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Akcakaya MO, Mirkhasilova M, Ozturk O, Ugurlar D, Tonge M, Alco G, Ercan T, Igdem S, Karadereler S. Gamma Knife radiosurgery for the treatment of trigeminal neuralgia: A single center-experience. NEUROCIRUGIA (ENGLISH EDITION) 2024:S2529-8496(24)00020-0. [PMID: 38642616 DOI: 10.1016/j.neucie.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/20/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION AND OBJECTIVES We aimed to assess the outcomes of patients with trigeminal neuralgia (TGN) who underwent Gamma Knife radiosurgery (GKRS). MATERIALS AND METHODS Fifty-three patients with typical TGN underwent GKRS from May 2012 until December 2022. Among these patients, 45 patients who were follow-up for at least 12 months were included in the study. A mean dose of 87.5 Gy (range, 80-90) was administered to the trigeminal nerve. Postoperatively, outcome was considered excellent if the patient was pain- and medication-free. RESULTS The mean symtpom duration was 9.53 years, and the mean patient age was 59.8 years (range, 34-85). The mean follow-up period was 46.8 months (range, 12-127 months). 46.7% of patients had a history of previous surgical interventions. A single nerve division was affected in 14 patients (31.1%), and multiple divisions were affected in 31 patients (68.9%). The rate of initial pain relief was 80%. Hypoesthesia in the area of trigeminal nerve developed in 30 (66.7%). Twenty patients (44.4%) exhibited excellent results within 72.4 months. Recurrence occurred in 11 patients (24.4%) with 27.6 months. CONCLUSIONS Our results suggest that GKRS is a safe and effective procedure. Thus, it is an attractive first- and second-line treatment choice for TGN.
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Affiliation(s)
- Mehmet Osman Akcakaya
- Department of Neurosurgery, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | | | - Onur Ozturk
- Department of Neurosurgery, Acibadem Taksim Hospital, Istanbul, Turkey.
| | - Doga Ugurlar
- Department of Neurosurgery, Samatya Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Tonge
- Department of Neurosurgery, Medipol Mega Hospital, Istanbul, Turkey
| | - Gul Alco
- Department of Radiation Oncology, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | - Tulay Ercan
- Department of Radiation Oncology, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | - Sefik Igdem
- Department of Radiation Oncology, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | - Selhan Karadereler
- Department of Neurosurgery, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
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Orlev A, Feghali J, Kimchi G, Sun L, Pierre C, Gragnaniello C, Cotrutz C, Loiselle C, Vermeulen S, Litvack Z. TN-RS: a novel scoring system predicts Gamma Knife Radiosurgery outcome for trigeminal neuralgia patients. Acta Neurochir (Wien) 2023; 165:3895-3903. [PMID: 37922000 DOI: 10.1007/s00701-023-05835-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/03/2023] [Indexed: 11/05/2023]
Abstract
BACKGROUND Gamma Knife Radiosurgery (GKRS) is an effective treatment option for medically refractory trigeminal neuralgia (TN). This study examines GKRS outcome in a large cohort of TN patients and highlights pretreatment factors associated with pain relief. METHODS This is a single-center retrospective analysis of patients treated with GKRS for TN between 2011 and 2019. Pain relief was assessed at 1 year, and 2-3 years following GKRS. Multivariable analysis identified several factors that predicted pain relief. These predicting factors were applied to establish a pain relief scoring system. RESULTS A total of 162 patients met inclusion criteria. At 1 year post-GKRS, the breakdown of Barrow Neurological Institute (BNI) score for pain relief was as follows: 77 (48%) score of I, 13 (8%) score of II, 37 (23%) score of III, 22 (14%) score of IV, and 13 (8%) score of V. Factors that were significantly associated with pain-free outcome at 1 year were: Typical form of TN (OR = 2.2 [1.1, 4.9], p = 0.049), No previous microvascular decompression (OR = 4.4 [1.6, 12.5], p = 0.005), Response to medical therapy (OR = 2.7 [1.1, 6.1], p = 0.018), and Seniority > 60 years (OR = 2.8 [1.4, 5.5], p = 0.003). The term "Trigeminal Neuralgia-RadioSurgery" was used to create the TN-RS acronym representing the significant factors. A stepwise increase in the median predicted probability of pain-free outcome at 1 year from 3% for patients with a score of 0 to 69% for patients with a maximum score of 4. CONCLUSION The TN-RS scoring system can assist clinicians in identifying patients that may benefit from GNRS for TN by predicting 1-year pain-free outcomes.
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Affiliation(s)
- Alon Orlev
- Swedish Neuroscience Institute, Seattle, WA, USA.
- Department of Neurosurgery, Rabin Medical Center, Affiliated to Sackler Medical School, 39 Jabotynski St., 49414, Petach Tikva, Israel.
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gil Kimchi
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Affiliated to Sackler Medical School, Tel-Aviv University, Tel-Aviv, Israel
| | - Lian Sun
- Department of Biology, University of Washington, Bothell, WA, USA
| | | | - Cristian Gragnaniello
- Swedish Neuroscience Institute, Seattle, WA, USA
- Department of Neurosurgery, Long School of Medicine, University of Texas, San Antonio, TX, USA
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Wang JJ, Zhao Z, Chai SS, Wang YH, Xiang W. Microvascular decompression as a second step treatment for trigeminal neuralgia in patients with failed two-isocentre gamma knife radiosurgery. Neurosurg Rev 2021; 45:783-791. [PMID: 34292437 DOI: 10.1007/s10143-021-01587-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/12/2021] [Accepted: 06/12/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Subsequent microvascular decompression (MVD) might be affected by the previous two-isocentre gamma knife radiosurgery (GKS) due to the tissue changes caused by its higher dose radiation and larger treatment volume. This study aimed to evaluate the safety and efficacy of MVD as a second step treatment after two-isocentre GKS. METHODS Between December 2016 and May 2019, data from 19 consecutive trigeminal neuralgia (TN) patients who experienced MVD after failed two-isocentre GKS were collected. The clinical characteristics, intraoperative findings, surgical outcomes and complications were reviewed and compared with 158 patients who underwent MVD as an initial treatment. RESULTS Fifteen patients (78.9%) achieved complete pain relief (Barrow Neurological Institute, BNI class I) immediately after surgery and nine patients (47.4%) maintained complete pain relief at the last follow-up, which was similar to patients who underwent initial MVD. The median follow-up period was 36 months. The incidence of new or worsened facial numbness showed no statistical significance between the groups. During surgery, trigeminal nerve atrophy was noted in 9 patients (47.4%), thickened arachnoid in 3 patients (15.8%), atherosclerotic plaque in 3 patients (15.8%) and neurovascular adhesion in 1 patient (5.3%). CONCLUSIONS MVD remains an effective and safe rescue therapy for patients who elect the minimally invasive treatment with two-isocentre GKS for the first time, without an increased risk of facial numbness.
