Open surgery vs. stereotactic radiosurgery for tumour-related trigeminal neuralgia: A systematic review

Factors Affecting Long-Term Pain Control After Gamma Knife Radiosurgery in Secondary Tumor-Related Trigeminal Neuralgia

BACKGROUND AND OBJECTIVES

Trigeminal neuralgia (TN) can often result from compression of the trigeminal root by various tumors. Although the efficacy of Gamma Knife radiosurgery (GKRS) in treating these tumors is well documented, it remains to be determined if tumor control drives pain relief in tumor-related TN.

METHODS

We retrospectively analyzed all patients who underwent GKRS for secondary TN at our center, recording preoperative clinical and radiological data, and assessing outcomes regarding Barrow Neurological Institute (BNI) pain scores and tumor volume at follow-up. We then analyzed the factors that predicted pain relief, including long-term tumor control.

RESULTS

The mean age of 156 patients (90 women and 66 men) was 52.2 ± 13.9 years. The most frequent pathology was schwannoma (108 cases, 67.9%), followed by meningioma (48 cases, 29.6%). The mean dose of GKRS administered was 12.08 ± 5.5 Gy. The mean follow-up was 49.7 ± 17.1 months. Four patients (2.5%) were lost to follow-up. At latest follow-up, 59 patients (38.8%) achieved complete pain relief (BNI 1), whereas 72 patients (47.4%) achieved adequate pain relief (BNI 2 and 3). Failure of pain relief occurred in 21 patients (13.8%). Multivariate analysis revealed that patients aged younger than 50 years (odds ratio: 6.95, 95% CI: 2, 22.8, P = .001) and increase in tumor volume at follow-up (odds ratio: 40.38, 95% CI: 5.39, 321.45, P < .001) predicted failure of pain relief.

CONCLUSION

GKRS is effective among patients with secondary tumor-related TN, with complete pain relief in 38.8% of patients and adequate pain relief in 47.4%. The most frequent complication is facial hypesthesia, affecting 8.3% of patients. Age ≥50 years and decreased or stable tumor volume significantly predict BNI 1-3 pain relief at the latest follow-up. Although pain relief is linked to long-term tumor control, it is not the sole factor at play.

Stereotactic radiosurgery for tumor-related trigeminal neuralgia: a systematic review and meta-analysis

BACKGROUND

Tumor-related trigeminal neuralgia (TRTN) accounts for approximately 6% of all facial pain syndromes. Conventional medical treatments have short-term pain relief effects in TRTN cases; however, they are correlated with substantial failure rates of 63-100%. Microsurgical resection (MS) and stereotactic radiosurgery (SRS) are the two primary therapeutic options for the management of TRTNs. This systematic review and meta-analysis evaluated the pain-related outcomes and complications of SRS in TRTNs.

METHODS

A systematic literature search was conducted on February 24, 2025, comparing PubMed, Embase, Scopus, and Web of Science. Studies reporting pain-related outcomes and adverse radiation effects (ARE) for SRS in TRTNs were included.

RESULTS

Nineteen studies with 454 patients were included. Meningioma (67.7%, 304/449) was the most common tumor, followed by vestibular schwannoma (VS) (18.3%, 82/449) and trigeminal schwannoma (8.2%, 37/449). Our meta-analysis demonstrated that SRS is associated with a pooled complete pain-free rate of 38% (95% CI: 27-50%), an adequate pain relief rate of 73% (95% CI: 63-83%), and an ARE rate of 14% (95% CI: 7-22%). In those where the underlying etiology was pertoclival meningiomas, SRS resulted in a pooled complete pain-free rate of 30% (95%CI: 5-64%), an adequate complete pain relief rate of 64% (95%CI: 33-90%), and an ARE rate of 13% (95%CI: 0-48%).

CONCLUSION

SRS is associated with favorable pain-related outcomes and low ARE rates in patients with TRTN. Both tumor-only related and dual-targeted approaches are associated with comparable outcomes.

Trigeminal neuralgia secondary to minor size lesion, anatomical considerations and pathophysiology

Trigeminal neuralgia is a well-characterized disorder of high prevalence among the current population. It may be caused, among many other causes, by a tumor which contacts with the trigeminal nerve, often of large volume. We present the case of a middle-aged woman without any remarkable medical background who suffered a trigeminal neuralgia caused by a subcentimeter tumor which appeared to be a meningioma. Some small tumors like this one may be symptomatic whereas larger ones will not. We discuss the pathogenesis and characterization of the trigeminal neuralgia in such cases proposing some mechanisms that could be involved in the development of a secondary neuralgia.

