 

Preoperative nTMS analysis, combined with nTMS-based fiber tracking, improves the delineation of safe resection limits. This leads to increased gross total resection rates—by up to 40%— and the potential for extended progression-free survival.2,3  

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Improve clinical outcomes 

Using nTMS mapping results as a region of interest facilitates function-based fiber tracking and may improve motor outcomes in up to 12% of tumor resection cases.2 

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Benefits backed by extensive scientific evidence 

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Brainlab and Nexstim
join forces

Brainlab and Nexstim have started a collaboration by signing a development and distributorship cooperation agreement. Together, the two companies will develop new solutions and improved workflows in the neurosurgery field. 

nTMS for preoperative functional mapping  

Visualize functional reorganization  

The location of motor or language functions may be unclear in tumor resection cases as lesions in the brain can cause functional reorganization in 40 – 50% of patients.4  

nTMS enables the visualization of lesion-induced functional reorganization.  

nTMS results allow clinicians to adapt treatment plans, offering a precise and patient-specific approach. By ruling out motor cortex involvement, tumors initially considered inoperable may be deemed suitable for surgery.3  


Image source: Frey D., Navigated transcranial magnetic stimulation improves the treatment outcome in patients with brain tumors in motor eloquent locations. Neuro Oncology 2014 Oct; 16(10): 1365–1372  

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Preserve language function  

nTMS language mapping creates a map of positive and negative responses, indicating areas that may be safe to resect.  

Streamline intraoperative awake mapping by using these nTMS language hotspots as a starting point. Eliminate the need for extensive exploration of functional areas.  

This approach can significantly reduce O.R. time and minimize the time a patient needs to be awake in surgery.4 


Image source: S. Krieg, Nexstim navigated TMS in presurgical mapping of cognitive task function, https://www.youtube.com/watch?v=EDG2r_EEgDs  

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Perform function-based fiber tracking  

nTMS data can be imported into Brainlab Elements for further preoperative planning.  

Functional motor and speech mapping results define more exact regions of interest for Elements Fibertracking, enabling reliable and standardized tractography.3,5 

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Complement intraoperative monitoring  

By accurately assessing surgical risk with nTMS data, the use of intraoperative neurophysiological
mapping and monitoring can be planned case-specifically. This facilitates clear communication between
surgeons and clinical neurophysiologists.  

Displaying nTMS data in Cranial Navigation can guide direct cortical stimulation (DCS), improving
operational efficiency and decreasing O.R. time related to intraoperative mapping.6,7,8,9,1 

35% increase in gross total resection rate, n = 200* 

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40% increase in gross total resection rate, n = 350** 

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*Krieg, Sandro M, et al. “Preoperative Motor Mapping by Navigated Transcranial Magnetic Brain Stimulation Improves Outcome for Motor Eloquent Lesions.” Neuro-Oncology 16.9 (2014):1274-282 

**Frey, Dietmar, et al. “Navigated Transcranial Magnetic Stimulation Improves the Treatment Outcome in Patients with Brain Tumors in Motor Eloquent Locations.” Neuro Oncology (2014):nou110v1-nou110. 

Nexstim nTMS and Brainlab Elements:
A smooth workflow 

Integrate Nexstim nTMS results with Brainlab Elements to enable function-based fiber tracking
for preoperative planning—providing the tools to preserve what is essential. 

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Uniquely precise and reliable  

Nexstim’s unique SmartFocus® nTMS technology integrates navigated TMS with advanced electric field (E-field) modeling. This enables the visualization of the location of the coil’s induced E-field on the individual’s brain anatomy, allowing for accurate and reliable nTMS mapping.11  

Clinical studies in neurosurgery have validated that this technology achieves accuracy on the order of millimeters.7  

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Perform safe mapping on children

nTMS uniquely offers pediatric patients access to non-invasive brain mapping.  