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Affiliation(s)
- Jia-Jing Wang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, 430022, People's Republic of China
| | - Zhen Zhao
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, 430022, People's Republic of China
| | - Song-Shan Chai
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, 430022, People's Republic of China
| | - Yi-Hao Wang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, 430022, People's Republic of China
| | - Wei Xiang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, 430022, People's Republic of China.
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Barzaghi LR, Albano L, Scudieri C, Gigliotti CR, Del Vecchio A, Mortini P. Factors affecting long-lasting pain relief after Gamma Knife radiosurgery for trigeminal neuralgia: a single institutional analysis and literature review. Neurosurg Rev 2021; 44:2797-2808. [PMID: 33432463 DOI: 10.1007/s10143-021-01474-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/16/2020] [Accepted: 01/05/2021] [Indexed: 12/29/2022]
Abstract
Gamma Knife radiosurgery (GKRS) is a well-established safe and effective treatment for trigeminal neuralgia (TN) with high initial success rate (80-90%). Why the pain relief is progressively decreased with time is a matter of considerable debate. To investigate factors related to long-lasting pain relief, the authors conducted a retrospective analysis focusing on anatomical and radiosurgical related parameters, chosen according to literature review. One hundred and twelve patients with classical trigeminal neuralgia and follow-up longer than 12 months were selected from our institutional consecutive series of patients treated by GKRS. Patients were followed for a mean period of 61.5 ± 3.5 months (range, 12-126 months) to evaluate, as endpoints, long-term pain relief and hypoesthesia onset. The median maximum radiation dose was 80 Gy (range 70-90 Gy). Factors related to poor long-term pain relief were prescription dose < 80 Gy (p = 0.038), calibration dose rate < 2.5 Gy/min (p = 0.018), and distance between isocenter and trigeminal nerve emergence > 8 mm (p < 0.001). When analyzing patients who received 80 Gy as maximum dose without any sector blocking, we notice that ID50 < 2.7 mJ was predictive for longer period of pain control (p = 0.043). It was experienced also among patients in which a small volume of the nerve (< 35%) received more than 80% of the maximal dose, compared to those in which a larger volume of the nerve was irradiated with maximal dose (p 0.034). This last result was significant if the shot was 8 mm or less from the pons. Several single-patient anatomical and radiosurgical parameters should be considered to improve GKRS effectiveness.
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Affiliation(s)
- Lina R Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy.
| | - Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy.,Neuroimaging Research Unit, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - Claudia Scudieri
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
| | - Carmen R Gigliotti
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute and Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy
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Constanzo F, Silva RSD, de Almeida DB, Ferragut MA, Coelho Neto M, Toledo HV, Ramina R. Gamma knife radiosurgery for trigeminal neuralgia: first case series from Latin America. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 77:232-238. [PMID: 31090803 DOI: 10.1590/0004-282x20190027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 12/21/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Gamma Knife® radiosurgery (GKRS) for trigeminal neuralgia is an effective treatment with at least a 50% reduction of pain in 75-95% of patients. OBJECTIVE To present the first series of patients treated for trigeminal neuralgia using GKRS in Latin America. METHODS Retrospective analysis. Analysis consisted of time to improvement of symptoms, best Barrow Neurological Institute scale (BNI) score after procedure, time without pain, time to recurrence and post-procedural hypoesthesia. RESULTS Nineteen cases of classical trigeminal neuralgia were analyzed and three cases of symptomatic trigeminal neuralgia were described. Mean time from symptom onset to radiosurgery was 99.6 months, and 78.9% of patients had undergone invasive procedures before treatment. Patients were followed for a mean of 21.7 months. BNI I was achieved in 36.8%, IIIa in 21.1%, IIIb in 21.1%, IV in 5.3% and V in 15.7%. New hypoesthesia developed in 12.1% patients, which was associated with achieving BNI I after the procedure (p < 0.05). Time from diagnosis to GKRS was higher in patients who failed to achieve BNI I (143 vs. 76 months). The distance from the root entry zone in patients who achieved BNI I was greater than patients who did not (1.94 vs. 1.14 mm). Mean distance from the root entry zone in patients with new hypoesthesia was 2.85 mm vs. 1.06 mm (p = 0.06). CONCLUSION Clinical response to GKRS is related to the time between diagnosis and procedure, thus its indication should be considered early in the management of these patients.
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Affiliation(s)
- Felipe Constanzo
- Instituto de Neurologia de Curitiba, Departamento de Neurocirurgia, Curitiba PR, Brasil
| | - Rodrigo Souza da Silva
- Instituto de Neurologia de Curitiba, Departamento de Anestesiologia, Curitiba PR, Brasil
| | - Daniel Benzecry de Almeida
- Instituto de Neurologia de Curitiba, Departamento de Neurocirurgia, Curitiba PR, Brasil.,Instituto de Neurologia de Curitiba, Departamento de Gamma Knife, Curitiba PR, Brasil
| | - Maria Alice Ferragut
- Instituto de Neurologia de Curitiba, Departamento de Gamma Knife, Curitiba PR, Brasil
| | - Mauricio Coelho Neto
- Instituto de Neurologia de Curitiba, Departamento de Neurocirurgia, Curitiba PR, Brasil.,Instituto de Neurologia de Curitiba, Departamento de Gamma Knife, Curitiba PR, Brasil
| | - Hugo Veroneze Toledo
- Instituto de Neurologia de Curitiba, Departamento de Gamma Knife, Curitiba PR, Brasil.,Clínica Paranaense de Tumores, Curitiba PR, Brasil
| | - Ricardo Ramina
- Instituto de Neurologia de Curitiba, Departamento de Neurocirurgia, Curitiba PR, Brasil
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Park SH, Chang JW. Gamma Knife Radiosurgery on the Trigeminal Root Entry Zone for Idiopathic Trigeminal Neuralgia: Results and a Review of the Literature. Yonsei Med J 2020; 61:111-119. [PMID: 31997619 PMCID: PMC6992458 DOI: 10.3349/ymj.2020.61.2.111] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/24/2019] [Accepted: 12/30/2019] [Indexed: 01/03/2023] Open
Abstract
Trigeminal neuralgia (TN) is a chronic disorder of the trigeminal nerve characterized by repeated electrical shock-like sensations on one side of the face. It can cause severe pain in the face and disrupt or impair quality of life in patients. Options for the management of TN consist of pharmacological and surgical treatments, including Gamma Knife radiosurgery (GKRS). GKRS has been used for TN for a long time because of its low rate of complications and high success rate. Moreover, GKRS can be of use for drug-resistant TN patients who are poor surgical candidates due to medical comorbidities, patients of older age, or patients who refuse invasive therapy. We reviewed the rationale, effects, safety, and current treatment policies of GKRS for TN in view of our institution's results and a review of the literature to date.
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Affiliation(s)
- So Hee Park
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.
