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Summary   Objective  Navigated transcranial magnetic stimulation ( nTMS ) is becoming increasingly popular in noninvasive preoperative language mapping, as its results correlate well enough with those obtained by direct cortical stimulation ( DCS ) during awake surgery in adult patients with tumor. Reports in the context of epilepsy surgery or extraoperative  DCS  in adults are, however, sparse, and validation of  nTMS  with  DCS  in children is lacking. Furthermore, little is known about the risk of inducing epileptic seizures with  nTMS  in pediatric epilepsy patients. We provide the largest validation study to date in an epilepsy surgery population.    Methods  We compared language mapping with  nTMS  and extraoperative  DCS  in 20 epilepsy surgery patients (age range 9‐32 years; 14 children and adolescents).    Results  In comparison with  DCS , sensitivity of  nTMS  was 68%, specificity 76%, positive predictive value 27%, and negative predictive value 95%. Age, location of ictal‐onset zone near or within  DCS ‐mapped language areas or severity of cognitive deficits had no significant effect on these values. None of our patients had seizures during  nTMS .    Significance  Our study suggests that  nTMS  language mapping is clinically useful and safe in epilepsy surgery patients, including school‐aged children and patients with extensive cognitive dysfunction. Similar to in tumor surgery, mapping results in the frontal region are most reliable. False negative findings may be slightly more likely in epilepsy than in tumor surgery patients. Mapping results should always be verified by other methods in individual patients.

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Language mapping with navigated transcranial magnetic stimulation in pediatric and adult patients undergoing epilepsy surgery: Comparison with extraoperative direct cortical stimulation