Stimulating deep cortical structures with the batwing coil: how to determine the intensity for transcranial magnetic stimulation using coil-cortex distance

Transcranial magnetic stimulation (TMS) is increasingly used in cognitive neuroscience to probe non-motor cortical regions. A key question for such studies is the choice of stimulation intensity. Early studies used a simple metric such as 115% of motor threshold (MT) for non-motor regions; where MT is the stimulation intensity required to elicit a particular amplitude of motor evoked potential or visible muscle twitch when the coil is placed over primary motor cortex. Recently, however, it was demonstrated that this simple metric for stimulation of non-motor regions is inadequate - it could lead to over or under-stimulation depending on the distance between the coil and the cortex. Instead, a method was developed to scale the motor threshold based on coil-cortex distance, at least for standard figure-of-eight stimulating coils. Here we validate the same method for a ‘batwing coil’, which is designed to stimulate deeper cortical structures such as the medial frontal cortex. We modulated coil-cortex distance within-participant by inserting spacers of different thickness between coil and scalp. We then measured MT at each spacer. We show that for every millimeter between coil and scalp an additional 1.4% of TMS output is required to induce an equivalent level of brain stimulation at the motor cortex. Using this parameter we describe a linear function to adjust MT for future studies of non-motor regions-of-interest using the batwing coil. This is the first study to demonstrate the effects of coil-cortical distance on stimulation efficiency via a monophasic system using a batwing coil.