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Efficacy of coblation versus radiofrequency thermocoagulation for the clinical treatment of trigeminal neuralgia. Wideochir Inne Tech Maloinwazyjne 2020; 15:620-624. [PMID: 33294078 PMCID: PMC7687662 DOI: 10.5114/wiitm.2020.92409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/06/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction Postoperative facial numbness is the main complication of radiofrequency thermocoagulation in treating trigeminal neuralgia, which could seriously affect the surgical efficacy. This problem is expected to be resolved by coblation technique. Aim To compare the long-term efficacy and safety of coblation and percutaneous trigeminal radiofrequency thermocoagulation (PT-RFT) under fluoroscopic guidance in the treatment of trigeminal neuralgia (TN). Material and methods A case-control prospective study was carried out. Patients with TN were randomly scheduled to receive coblation or PT-RFT. Both surgical procedures were performed under fluoroscopic guidance. The data, including the degree of pain, pain relief and complications, were recorded during follow-up evaluation, which was performed on the first day and at the end of the first month, third month, sixth month and first year after surgery. Results A total of 50 patients were enrolled in this study, with 25 patients in each group. The visual analog scale (VAS) scores in both groups at each time point after surgery were significantly lower compared with before surgery (p < 0.05). There were no significant differences in VAS scores or pain relief between the two groups at any time point after surgery (p > 0.05). However, patients in the PT-RFT group exhibited greater facial numbness after surgery (p < 0.05). For other complications, there were no significant differences between the two groups (p > 0.05). Conclusions Coblation and PT-RFT showed similar effectiveness in reducing pain; however, coblation was associated with a lower rate of postoperative facial numbness. Therefore, coblation may be a better treatment option for TN.
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Romanelli P, Conti A, Redaelli I, Martinotti AS, Bergantin A, Bianchi LC, Beltramo G. Cyberknife Radiosurgery for Trigeminal Neuralgia. Cureus 2019; 11:e6014. [PMID: 31815078 PMCID: PMC6881081 DOI: 10.7759/cureus.6014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Image-guided robotic radiosurgery is an emerging minimally-invasive treatment option for trigeminal neuralgia (TN). Our group has treated 560 cases up to date, and report here the clinical outcomes of 387 treatments with three years follow-up. This study represents the largest single-center experience on CyberKnife radiosurgery for the treatment of TN so far reported. Methods CyberKnife radiosurgery treatment was offered to patients with drug-resistant TN, after the failure of other treatments or refusal of invasive procedures. A second treatment was offered to patients with a poor response after the first treatment or with recurrent pain. Treatment protocol required the non-isocentric delivery of 60 Gy prescribed to the 80% isodose to a 6 mm retrogasserian segment of the affected trigeminal nerve. Retreatments typically received 45 Gy, again prescribed to the 80% isodose. The final plan was developed accordingly to individual anatomy and dose distribution over the trigeminal nerve, gasserian ganglion, and brainstem. Clinical outcomes such as pain control and hypoesthesia/numbness have been evaluated after 6, 12, 24, and 36 months. Results Our group has treated 527 patients with Cyberknife radiosurgery at Centro Diagnostico Italiano (CDI), Milan, Italy, during the last decade. A minimum follow-up of six months was available on 496 patients. These patients received 560 treatments: 435 patients (87.7%) had a single treatment, 60 patients (12.1%) had two treatments, and one patient (0.2%) had five treatments (two on the right side, three on the left side). Twenty four patients had multiple sclerosis (4.8%). Four hundred and forty-three patients (84%) received the treatment without previous procedures, while 84 patients (16%) underwent radiosurgery after the failure of other treatments. A neurovascular conflict was identified in 59% of the patients. Three hundred and forty-three patients (receiving a total of 387 treatments) had a minimum of 36 months follow up. Pain relief rate at 6, 12, 18, 24, 30 and 36 months was respectively 92, 87, 87, 82, 78 and 76%. Forty-four patients out of 343 (12.8%) required a second treatment during the observed period. At 36 months post-treatment, 21 patients (6,1%) reported the presence of bothering facial hypoesthesia. Eighteen patients out of 21 (85.7%) developed this complication after a repeated treatment. Conclusions Frameless image-guided robotic radiosurgery in experienced hands is a safe and effective procedure for the treatment of TN, providing excellent pain control rates in the absence of major neurological complications. Repeated treatments due to recurrent pain are associated with restored pain control but at the price of a higher rate of sensory complications.
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Affiliation(s)
- Pantaleo Romanelli
- Neurosurgery, Cyberknife Center, Centro Diagnostico Italiano, Milano, ITA
| | | | - Irene Redaelli
- Medical Physics, Cyberknife Center, Centro Diagnostico Italiano, Milano, ITA
| | | | - Achille Bergantin
- Medical Physics, Cyberknife Center, Centro Diagnostico Italiano, Milano, ITA
| | | | - Giancarlo Beltramo
- Radiation Oncology, Cyberknife Center, Centro Diagnostico Italiano, Milano, ITA
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Tavakol S, Jackanich A, Strickland BA, Marietta M, Ravina K, Yu C, Chang EL, Giannotta S, Zada G. Effectiveness of Gamma Knife Radiosurgery in the Treatment of Refractory Trigeminal Neuralgia: A Case Series. Oper Neurosurg (Hagerstown) 2019; 18:571-576. [DOI: 10.1093/ons/opz311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/29/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Medical management is the first line of treatment for trigeminal neuralgia (TN). Patients with medically refractory TN may undergo a variety of invasive surgical interventions with varying success rates. Management of TN refractory to both medical and surgical intervention remains somewhat controversial.
OBJECTIVE
To assess the effectiveness of Gamma Knife radiosurgery (GKRS; Elekta Instruments AB) for medically refractory TN.
METHODS
A retrospective review was conducted for 57 cases (47 patients) who underwent GKRS for refractory TN at our institution between 2005 and 2018. TN pain outcomes were evaluated using the Barrow Neurological Institute (BNI) Pain Scale. A good outcome was defined by post-GKRS BNI score of I-III, whereas treatment failure was defined BNI score IV-V.
RESULTS
Of the total 57 GKRS procedures, 47 (82.5%) had good outcomes. A total of 22 patients (46.8%) experienced complete pain relief off medications (BNI I). The average time to pain relief was 30 d (range 1-120 d). Prior invasive surgical treatment for TN was not found to have a significant impact on GKRS outcomes (P = .32). Target and treatment volumes were not found to correlate significantly with GKRS outcomes (.47 and .47, respectively). Complications included 2 cases (4.2%) of facial numbness. A total of 37 patients (78.7%) did not have any additional invasive surgical interventions following GKRS treatment.
CONCLUSION
GKRS is a safe and effective treatment modality for both medically and surgically refractory TN. Complete symptom relief was possible in patients with prior surgical or GKRS treatments. Recurrent symptoms following surgery or GKRS should not exclude a patient from future GKRS consideration.