Patients are not required to be sedated, remain still or be confined to a closed and isolated environment like an imaging scanner.10  

Functional mapping with nTMS has been successful for nearly 90% of patients of whom fMRI was not able to provide a motor and/or language map.10 The youngest reported patient with successful motor mapping was 8 weeks old.10  

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Facilitate treatment consultation  

The presentation of nTMS mapping results facilitates patient consultation and can help patients better understand their treatment options.3,12  

At the same time, patients get acquainted with the language assessment process that will be used intraoperatively.12 

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The NBS system:
A fully integrated system

  • The hardware components are precision-manufactured and designed to work together as a fully-integrated system  

  • MRI-based E-field modeling enables users to accurately visualize where they are stimulating and confirm stimulation intensity received at the target  

  • The system also includes: workstation, foot-pedal control, infrared tracking camera, EMG unit, stimulator, cooling unit, stimulating coil, electronically-adjustable patient chair  

  • Disposables: head tracker, EMG surface electrodes

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Related topics

  1. Vucic S. et al., Clinical diagnostic utility of transcranial magnetic stimulation in neurological disorders. Updated report of an IFCN committee. Clin Neurophysiol. 2023 Jun:150:131-175 

  2. Krieg S. et al., Preoperative motor mapping by navigated transcranial magnetic brain stimulation improves outcome for motor eloquent lesions. Neuro Oncol. first published online February 9, 2014 

  3. Frey D., Navigated transcranial magnetic stimulation improves the treatment outcome in patients with brain tumors in motor eloquent locations. Neuro Oncology 2014 Oct; 16(10): 1365–1372  

  4. Krieg S., Nexstimnavigated TMS in presurgical mapping of cognitive task function, https://www.youtube.com/watch?v=EDG2r_EEgDs 

  5. Frey D. et al., A new approach for corticospinal tract reconstruction based on navigated transcranial stimulation and standardized fractional anisotropy values. Neuroimage 2012, 62(3):1600-9 

  6. Krieg S., Navigated Transcranial Magnetic Stimulation in Neurosurgery, Springer, 2017 

  7. Raffa G. et al., The role of navigated transcranial magnetic stimulation for surgery of motor-eloquent brain tumors: a systematic review and meta-analysis. Clin Neurol Neurosurg. 2019 May: 180:7-17 

  8. Rosenstock T. et al., Improving postsurgical paresis in brain tumor patients by transcranial magnetic stimulation, J Neurooncol. 2025 Jan 23 

  9. Mirza A.B. et al., Preoperative and intraoperative neuromonitoring and mapping techniques impact oncological and functional outcomes in supratentorial function-eloquent brain tumours: a systematic review and meta-analysis. eClinicalMedicine, Volume 80, February 2025, 103055 

  10. Narayana S. et al., Clinical Utility of Transcranial Magnetic Stimulation (TMS) in the Presurgical Evaluation of Motor, Speech, and Language Functions in Young Children With Refractory Epilepsy or Brain Tumor: Preliminary Evidence, Front Neurol. 2021 May 19:12:650830 

  11. Krieg S., E-field vs line navigation, Navigated Transcranial Magnetic Stimulation in Neurosurgery. p 14-18 Springer, 2017 

  12. Sollmann N. et al., Risk Assessment by Presurgical Tractography Using Navigated TMS Maps in Patients with Highly Motor-or Language-Eloquent Brain Tumors, Cancers (Basel). 2020 May 17;12(5):1264

Indications for use

CE mark & FDA clearance: The Nexstim Navigated Brain Stimulation (NBS) System 5 is indicated for non-invasive mapping of the primary motor cortex of the brain to its cortical gyrus. The Nexstim NBS System 5 provides information that may be used in the assessment of the primary motor cortex for pre-procedural planning.

Nexstim NexSpeech®, when used together with the NBS System 5, is indicated for non-invasive localization of cortical areas that do not contain essential speech function. NexSpeech® provides information that may be used in pre-surgical planning in patients undergoing brain surgery. Intra-operatively, the localization information provided by NexSpeech® is intended to be verified by direct cortical stimulation.

The Nexstim NBS System 5 and NBS System 5 with NexSpeech® are not intended to be used during a surgical procedure. The Nexstim NBS System 5 and NBS System 5 with NexSpeech® are intended to be used by trained clinical professionals.