Gamma knife radiosurgery for trigeminal neuralgia secondary to benign lesions

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.

Role of stereotactic radiosurgery for intracranial epidermoid tumors: a systematic review to assess its safety, efficacy, and complication profile

BACKGROUND

Even a gross total resection of a benign epidermoid tumor (ET) carries a high risk of recurrence. The management strategy mostly involves redo surgical excision but at a significant cost of morbidity and mortality. The role of adjuvant radiation therapies in this scenario is still undefined.

OBJECTIVE

To evaluate the feasibility, safety, efficacy, and complication profile of radiosurgery as a standalone or adjuvant therapy for intracranial epidermoid in the published literature.

METHODOLOGY

Following PRISMA guidelines, a comprehensive search of the databases PubMed, Embase, Scopus, and Web of Science in published English language was conducted. We included studies with radiosurgery for benign ET and in patients with malignant transformation of ET (MTET). All studies were evaluated for tumor characteristics, pattern of treatment, dosimetric profile, outcome, and complications. We included all studies with at least one outcome of interest i.e. local control (LC); progression-free survival (PFS); symptomatic toxicity; disease progression; retreatment; and overall survival (OS); and cause-specific mortality.

RESULTS

The search revealed 403 articles, of which 6 and 8 studies with patients of benign ET and MTET respectively were included. 25 (65.7%) patients received primary SRS. 27 patients presented with hyperactive cranial nerve syndromes; 77.7% gained complete improvement. The overall median age was 46.7 years (22-67) and the median tumor volume ranged from 0.38 to 6.2cc in benign ET. Volumetric reduction was seen in 6 cases; progression was seen in 2 cases while ET remained stable in the rest. Mean follow-up duration ranged from 33.7 to 60 months, and no recurrence was reported at the latest follow-up in any case of benign ET. 9.5% of patients suffered from transient cranial nerve deficits with no prolonged adverse radiation effect. OS in the MTET group was 6 to 60 months following GKRS with 50% of patients alive at the latest follow-up.

CONCLUSION

SRS may be a promising treatment option for a conventionally benign and radioresistant ET making a meaningful change in the natural history of the disease. It is a valuable adjuvant technique in patients with MTET.

Gamma knife radiosurgery for benign tumor-related trigeminal neuralgia: a single-institution retrospective study

BACKGROUND

Gamma knife stereotactic radiosurgery (GKRS) is recognized as an effective and safe alternative treatment for skull base tumors and trigeminal neuralgia. This study aims to evaluate the efficacy of targeting both tumor and trigeminal nerve in a single procedure for patients with benign tumor-related trigeminal neuralgia.

METHODS

A retrospective study was conducted on 44 patients with benign tumor-related trigeminal neuralgia who underwent GKRS targeting both tumor and trigeminal nerve in a single procedure between December 2016 and December 2022. The cohort included 30 meningiomas, 9 vestibular schwannomas, and 5 trigeminal schwannomas. The median tumor volume was 3.62 mL (range: 0.14-20.74 mL). The median radiation dose was 12-13.4 Gy for the tumors and 88.9 Gy (range: 85-90 Gy) at the 100% isodose line for the trigeminal nerve. The facial pain before and after GKRS was assessed using the Barrow Neurological Institute (BNI) pain intensity scale.

RESULTS

Following GKRS, 38 patients (86.4%) experienced significant pain improvement, with a median latency period of 2 months (range: 0.3-12 months). Sixteen patients (36.4%) experienced a relapse at a median time of 6 months (range: 1-30 months) post-GKRS. After a median follow-up time of 31.9 months (12.1-77.3 months), 22 patients (50.0%) continued to experience durable pain relief. Fourteen patients (31.8%) developed GKRS-related complications, most of which fully resolved, except in 3 patients (6.8%) who experienced permanent facial hypoesthesia. Tumor control rate was 86.2%.

CONCLUSIONS

GKRS targeting both the tumor and trigeminal nerve in a single session demonstrated favorable outcomes in terms of pain relief and tumor control in patients with benign tumor-related trigeminal neuralgia.