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Affiliation(s)
- Sherwin Tavakol
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Anna Jackanich
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael Marietta
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kristine Ravina
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Cheng Yu
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steven Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Somaza S, Montilla EM, Mora MC. Gamma knife radiosurgery on the trigeminal ganglion for idiopathic trigeminal neuralgia: Results and review of the literature. Surg Neurol Int 2019; 10:89. [PMID: 31528427 PMCID: PMC6744789 DOI: 10.25259/sni-134-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/21/2019] [Indexed: 11/04/2022] Open
Abstract
Background In the present study, we evaluate the results of gamma knife surgery (GKS) for the treatment of trigeminal neuralgia (TN) using the trigeminal ganglion (TG') and the adjacent fibers of trigeminal nerve as a target. Methods From February 2013 to July 2017, we treated 30 cases of TN with GKS. In this group, all patients had an idiopathic typical TN. The radiosurgical target was conformed through two isocenters, 8 and 4 mm at the cavum de Meckel. The maximum dose was 86 Gy using the isodose line of 50%. The median age of the patients was 58.5 (range 28-94) years old, and the median time from diagnosis to GKS was 94 months (range 13-480 months). The median follow-up was 28.5 (range 12-49) months. Clinical outcomes were analyzed. Univariate and multivariate analyses were performed to evaluate factors that correlated with a favorable, pain-free outcome. Results The mean time to relief of pain was 7 (range 1-40) days. The percentage of patients with significant pain relief was 93.3%. Relapse in pain was noted in four patients at 3, 16, 19, and 36 months. Nine patients were treated in acute status. Fourteen patients had intense pain between 1 and 7 days before the procedure. Among those with the recurrence of their symptoms, one patient had a microvascular decompression. Multivariate regression adjusted for age and sex suggests that, by 40 months, 70% of the patients treated with radiosurgery will remain pain free. At the last follow-up, GKS resulted in pain relief in 86.6% of patients. Our analysis suggests that, using this technique, we can expect that approximately 70% of patients with TN will have some degree of pain improvement at 3 years' post radiosurgery. Conclusions GKS on TG appears to be a reasonable treatment option with short latency period, minor collateral effects, and high percentage of pain control. The mechanism of action of radiosurgery could be related to the inactivation of the satellite glial cells in the TG.
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Affiliation(s)
- Salvador Somaza
- Departments of Neurosurgery, Centro Diagnostico Docente Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Eglee M Montilla
- Departments of Radiation Oncology, Centro Diagnostico Docente Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Maria C Mora
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, United States
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Sjölund J, Riad S, Hennix M, Nordström H. A linear programming approach to inverse planning in Gamma Knife radiosurgery. Med Phys 2019; 46:1533-1544. [PMID: 30746722 PMCID: PMC6850474 DOI: 10.1002/mp.13440] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 12/19/2018] [Accepted: 01/15/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose Leksell Gamma Knife® is a stereotactic radiosurgery system that allows fine‐grained control of the delivered dose distribution. We describe a new inverse planning approach that both resolves shortcomings of earlier approaches and unlocks new capabilities. Methods We fix the isocenter positions and perform sector‐duration optimization using linear programming, and study the effect of beam‐on time penalization on the trade‐off between beam‐on time and plan quality. We also describe two techniques that reduce the problem size and thus further reduce the solution time: dualization and representative subsampling. Results The beam‐on time penalization reduces the beam‐on time by a factor 2–3 compared with the naïve alternative. Dualization and representative subsampling each leads to optimization time‐savings by a factor 5–20. Overall, we find in a comparison with 75 clinical plans that we can always find plans with similar coverage and better selectivity and beam‐on time. In 44 of these, we can even find a plan that also has better gradient index. On a standard GammaPlan workstation, the optimization times ranged from 2.3 to 26 s with a median time of 5.7 s. Conclusion We present a combination of techniques that enables sector‐duration optimization in a clinically feasible time frame.
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Affiliation(s)
- J Sjölund
- Elekta Instrument AB, Kungstensgatan 18, Box 7593, SE-103 93, Stockholm, Sweden
| | - S Riad
- Elekta Instrument AB, Kungstensgatan 18, Box 7593, SE-103 93, Stockholm, Sweden
| | - M Hennix
- Elekta Instrument AB, Kungstensgatan 18, Box 7593, SE-103 93, Stockholm, Sweden
| | - H Nordström
- Elekta Instrument AB, Kungstensgatan 18, Box 7593, SE-103 93, Stockholm, Sweden
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Yang AI, McShane BJ, Hitti FL, Sandhu SK, Chen HI, Lee JYK. Patterns of opioid use in patients with trigeminal neuralgia undergoing neurosurgery. J Neurosurg 2019; 131:1805-1811. [PMID: 30641832 DOI: 10.3171/2018.8.jns1893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE First-line treatment for trigeminal neuralgia (TN) is pharmacological management using antiepileptic drugs (AEDs), e.g., carbamazepine (CBZ) and oxcarbazepine (OCBZ). Surgical intervention has been shown to be an effective and durable treatment for TN that is refractory to medical therapy. Despite the lack of evidence for efficacy in patients with TN, the authors hypothesized that patients with neuropathic facial pain are prescribed opioids at high rates, and that neurosurgical intervention may lead to a reduction in opioid use. METHODS This is a retrospective study of patients with facial pain seen by a single neurosurgeon. All patients completed a survey on pain medications, medical comorbidities, prior interventions for facial pain, and a validated pain outcome tool (the Penn Facial Pain Scale). Patients subsequently undergoing neurosurgical intervention completed a survey at the 1-month follow-up in the office, in addition to telephone interviews using a standardized script between 1 and 6 years after intervention. Univariate and multivariate logistic regression were used to predict opioid use. RESULTS The study cohort consisted of 309 patients (70% Burchiel type 1 TN [TN1], 18% Burchiel type 2 [TN2], 6% atypical facial pain [AFP], and 6% TN secondary to multiple sclerosis [TN-MS]). At initial presentation, 20% of patients were taking opioids. Of these patients, 55% were receiving concurrent opioid therapy with CBZ/OCBZ, and 84% were receiving concurrent therapy with at least one type of AED. Facial pain diagnosis (for diagnoses other than TN1, odds ratio [OR] 2.5, p = 0.01) and facial pain intensity at its worst (for each unit increase, OR 1.4, p = 0.005) were predictors of opioid use at baseline. Neurosurgical intervention led to a reduction in opioid use to 8% at long-term follow-up (p < 0.01, Fisher's exact test; n = 154). Diagnosis (for diagnoses other than TN1, OR 4.7, p = 0.002) and postintervention reduction in pain at its worst (for each unit reduction, OR 0.8, p < 10-3) were predictors of opioid use at long-term follow-up. On subgroup analysis, patients with TN1 demonstrated a decrease in opioid use to 5% at long-term follow-up (p < 0.05, Fisher's exact test), whereas patients with non-TN1 facial pain did not. In the nonsurgical group, there was no statistically significant decrease in opioid use at long-term follow-up (n = 81). CONCLUSIONS In spite of its high potential for abuse, opioid use, mostly as an adjunct to AEDs, is prevalent in patients with facial pain. Opportunities to curb opioid use in TN1 include earlier neurosurgical intervention.