Trigeminal neuralgia caused by compression of the trigeminal nerve between the vertebral artery and Meckel's cave meningioma extending to the posterior fossa successfully treated with the endoscopic-assisted anterior petrosal approach

Background

Microvascular decompression (MVD) using a microscope is commonly performed for trigeminal neuralgia (TN). The advantages of endoscopic surgery for MVD are not clear. We report a case of TN caused by a Meckel's cave meningioma extending to the posterior fossa, which was successfully treated through surgical resection using a combination of a microscope and endoscope.

Case Description

A 63-year-old patient complained of left facial pain. Magnetic resonance imaging showed a 30 × 30 × 25 mm mass lesion in the left petroclival region that had extended into Meckel's cave. Three-dimensional computed tomography angiography demonstrated that the trigeminal nerve passed between the tumor and the tortuous vertebral artery (VA). We selected the anterior transpetrosal approach. The trigeminal nerve was displaced due to compression by the tumor, so the entire course of the trigeminal nerve was difficult to visualize even after tumor removal. Consequently, we switched from the microscope to an endoscope and observed the root entry zone (REZ) of the trigeminal nerve. We confirmed that the VA compressed the REZ of the trigeminal nerve and inserted small Teflon pieces to relieve the compression. TN disappeared, and he was discharged home with no complications.

Conclusion

Surgical resection of tumors near the trigeminal nerve causing TN must carefully examine the trigeminal nerve from the REZ to Meckel's cave to identify any coexistent vascular compression, which may be difficult using only a microscope due to significant displacement of the trigeminal nerve. In such cases, the use of an endoscope is effective to inspect the entire trigeminal nerve directly.

Management of large Trigeminal Schwannoma: long-term oncologic and functional outcome from a multicentric retrospective cohort

OBJECTIVE

Trigeminal schwannoma (TS), though a rare and benign tumor, becomes a significant surgical challenge due to its intricate location. This study aims to detail the long-term functional outcomes and tumor control post-surgical resection.

METHOD

We analyzed a multicentric retrospective cohort of 39 patients operated on for a TS in five tertiary centers between January 1993 and July 2022.

RESULTS

Six TS (15%) were in the middle fossa (type M), two (5%) in the posterior fossa (type P), and two (5%) were extracranial (type E). Twenty-nine (75%) were Dumbbell shape: Eighteen (47%) were MP type, seven (18%) were MPE type, and four (10%) were ME type. Fifth nerve symptoms were the foremost preoperative complaint: hypesthesia (51%), trigeminal neuralgia (36%), and paresthesia (30%). We report a favorable evolution course for 61% of preexisting deficits (half of patients with preoperative paresthesia and neuralgia improved while only 5% of preoperative hypesthesia improved). Postoperative hypesthesia was the most frequent de novo deficit 14 (74%) and resolved in solely half the cases. Various approaches were used according to tumor type. Gross total resection (GTR), Subtotal resection (STR), and partial resection (PR) were achieved in respectively 33% (N = 13), 10% (N = 4), and 56% (N = 22) of patients. The mean clinical and radiological FU was 63 months (12 - 283 months). GTR led to no sign of recurrence (mean FU: 60 months - range: 12-283 months). For STR or PR (67%): 23 (88%) were assigned to a Wait-&-rescan policy (WS group) which offered stability in 70% (N = 16). Three cases (8%) underwent a complementary GKS (GammaKnife) on the residual lesion (GK group) without tumor change.

CONCLUSION

For large TS, the completeness of resection must consider the potential functional burden of surgery. With giant infiltrating lesions, a strategy of planned subtotal resection, complemented by radiosurgery, either complementary or uppon regrowth, may provide similar oncological outcomes.

Optimizing Surgical Outcomes for Intracranial Epidermoid Tumors: A Retrospective Analysis of Clinical Predictors, Surgical Decisions, and Patient Clustering

BACKGROUND/OBJECTIVE

Intracranial epidermoid tumors (ETs) are rare, benign lesions that present significant challenges in neurosurgical management due to their propensity to encase vital neurovascular structures. We aimed to evaluate the impact of clinical, demographic, and tumor-specific factors on surgical decisions (gross total resection [GTR] vs. subtotal resection [STR]) and outcomes and identify patient clusters with distinct profiles and outcomes post-resection.

METHODS

We retrospectively analyzed 72 patients with ET treated from 1998 to 2022, employing multivariable logistic regression for GTR versus STR predictors and Kaplan-Meier curves for progression-free survival (PFS). K-prototype clustering classified patients based on clinical data.