Stereotactic radiosurgery for arteriovenous malformations presenting as secondary trigeminal neuralgia: a case series

Stereotactic radiosurgery (SRS) is a potential treatment for trigeminal neuralgia (TN) secondary to arteriovenous malformations (AVMs), though its efficacy and safety remain unclear due to the rarity of this condition. We analyzed 1211 brain AVM cases treated with Gamma Knife radiosurgery (GKRS) between 2005 and 2023 at our institution. Four patients (0.33%) were presented with TN secondary to AVM. Three patients received single-fraction GKRS while one underwent hypofractionated treatment. Treatment outcomes were assessed using magnetic resonance imaging, digital subtraction angiography, and the Barrow Neurological Institute pain intensity scale. The mean marginal dose and AVM volume were 21.5 Gy and 0.58 cc, respectively. The mean follow-up period was 85.75 months. Complete AVM obliteration was achieved in all patients, with all experiencing complete pain relief within a mean time of 18 months, enabling gradual discontinuation of medications. No radiation-related adverse effects were observed. Our literature review identified only 15 previously reported cases where SRS was used as primary treatment for TN secondary to AVM, with most cases showing favorable outcomes in pain relief and AVM obliteration. This study is the first case series to demonstrate the sole use and efficacy of GKRS in managing TN secondary to AVM, moving beyond individual case reports. SRS appears to be a safe and effective primary treatment option for TN secondary to AVM, particularly when conventional surgical approaches are contraindicated or pose excessive risks. The sustained pain relief and absence of complications in our series, combined with previous case reports, support its use in managing this rare condition.

Efficacy and safety of Dyna CT-assisted percutaneous balloon compression in the treatment of tumor-related trigeminal neuralgia: A single-center retrospective analysis

BACKGROUND

Percutaneous balloon compression (PBC) has been widely used in the treatment of trigeminal neuralgia (TN). Patients with tumor-related TN are typically treated by tumor resection. However, when craniotomy is not feasible, PBC may serve as a simple and effective method for pain relief. Currently, there is limited literature on the use of this technique in treating patients with tumor-related TN. In this study, we aim to evaluate the efficacy and safety of Dyna CT-assisted PBC in the treatment of tumor-related TN.

METHODS

From January 2018 to December 2023, a total of 19 patients with tumor-related TN underwent Dyna CT-assisted PBC at our institution. The modified Barrow Neurological Institute Pain Intensity Grading Scale and sensory reduction scores were employed to assess treatment outcomes. A retrospective analysis was conducted on the clinical characteristics, surgical efficacy, postoperative complications, and follow-up results of all patients.

RESULTS

Immediate and complete pain relief was observed in 18 patients following PBC, with one patient experiencing delayed recovery. Follow-up periods ranged from 4 to 62 months, revealing only 4 patients with pain recurrence at the last follow-up, and tumor-related TN patients with involvement of Meckel's cave were more prone to recurrence. No severe complications occurred throughout the follow-up period. Although facial numbness was reported in all 15 patients, jaw weakness in 8 patients, and postoperative headache in 7 patients, these symptoms resolved within a short period. There were no statistically significant differences in postoperative facial numbness and jaw weakness between tumor-related TN patients with or without Meckel's cave involvement. However, patients with Meckel's cave involvement were more likely to experience postoperative headaches. Patient satisfaction scores indicated a significant improvement in postoperative quality of life.

CONCLUSION

For patients with tumor-related TN, when craniotomy is not feasible, Dyna CT-assisted PBC proves to be a safe and effective alternative treatment. Additionally, we observed varying postoperative clinical outcomes based on the different sites of tumor compression on the trigeminal nerve. Patients with tumor-related TN not involving Meckel's cave exhibited more enduring clinical efficacy compared to those with Meckel's cave involvement.

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

BACKGROUND

Secondary trigeminal neuralgia is a facial pain in trigeminal nerve dermatome caused by an underlying disease, such as cerebellopontine angle tumours. Treatment options to relieve the pains were surgical tumour resection and stereotactic radiosurgery of the tumour or trigeminal nerve. This study aims to review the efficacy of open surgery and stereotactic radiosurgery and recommend the treatment of choice for secondary trigeminal neuralgia due to cerebellopontine angle tumours.

METHOD

The inclusion criteria were studies covering patients with trigeminal neuralgia associated with cerebellopontine angle tumours that were treated with either open surgery or stereotactic radiosurgery and reported pain outcomes after treatment. Non-English articles or studies with a population of less than five were excluded. We systematically searched studies from PubMed, Ebscohost, and Cochrane Library from inception until December 20, 2021. Several works of literature from manual search were also added. Selected articles were appraised using a critical appraisal tool for prognostic studies.