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Romanelli P, Conti A, Bianchi L, Bergantin A, Martinotti A, Beltramo G. Image-Guided Robotic Radiosurgery for Trigeminal Neuralgia. Neurosurgery 2018; 83:1023-1030. [PMID: 29294132 PMCID: PMC6195178 DOI: 10.1093/neuros/nyx571] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 12/06/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Frameless, non-isocentric irradiation of an extended segment of the trigeminal nerve introduces new concepts in stereotactic radiosurgery for medically resistant trigeminal neuralgia (TN). OBJECTIVE To report the results of the largest single-center experience about image-guided robotic radiosurgery for TN. METHODS A cohort of 138 patients treated with CyberKnife® (Accuray Incorporated, Sunnyvale, California) radiosurgery with a minimum follow-up of 36 mo were recruited. Pain relief, medications, sensory disturbances, rate and time of pain recurrence were prospectively analyzed. RESULTS Median follow-up was 52.4 mo; median dose 75 Gy; median target length 5.7-mm; median target volume 40 mm³; median prescription dose 60 Gy (80% isodose line). Actuarial pain control rate (Barrow Neurological Institute [BNI] class I-IIIa) at 6, 12, 24, and 36 mo were 93.5%, 85.8%, 79.7%, and 76%, respectively. Overall, 33 patients (24%) required a second treatment. Overall, 18.1% developed sensory disturbances after 16.4 ± 8.7 mo. One patient (0.7%) developed BNI grade IV dysfunction; 6 (4.3%) developed BNI grade III (somewhat bothersome) hypoesthesia after retreatment; BNI grade II (not bothersome) hypoesthesia was reported by 18 patients (11 after retreatment). Shorter nerve length (<6 mm vs 6 mm), smaller nerve volume (<30 mm3 vs >30 mm3), and lower prescription dose (<58 vs >58 Gy) were associated with treatment failure (P = .01, P = .02, P = .03, respectively). Re-irradiation independently predicted sensory disturbance (P < .001). CONCLUSION Targeting a 6-mm segment of the trigeminal nerve with a prescribed dose of 60 Gy appears safe and effective. Persistent pain control was achieved in most patients with acceptable risk of sensory complications, which were typically found after re-irradiation.
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Affiliation(s)
| | - Alfredo Conti
- Department of Neurosurgery, University of Messina, Messina, Italy
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Mitrasinovic S, Zhang M, Appelboom G, Sussman E, Moore JM, Hancock SL, Adler JR, Kondziolka D, Steinberg GK, Chang SD. Milestones in stereotactic radiosurgery for the central nervous system. J Clin Neurosci 2018; 59:12-19. [PMID: 30595165 DOI: 10.1016/j.jocn.2018.09.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Since Lars Leksell developed the first stereotactic radiosurgery (SRS) device in 1951, there has been growth in the technologies available and clinical indications for SRS. This expansion has been reflected in the medical literature, which is built upon key articles and institutions that have significantly impacted SRS applications. Our aim was to identify these prominent works and provide an educational tool for training and further inquiry. METHOD A list of search phrases relating to central nervous system applications of stereotactic radiosurgery was compiled. A topic search was performed using PubMed and Scopus databases. The journal, year of publication, authors, treatment technology, clinical subject, study design and level of evidence for each article were documented. Influence was proposed by citation count and rate. RESULTS Our search identified a total of 10,211 articles with the top 10 publications overall on the study of SRS spanning 443-1313 total citations. Four articles reported on randomized controlled trials, all of which evaluated intracranial metastases. The most prominent subtopics included SRS for arteriovenous malformation, glioblastoma, and acoustic neuroma. Greatest representation by treatment modality included Gamma Knife, LINAC, and TomoTherapy. CONCLUSIONS This systematic reporting of the influential literature on SRS for intracranial and spinal pathologies underscores the technology's rapid and wide reaching clinical applications. Moreover the findings provide an academic guide to future health practitioners and engineers in their study of SRS for neurosurgery.
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Affiliation(s)
- Stefan Mitrasinovic
- Department of Neurosurgery, Stanford University School of Medicine, Stanford Health Care and Stanford Children's Health, Stanford Neuroscience Health Center, 213 Quarry Road, Palo Alto, CA 94304-5979, United States
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford Health Care and Stanford Children's Health, Stanford Neuroscience Health Center, 213 Quarry Road, Palo Alto, CA 94304-5979, United States
| | - Geoff Appelboom
- Department of Neurosurgery, Stanford University School of Medicine, Stanford Health Care and Stanford Children's Health, Stanford Neuroscience Health Center, 213 Quarry Road, Palo Alto, CA 94304-5979, United States.
| | - Eric Sussman
- Department of Neurosurgery, Stanford University School of Medicine, Stanford Health Care and Stanford Children's Health, Stanford Neuroscience Health Center, 213 Quarry Road, Palo Alto, CA 94304-5979, United States
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, 110 Francis Street, Lowry Suite 3B, Boston, MA 02215-5501, United States
| | - Steven L Hancock
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford Health Care and Stanford Children's Health, Stanford Cancer Center, MC 5847, 875 Blake Wilbur Dr, Stanford, CA 94305-5847, United States
| | - John R Adler
- Department of Neurosurgery, Stanford University School of Medicine, Stanford Health Care and Stanford Children's Health, Stanford Neuroscience Health Center, 213 Quarry Road, Palo Alto, CA 94304-5979, United States
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, 530 First Avenue, Suite 8R, New York, NY 10016, United States
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford Health Care and Stanford Children's Health, Stanford Neuroscience Health Center, 213 Quarry Road, Palo Alto, CA 94304-5979, United States
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford Health Care and Stanford Children's Health, Stanford Neuroscience Health Center, 213 Quarry Road, Palo Alto, CA 94304-5979, United States
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Mhatre VR, Chadha P, Kumar AP, Talapatra K. Dosimetric Comparison of 6 MV Flattening Filter Free and 6 MV Stereotactic Radiosurgery Beam Using 4 mm Conical Collimator for Trigeminal Neuralgia Radiosurgery. ACTA ACUST UNITED AC 2018. [DOI: 10.14407/jrpr.2018.43.3.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Rashid A, Pintea B, Kinfe TM, Surber G, Hamm K, Boström JP. LINAC stereotactic radiosurgery for trigeminal neuralgia -retrospective two-institutional examination of treatment outcomes. Radiat Oncol 2018; 13:153. [PMID: 30134992 PMCID: PMC6106738 DOI: 10.1186/s13014-018-1102-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In this pooled 2-center series LINAC radiosurgery (SRS) has been applied as a treatment option for a subset of refractory trigeminal neuralgia (TN) patients. This study approached to retrospectively assess the efficacy and safety of LINAC SRS and to provide a brief overview addressed to the technical development from frame-based towards frameless robotic SRS. METHODS From 2001 to 2017 n = 55 patients (pts) were treated, n = 28 were female (51%), mean age: 66 years (range 36-93 years); TN etiology: 37 classic TN, 15 multiple sclerosis (MS)-related TN, 2 symptomatic TN, and 1 atypical TN. Previous treatment was present in n = 35 (63.6%) pts. (some multiple or combined) with n = 23 microsurgical vascular decompression and n = 17 percutaneous retrogasserian rhizotomy. A 6 MV LINAC (4-5 mm collimators) was applied in all pts. (n = 26 framebased - n = 29 frameless robotic). The dorsal root entry zone (DREZ) was targeted in n = 35 cases and the retrogasserian target in n = 20 pts. with a homogeneous dose for the entire study cohort (90 Gy). SRS outcome was measured using the Barrow Neurological Institute (BNI) score for pain and hypaesthesia and statistically evaluated by univariate and multivariate analyzes. RESULTS Mean follow-up (FU) was 30 months (2 lost FU); the total rate of post SRS BNI pain I-IIIa (=painfree w or w/o medication) was 69% (88% for the classic TN pts), 29% (38.8% classic TN) were classified as BNI pain I-II (=painfree w/o medication). A BNI hypaesthesia II-III was present in 9.4% (n = 5) and BNI hypaesthesia IV in n = 2. Between groups analysis demonstrated no correlation of SRS responsiveness with age, gender, MS- or not MS-associated TN, previous surgery, framebased/frameless robotic SRS. DREZ targeting significantly better suppressed TN compared to RG targeting (p = 0.01). Additionally, a statistical trend for a better BNI pain outcome (p = 0.07) along with a significant increase in BNI hypaesthesia (p = 0.01) was found when using a larger partial trigeminal 70 Gy volume. CONCLUSION Our retrospective analysis support LINAC SRS as an effective and safe treatment option in TN. Frameless robotic SRS of TN is safe when using a dedicated LINAC system. A target definition closer to the brainstem and tendencially a larger target volume were associated with a better outcome for pain.
