Optimal number of pulses as outcome measures of neuronavigated transcranial magnetic stimulation

Objective: Identify the optimal number of pulses necessary to achieve reliable measures of motor evoked potentials (MEPs) in transcranial magnetic stimulation (TMS) studies. Methods: Retrospective data was obtained from 54 healthy volunteers (30 men, mean age 61.7 +/- 13.1 years) who as part of prior studies had completed three blocks of 30 consecutive TMS stimuli using neuronavigation. Data from four protocols were assessed: single-pulse TMS for measures of amplitude and latency of MEPs; paired-pulse TMS for short-interval intracortical inhibition (sICI) and intracortical facilitation (ICF); and single-pulse TMS to assess the effects of intermittent theta burst stimulation (iTBS). Two statistical methods were used: an internal consistency analysis and probability of inclusion in the 95% confidence interval (CI) around the mean MEPs amplitude. Results: For single-pulse TMS, the minimum number of pulses needed to achieve reliable amplitude and latency MEPs measures was 21 and 23, respectively. For paired-pulse TMS, the minimum number of pulses needed to achieve reliable sICI and ICF measures was 20 and 25, respectively. Finally, the minimum number of pulses needed to achieve reliable amplitude and latency MEPs measures after iTBS was 22 and 23, respectively. Conclusions: This study provides guidelines regarding the minimum number of pulses needed to achieve reliable MEPs measurements in various study protocols using neuronavigated TMS. Significance: Results from this study have the potential to increase the reliability and quality of future neuronavigated TMS studies. (C) 2016 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.