RESULT

Included articles were 26 retrospective studies and one prospective study comprising 517 patients. Of 127 schwannomas, 226 epidermoids, 154 meningiomas, and ten other tumours, 320 cases received surgical tumour excision with or without MVD, 196 had tumour-targeted radiosurgery, and 22 underwent nerve-targeted radiosurgery. In surgical series, 92.2 % gained pain improvement, 2.8 % were unchanged, and 4.5 % had recurrence; none of the patients had worsened outcomes. In cases treated with tumour-targeted radiosurgery, the improvement rate was 79.1 %, unchanged at 14.3 %, recurrence at 26.5 %, and worse symptoms rate after the intervention was 6.6 %. Six patients with recurrent pain after tumour-targeted radiosurgery received secondary nerve-targeted radiosurgery with improved outcomes. Only one patient in our review underwent primary nerve-targeted radiosurgery, and the result was satisfactory. One study treated 15 patients with a single session of tumour-targeted and nerve-targeted radiosurgery, with an improvement rate of 93.3 % and a recurrence rate of 21.4 %.

CONCLUSION

Open surgery releasing the nerve root from compressive lesions is advocated to be the first-line treatment to gain satisfactory outcomes. Total removal surgery is recommended if possible. Nerve-targeted radiosurgery should be reserved as a secondary treatment for recurrent cases.

Stereotactic radiosurgery for trigeminal neuralgia secondary to tumor: a single-institution retrospective series

OBJECTIVE

Trigeminal neuralgia (TN) secondary to tumor represents a rare and diverse entity, and treatment for secondary TN remains controversial. This report reviews a single institution’s experience in treating secondary TN with stereotactic radiosurgery (SRS) and focuses on the durability of pain relief with respect to various treatment targets, i.e., the trigeminal nerve, offending tumor, or both.

METHODS

Between the years 2009 and 2021, 21 patients with TN secondary to benign (n = 13) or malignant (n = 8) tumors underwent SRS. Barrow Neurological Institute (BNI) pain intensity scale scores were collected from patient electronic medical records at baseline, initial follow-up, and 1 and 3 years post-SRS. The interval change in BNI scale score (ΔBNI) at the various follow-up time points was also calculated to assess the durability of pain relief following SRS.

RESULTS

The median follow-up period was 24 (range 0.5–155) months. Five patients (24%) received treatment to the trigeminal nerve only, 10 (48%) received treatment to the tumor only, and 6 (29%) had treatment to both the nerve and tumor. The overall radiation dosage ranged from 14 to 60 Gy delivered in 1–5 fractions, with a median overall dose of 26 Gy. The median dose to the tumor was 22.5 (range 14–35) Gy, delivered in 1–5 fractions. Of the treatments targeting the tumor, 25% were delivered in a single fraction with doses ranging from 14 to 20 Gy, 60% were delivered in 3 fractions with doses ranging from 18 to 27 Gy, and 15% were delivered in 5 fractions with doses ranging from 25 to 35 Gy. The most common dose regimen for tumor treatment was 24 Gy in 3 fractions. The median biologically effective dose (with an assumed alpha/beta ratio of 10 [BED10]) for tumor treatments was 43.1 (range 13.3–60.0) Gy. There was a significant difference in the proportion of patients with recurrent pain (ΔBNI score ≥ 0) at the time of last follow-up across the differing SRS treatment targets: trigeminal nerve only, tumor only, or both (p = 0.04). At the time of last follow-up, the median ΔBNI score after SRS to the nerve only was −1, 0 after SRS to tumor only, and −2 after SRS to both targets.

CONCLUSIONS

SRS offers clinical symptomatic benefit to patients with TN secondary to tumor. For optimal pain relief and response durability, treatment targeting both the tumor and the trigeminal nerve appears to be most advantageous.

Trigeminal Neuralgia Secondary to Meningiomas and Vestibular Schwannoma Is Improved after Stereotactic Radiosurgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Trigeminal neuralgia (TN) secondary to tumors is encountered in up to 6% of patients with facial pain syndromes and is considered to be associated with tumors affecting the trigeminal nerve pathways. The most frequent are meningiomas and vestibular schwannomas (VS). Stereotactic radiosurgery (SRS) has emerged as a valuable treatment, with heterogeneity of clinical results. We sought to review the medical literature on TN treated with SRS for meningiomas and VS and investigate the rates of improvement of TN symptoms.

METHODS

We reviewed articles published between January 1990 and December 2019 in PubMed. Pain relief after SRS, the maintenance of pain relief, and TN recurrence and complications were evaluated with separate meta-analyses, taking into account the data on individual patients.

RESULTS

Pain relief after SRS was reported as Barrow Neurological Institute (BNI) pain intensity scores of BNI I in 50.5% (range 36-65.1%) of patients and BNI I-IIIb in 83.8% (range 77.8-89.8%). There was no significant difference in series discussing outcomes for tumor targeting versus tumor and nerve targeting. Recurrences were described in 34.7% (range 21.7-47.6; tumor targeting). Maintenance of BNI I was reported in 36.4% (range 20.1-52.7) and BNI I-IIIb in 41.2% (range 29.8-52.7; tumor targeting series). When both the nerve and the tumor were targeted, only 1 series reported 86.7% with BNI I-IIIb at last follow-up. Complications were encountered in 12.6% (range 6.3-18.8; tumor targeting series) of patients; however, they were much higher, as high as 26.7%, in the only study reporting them after targeting both the nerve and the tumor. The most common complication was facial numbness.