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Affiliation(s)
- Ali Rashid
- Department of Radiosurgery and Stereotactic Radiotherapy, MediClin Robert Janker Clinic and MediClin MVZ Bonn, Villenstrasse 8, 53129, Bonn, Germany
| | - Bogdan Pintea
- Department of Neurosurgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Thomas M Kinfe
- Department of Psychiatry, Division of Medical Psychology, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Gunnar Surber
- CyberKnife Zentrum Mitteldeutschland, Nordhäuser Strasse 74, 99089, Erfurt, Germany
| | - Klaus Hamm
- CyberKnife Zentrum Mitteldeutschland, Nordhäuser Strasse 74, 99089, Erfurt, Germany
| | - Jan P Boström
- Department of Radiosurgery and Stereotactic Radiotherapy, MediClin Robert Janker Clinic and MediClin MVZ Bonn, Villenstrasse 8, 53129, Bonn, Germany. .,Department of Neurosurgery, University of Bonn Medical Center, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
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Amagasaki K, Nagayama M, Watanabe S, Shono N, Nakaguchi H. Acute Glaucoma Attack Following Microvascular Decompression Surgery for Trigeminal Neuralgia. Neurol Med Chir (Tokyo) 2018; 58:266-269. [PMID: 29769452 PMCID: PMC6002677 DOI: 10.2176/nmc.cr.2017-0251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Microvascular decompression (MVD) is widely accepted as an effective surgical method to treat trigeminal neuralgia (TN), but the risks of morbidity and mortality must be considered. We experienced a case of acute angle-closure glaucoma attack following MVD for TN in an elderly patient, considered to be caused by lateral positioning during and after the surgery. A 79-year-old female underwent MVD for right TN in the left lateral decubitus position, and TN disappeared after the surgery. Postoperatively, the patient tended to maintain the left lateral decubitus position to prevent wound contact with the pillow, even after ambulation. Two days after the surgery, she complained of persistent left ocular pain with visual disturbance. The left pupil was dilated with only light perception, and the intraocular pressure (IOP) was 44 mmHg. Acute angle-closure glaucoma attack was diagnosed. After drip infusion of mannitol, emergent laser iridotomy was performed. The corrected visual acuity recovered with normalization of IOP (14 mmHg). The subsequent clinical course was uneventful and she was discharged from our hospital. The left lateral positioning during and after the surgery was considered to have contributed to increase IOP of the eye on the dependent side, which resulted in acute angle-closure glaucoma attack. The potential pathology is difficult to assess preoperatively, but patient management should always consider the increased possibility of this condition with age.
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Affiliation(s)
| | | | | | - Naoyuki Shono
- Department of Neurosurgery, Mitsui Memorial Hospital
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Tuleasca C, Régis J, Sahgal A, De Salles A, Hayashi M, Ma L, Martínez-Álvarez R, Paddick I, Ryu S, Slotman BJ, Levivier M. Stereotactic radiosurgery for trigeminal neuralgia: a systematic review. J Neurosurg 2018; 130:733-757. [PMID: 29701555 DOI: 10.3171/2017.9.jns17545] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/11/2017] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The aims of this systematic review are to provide an objective summary of the published literature specific to the treatment of classical trigeminal neuralgia with stereotactic radiosurgery (RS) and to develop consensus guideline recommendations for the use of RS, as endorsed by the International Society of Stereotactic Radiosurgery (ISRS). METHODS The authors performed a systematic review of the English-language literature from 1951 up to December 2015 using the Embase, PubMed, and MEDLINE databases. The following MeSH terms were used in a title and abstract screening: "radiosurgery" AND "trigeminal." Of the 585 initial results obtained, the authors performed a full text screening of 185 studies and ultimately found 65 eligible studies. Guideline recommendations were based on level of evidence and level of consensus, the latter predefined as at least 85% agreement among the ISRS guideline committee members. RESULTS The results for 65 studies (6461 patients) are reported: 45 Gamma Knife RS (GKS) studies (5687 patients [88%]), 11 linear accelerator (LINAC) RS studies (511 patients [8%]), and 9 CyberKnife RS (CKR) studies (263 patients [4%]). With the exception of one prospective study, all studies were retrospective.The mean maximal doses were 71.1-90.1 Gy (prescribed at the 100% isodose line) for GKS, 83.3 Gy for LINAC, and 64.3-80.5 Gy for CKR (the latter two prescribed at the 80% or 90% isodose lines, respectively). The ranges of maximal doses were as follows: 60-97 Gy for GKS, 50-90 Gy for LINAC, and 66-90 Gy for CKR.Actuarial initial freedom from pain (FFP) without medication ranged from 28.6% to 100% (mean 53.1%, median 52.1%) for GKS, from 17.3% to 76% (mean 49.3%, median 43.2%) for LINAC, and from 40% to 72% (mean 56.3%, median 58%) for CKR. Specific to hypesthesia, the crude rates (all Barrow Neurological Institute Pain Intensity Scale scores included) ranged from 0% to 68.8% (mean 21.7%, median 19%) for GKS, from 11.4% to 49.7% (mean 27.6%, median 28.5%) for LINAC, and from 11.8% to 51.2% (mean 29.1%, median 18.7%) for CKR. Other complications included dysesthesias, paresthesias, dry eye, deafferentation pain, and keratitis. Hypesthesia and paresthesia occurred as complications only when the anterior retrogasserian portion of the trigeminal nerve was targeted, whereas the other listed complications occurred when the root entry zone was targeted. Recurrence rates ranged from 0% to 52.2% (mean 24.6%, median 23%) for GKS, from 19% to 63% (mean 32.2%, median 29%) for LINAC, and from 15.8% to 33% (mean 25.8%, median 27.2%) for CKR. Two GKS series reported 30% and 45.3% of patients who were pain free without medication at 10 years. CONCLUSIONS The literature is limited in its level of evidence, with only one comparative randomized trial (1 vs 2 isocenters) reported to date. At present, one can conclude that RS is a safe and effective therapy for drug-resistant trigeminal neuralgia. A number of consensus statements have been made and endorsed by the ISRS.