RESULTS

The mean age of our cohort was 39.8 ± 20.1 years. About 13.9% of patients had a recurrence, with a median PFS of 108 months (interquartile range: 57 -206). Seizures significantly predicted GTR (P < 0.05), whereas adherence to critical structures reduced GTR likelihood (P < 0.05). Initial surgeries more often achieved GTR, correlating with longer PFS (P < 0.0001) and reduced recurrence (P < 0.01) versus re-operations. Cluster analysis identified three distinct groups, with the initial GTR cluster showing superior PFS and the lowest recurrence (P < 0.0001 and P < 0.01, respectively). Statistically significant predictors of PFS included age and preoperative seizure presence, with older age favoring longer PFS (P < 0.01) and seizures associated with reduced PFS (P < 0.01). In addition, patients with previous surgeries showed a trend toward shorter PFS (P < 0.05).

CONCLUSIONS

This study emphasizes the importance of tailored surgical strategies in managing intracranial ETs, advocating for GTR to optimize long-term outcomes where possible. Future prospective studies are essential to further refine treatment approaches, enhancing survival for ET patients.

The efficacy of surgery over stereotactic radiosurgery in the management of tumor-related trigeminal neuralgia

Tumor-related trigeminal neuralgia (TN) is a deeply debilitating condition that severely impacts patient quality of life. Two principal treatment methods in use are open surgical resection of the causative tumor or the use of stereotactic radiosurgery (SRS). In this letter, we aim to evaluate the use of both treatment methods and highlight that in patients with commensurate anatomy, open surgical resection continues to provide greater rates of symptomatic relief, lower rates of recurrence, and complication compared to stereotactic radiosurgery.

Fully endoscopic far-lateral supracerebellar infratentorial approach for trigeminal neuralgia: illustrative case reports

BACKGROUND

Trigeminal neuralgia (TN) is a common cause of craniofacial pain. The retrosigmoid approach is usually used to treat TN, but no cases of endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA) were used to undergo operation for TN.

CASE PRESENTATION

Two patients were presented with severe facial pain and preliminary diagnosis was TN. Preoperative magnetic resonance imaging revealed that a superior cerebellar artery (SCA) compressed the trigeminal nerve in case 1, and a tumor located in the petrous apex extending into the Meckel's cave compressed the trigeminal nerve in case 2. Operations were achieved through the EF-SCITA. The pain was totally relieved with no postsurgical complications in both cases.

CONCLUSIONS

We present the first two case reports of EF-SCITA to relieve classical and secondary TN successfully. The EF-SCITA can be a promising approach for treating TN.

[Posterior petrous meningioma with secondary trigeminal neuralgia: microsurgical resection after stereotactic radiosurgery (case report and literature review)]

According to the literature, cerebellopontine angle tumors cause secondary trigeminal neuralgia and other symptoms of neurovascular compression in 1-9.9% of cases. We present a 58-year-old patient with left-sided secondary trigeminal neuralgia caused by ipsilateral posterior petrous meningioma. Stereotactic irradiation was followed by effective tumor growth control. However, residual trigeminal pain paroxysms significantly reduced the quality of life and required subsequent microsurgery. Trigeminal facial pain regressed after total resection of tumor. Considering this clinical case, we would like to discuss several issues: follow-up of meningioma requiring radiosurgery, course of secondary trigeminal neuralgia in a patient with apical petrous meningioma, characteristics of pain before and after radiosurgery, the best treatment option for these patients. Stereotactic radiosurgery seems unreasonable for CPA tumors with secondary trigeminal neuralgia. Indeed, persistent pain is possible even after tumor shrinkage. Moreover, primary stereotactic irradiation significantly complicates subsequent resection of tumor.

[Surgical treatment of secondary trigeminal neuralgia]

OBJECTIVE

To present a case series analysis of surgical treatment of patients with secondary trigeminal neuralgia.

MATERIAL AND METHODS

The treatment of 8 patients with secondary trigeminal neuralgia who underwent surgery since 2021 was analyzed. All records, neuroimaging archive, and follow-up observations were reviewed.

RESULTS

There were 5 patients with trigeminal neuralgia associated with multiple sclerosis; with neurosarcoidosis (n=1); with tumor (n=1); with unspecified degenerative disease (n=1). The mean age was 61 years (from 48 to 73), the mean duration of disease was 7.2 years (from 5 to 13). Radiofrequency ablation (RF) was performed in 4 cases, balloon compression in 3 cases, tumor removal in 1 case. Relief of trigeminal neuralgia after surgery was observed in 7 patients, partial reduction in 1 patient. A complication was noted in a patient with neurosarcoidosis after RF with the appearance of dysesthesia, dry eye. The mean follow-up was 10 months (1 to 29). Pain recurrence occurred in 2 patients, one of them underwent the surgery twice.

CONCLUSION

Surgical treatment of patients with secondary trigeminal neuralgia contributes to pain relief.