CONCLUSION

SRS for TNB secondary to benign tumors, such as meningiomas and VS, is associated with favorable clinical course, but less favorable than in idiopathic TN. There was, however, heterogeneity among reports and targeting approaches. Although targeting both the nerve and the tumor seemed to achieve better long-term results, the rate of complications was much higher and the number of patients treated was limited. Future clinical studies should focus on the standard reporting of clinical outcomes and randomization of targeting methods.

Treatment Outcomes in Trigeminal Neuralgia-A Systematic Review of Domains, Dimensions and Measures

BACKGROUND

Trigeminal neuralgia (TN) is a painful disorder characterized by sudden electric shock-like pain. It is a rare condition for which multiple treatments are available, including medical and surgical. The best treatment option is yet to be defined, and this is related to the lack of definition in the treatment outcomes and outcome measures. The aim of this systematic review was to summarize all the outcomes and outcomes measures that have been published to date and highlight variability in their use.

METHODS

We have conducted a literature search using a wide range of databases (1946-2019 for medical and 2008-2019 for surgical treatment), for all intervention studies in TN. Four hundred and sixty-seven studies were selected for data extraction on TN classification, data collection method, intervention, and treatment outcomes mapped to the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT guidelines).

RESULTS

Most studies collected data on pain (n = 459) and side effects (n = 386) domains; however, very few collected data on the impact of treatment on physical (n = 46) and emotional functioning (n = 17) and on patient satisfaction (n = 35). There was high variability on outcome measures used for pain relief (n = 10), pain intensity (n = 9), and frequency of pain episodes (n = 3).

CONCLUSIONS

A clear definition of what are the important outcomes for patients with TN is essential. The choice of standardized outcome measures allowing for consistent reporting in TN treatment will allow for comparison of studies and facilitate treatment choice for patients and clinicians thus, improving health outcomes and reducing health care cost.

Radiosurgery for Epidermoid Tumors: Dramatic Pain Relief from Trigeminal Neuralgia

Purpose 

The purpose of this study is to discuss the long-term effects of radiosurgery for epidermoid tumors, including the symptoms of trigeminal neuralgia and/or facial spasm, which we have originally reported before.

Background

Intracranial epidermoids are slow-growing tumors that can become symptomatic once they develop into large tumors. The mainstay of the treatment is surgery. However, eradicating the whole tumor is often difficult and some tumors may recur. In addition to their mass effects on the brain, these tumors are often associated with hyperactive nerve dysfunction syndromes such as trigeminal neuralgia, glossopharyngeal neuralgia, and/or facial spasm.

Cases and methods 

We report 13 cases of epidermoid tumors, 12 of which were located in the cerebellopontine angle (CPA), which were treated using 14 radiosurgery procedures. The inclusion criteria for radiosurgery were the presence of well-localized small tumors and/or severe associated neuralgia or facial spasms. The mean target volume ranged from 0.17 to 9.5 cm³ with a mean of 2.85 cm³. The lesions were treated with a mean maximum and a marginal dose of 28.2 Gy and 14.2 Gy, respectively.

Results

Among the 14 gamma knife procedures that were performed in 13 patients, dose planning to ensure total and partial coverage for relief from hyperactive cranial nerve dysfunction (HCND) was performed. Six cases were totally and another eight were partially covered at the dose planning. The irradiated tumors showed a minor decrease or no remarkable changes during a mean follow-up period of 86.1 months. Tumor progression requiring a second surgery was seen in two cases. The trigeminal neuralgias either improved or disappeared soon after the procedure, enabling the discontinuation of the medication.

Conclusion 

Radiosurgery led to a dramatic improvement in HCND. In fact, the immediate cure of neuralgia after the radiosurgery was observed in several cases, even after partial coverage with radiosurgery. The interface between the tumor and the nerve was the main target. The definite mechanisms for this favorable outcome have not been verified yet, but the functional modulation by the radiosurgery could be one. Electrophysiological alteration at the interface between the tumor and nerve has been considered. When the tumors were totally covered with radiosurgery, persistent tumor control was expected. Sufficient tumor control is possible if the tumor can be covered entirely with radiosurgery. Functional modulation of trigeminal neuralgia and facial spasms can also be attained even by partial dose planning for the nerve-tumor interface.