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Affiliation(s)
- Constantin Tuleasca
- 1Centre Hospitalier Universitaire Vaudois, Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center
- 4Signal Processing Laboratory (LTS 5), Ecole Politechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Jean Régis
- 11Department of Functional and Stereotactic Neurosurgery and Gamma Knife Unit, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Arjun Sahgal
- 5Department of Radiation Oncology, University of Toronto, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - Antonio De Salles
- 6Department of Neurosurgery, University of California, Los Angeles, California
| | - Motohiro Hayashi
- 7Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
| | - Lijun Ma
- 8Department of Radiation Oncology, Kyoto University, Kyoto, Japan
- 9Department of Radiation Oncology, University of California, San Francisco, California
| | | | - Ian Paddick
- 14Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Samuel Ryu
- 12Department of Radiation Oncology, Stony Brook University, Stony Brook, New York
| | - Ben J Slotman
- 13Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; and
| | - Marc Levivier
- 10Department of Neurosurgery, Ruber International Hospital, Madrid, Spain
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Abstract
OBJECTIVE The aim of this study was to describe and evaluate the long-term clinical outcome of "nerve combing" for trigeminal neuralgia (TN) without vascular compression. METHODS Fifteen patients with TN treated with microvascular decompression had no visible vascular compression intraoperatively. All of them underwent trigeminal nerve combing. RESULTS The long-term excellent relief was achieved in 73.3% of patients, 2 patients had good outcome, 1 patient experienced obvious partial relief, and the intensity of the residual pain was not severe enough to require medication. Three patients suffered facial numbness postoperatively, but it completely disappeared by 4 months after operation. CONCLUSION Nerve combing is an effective method in treating TN without vascular compression; however, further studies should be carried out to explore the possible mechanisms of underlying pain relief.
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Krishnan S, Bigder M, Kaufmann AM. Long-term follow-up of multimodality treatment for multiple sclerosis-related trigeminal neuralgia. Acta Neurochir (Wien) 2018; 160:135-144. [PMID: 29167978 DOI: 10.1007/s00701-017-3383-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 10/29/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The treatment for multiple sclerosis-related trigeminal neuralgia (MS-TN) is less efficacious and associated with higher recurrence rates than classical TN. No consensus has been reached in the literature on the choice procedure for MS-TN patients. The aim of this study was to assess the incidence and surgical outcomes of medically refractory MS-TN. METHODS Patient records were retrospectively reviewed for all Manitobans undergoing first procedure for medically refractory MS-TN between 2000 and 2014. Subsequent procedures were then recorded and analyzed in this subgroup of patients. The primary outcome measure was time to treatment failure. RESULTS The incidence of medically refractory MS-TN was 1.2/million/year. Twenty-one patients with 26 surgically treated sides underwent first rhizotomy including 13 GammaKnife and 13 percutaneous rhizotomies comprised of ten glycerol injections and three balloon compressions. Subsequent procedures were required on 23 sides (88%), including 24 GammaKnife, 19 glycerol injections, 25 balloon compressions, two microvascular decompressions, and four open partial surgical rhizotomies with a total of 99 surgeries on 26 sides (range, 1-12 each). CONCLUSIONS The majority of MS-TN patients become medically refractory and require multiple repeat surgical procedures. MS-TN procedures were associated with high rates of pain recurrence and our data suggests reoperation within 1 year is often necessary. Optimal management strategy in this patient population remains to be determined. Patients need to be counseled on managing expectations as treatments commonly afford only temporary relief.
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Affiliation(s)
- Sandeep Krishnan
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
- Health Sciences Centre, GB129-820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
| | - Mark Bigder
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.
- Health Sciences Centre, GB129-820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
| | - Anthony M Kaufmann
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
- Health Sciences Centre, GB129-820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
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Martínez Moreno NE, Gutiérrez-Sárraga J, Rey-Portolés G, Jiménez-Huete A, Martínez Álvarez R. Long-Term Outcomes in the Treatment of Classical Trigeminal Neuralgia by Gamma Knife Radiosurgery: A Retrospective Study in Patients With Minimum 2-Year Follow-up. Neurosurgery 2017; 79:879-888. [PMID: 27560193 DOI: 10.1227/neu.0000000000001404] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Gamma knife radiosurgery (GKRS) is one of the alternatives for treatment for classical trigeminal neuralgia (TN). OBJECTIVE To retrospectively analyze long-term outcomes for TN using GKRS achieved at our institution. METHODS One hundred seventeen patients with medically refractory TN treated by GKRS at our institution were followed up between 1993 and 2011. Mean maximum dose was 86.5 Gy (range: 80-90 Gy; median: 90 Gy). Clinical response was defined based on the Burchiel classification. We considered classes I and II as a complete response. For toxicity, we use the Barrow Neurological Institute facial numbness scale. Mean duration of follow-up was 66 months (range: 24-171 months). RESULTS Complete response at last follow-up in our patients was 81%, with an excellent response while off medication in 52%. Pain-free rates without medication (class I) were 85% at 3 years (confidence interval [CI]: 78%-94%), 81% at 5 years (CI: 72%-91%), and 76% at 7 years (CI: 65%-90%). Complete response rates (classes I-II) were 91% at 3 years (CI: 86%-97%), 86% at 5 years (CI: 79%-93%), and 82% at 7 years (CI: 72%-93%). Poor treatment response rates differed significantly between patients who had undergone previous surgery and were refractory to management with medication prior to GKRS. New or worsening facial numbness was reported in 32.5% (30% score II and 2.5% score III). No anesthesia dolorosa was reported. Permanent recurrence pain rate was 12%. CONCLUSION GKRS achieved favorable outcomes compared with surgery in terms of pain relief and complication rates in our cohort of patients, notwithstanding decreasing pain-free survival rates over time. We consider GKRS to be an initial treatment in the management of medically intractable TN in selected patients. ABBREVIATIONS CI, confidence intervalGKRS, gamma knife radiosurgeryMVD, microvascular decompressionRS, radiosurgeryTN, trigeminal neuralgia.
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Affiliation(s)
- Nuria E Martínez Moreno
- *Department of Functional Neurosurgery and Gamma Knife Radiosurgery, and ‡Department of Neurology, Ruber International Hospital, Madrid, Spain
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Zhao H, Shen Y, Yao D, Xiong N, Abdelmaksoud A, Wang H. Outcomes of Two-Isocenter Gamma Knife Radiosurgery for Patients with Typical Trigeminal Neuralgia: Pain Response and Quality of Life. World Neurosurg 2017; 109:e531-e538. [PMID: 29038085 DOI: 10.1016/j.wneu.2017.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/02/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of 2-isocenter Gamma Knife surgery (GKS) by reviewing patients with trigeminal neuralgia (TN) from the last 10 years. METHODS A total of 247 patients were followed up and the Barrow Neurological Institute scale was used to evaluate pain degree. Patients' age, gender, pain duration and location, preoperative/postoperative Barrow Neurological Institute scale score, time to initial pain relief, recurrence time, and complications were documented and analyzed. RESULTS Patients who underwent a 2-isocenter GKS achieved earlier initial pain relief. The median time of initial pain relief was 2.0 months. Kaplan-Meier analysis showed that the patients with a shorter history of TN and the patients without preoperative surgery achieved earlier initial pain relief. During the 122.8 months of follow-up, the median time of recurrence-free pain relief was 49.7 months. Age was found to be a risk factor of recurrence. Patients who underwent 2-isocenter GKS had a higher rate of postoperative facial numbness, but only 9 cases reported bothersome facial numbness. Multibranch involvement was a risk factor for postoperative facial numbness. CONCLUSIONS Compared with other modalities, 2-isocenter GKS was a safe and highly effective option for patients with TN. However, more data need to be collected to verify its long-term effect.
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Affiliation(s)
- Hongyang Zhao
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Huazhong, Hubei Province, China
| | - Yin Shen
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Huazhong, Hubei Province, China
| | - Dongxiao Yao
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Huazhong, Hubei Province, China
| | - Nanxiang Xiong
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Huazhong, Hubei Province, China
| | - Ahmed Abdelmaksoud
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Huazhong, Hubei Province, China
| | - Haijun Wang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Huazhong, Hubei Province, China.
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Gubian A, Rosahl SK. Meta-Analysis on Safety and Efficacy of Microsurgical and Radiosurgical Treatment of Trigeminal Neuralgia. World Neurosurg 2017; 103:757-767. [DOI: 10.1016/j.wneu.2017.04.085] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 11/30/2022]
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Kerolus MG, Sen N, Mayekar S, Templeton A, Turian J, Diaz A, Munoz L, Byrne RW, Sani S. Truebeam Radiosurgery for the Treatment of Trigeminal Neuralgia: Preliminary Results at a Single Institution. Cureus 2017; 9:e1362. [PMID: 28721330 PMCID: PMC5511044 DOI: 10.7759/cureus.1362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 06/16/2017] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Radiosurgery is now an established method of satisfactory pain control in patients with trigeminal neuralgia (TN). The Varian Truebeam STx (Varian Medical Systems, Palo Alto, CA) linear accelerator (LINAC) system is an arc-based, frameless stereotactic radiosurgery system used for the treatment of TN. To our knowledge, there has been only one published series of patient histories that documents the use of a frameless LINAC system for the treatment of TN. We describe the treatment parameters, patient outcomes, and complications associated with the treatment of TN. METHODS All patients treated with the Truebeam system for TN between 2012 and 2015, with at least a six-month follow-up, were identified. A dose of 90 Gy was delivered to the isocenter using a 0.5 cm diameter cone. The cisternal segment of the trigeminal nerve was placed at the location of the LINAC isocenter using an ExacTrac™ (Brainlab, Munich, Germany) image guidance system. The radiosurgical dose, Barrow Neurologic Institute pain score (BNI PS), symptom recurrence, magnetic resonance imaging (MRI) radiographic changes, and other complications, including Barrow Neurologic Institute facial numbness score (BNI FN), were analyzed. RESULTS A total of 18 patients-15 women and 3 men-with a mean age of 58 years (median: 59 years; range: 22-84 years) were treated at our institution. Fourteen patients (78%) had a BNI PS of IIIb or better, which was considered successful treatment. Twelve patients had excellent (BNI PS I) pain relief and two patients had good (BNI PS II-IIIB; recurrence after one year) pain relief. The pain of four patients recurred after a mean of 10 months. CONCLUSION Truebeam radiosurgery can provide effective and safe treatment for patients suffering from TN. The efficacy appears similar to other frame- and frameless-based systems.
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Affiliation(s)
| | - Neilayan Sen
- Radiation Oncology, Rush University Medical Center
| | | | | | | | - Aidnag Diaz
- Radiation Oncology, Rush University Medical Center
| | | | | | - Sepehr Sani
- Neurosurgery, Rush University Medical Center
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Cohen J, Mousavi SH, Faraji AH, Akpinar B, Monaco EA, Flickinger JC, Niranjan A, Lunsford LD. Stereotactic Radiosurgery as Initial Surgical Management for Elderly Patients with Trigeminal Neuralgia. Stereotact Funct Neurosurg 2017; 95:158-165. [DOI: 10.1159/000468526] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 03/02/2017] [Indexed: 11/19/2022]
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Conti A, Pontoriero A, Iatì G, Esposito F, Siniscalchi EN, Crimi S, Vinci S, Brogna A, De Ponte F, Germanò A, Pergolizzi S, Tomasello F. Frameless Stereotactic Radiosurgery for Treatment of Multiple Sclerosis-Related Trigeminal Neuralgia. World Neurosurg 2017; 103:702-712. [PMID: 28454993 DOI: 10.1016/j.wneu.2017.04.102] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 04/15/2017] [Accepted: 04/17/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Trigeminal neuralgia (TN) affects 7% of patients with multiple sclerosis (MS). In such patients, TN is difficult to manage either pharmacologically and surgically. Radiosurgical rhizotomy is an effective treatment option. The nonisocentric geometry of radiation beams of CyberKnife introduces new concepts in the treatment of TN. Its efficacy for MS-related TN has not yet been demonstrated. METHODS Twenty-seven patients with refractory TN and MS were treated. A nonisocentric beams distribution was chosen; the maximal target dose was 72.5 Gy. The maximal dose to the brainstem was <12 Gy. Effects on pain, medications, sensory disturbance, rate, and time of pain recurrence were analyzed. RESULTS Median follow-up was 37 (18-72) months. Barrow Neurological Institute pain scale score I-III was achieved in 23/27 patients (85%) within 45 days. Prescription isodose line (80%) accounting for a dose of 58 Gy incorporated an average of 4.85 mm (4-6 mm) of the nerve and mean nerve volume of 26.4 mm3 (range 20-38 mm3). Seven out of 27 patients (26%) had mild, not bothersome, facial numbness (Barrow Neurological Institute numbness score II). The rate of pain control decreased progressively after the first year, and only 44% of patients retained pain control 4 years later. CONCLUSIONS Frameless radiosurgery can be effectively used to perform retrogasserian rhizotomy. Pain relief was satisfactory and, with our dose/volume constraints, no sensory complications were recorded. Nonetheless, long-term pain control was possible in less than half of the patients. This is a limitation that CyberKnife radiosurgery shares with other techniques in MS patients.
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Affiliation(s)
- Alfredo Conti
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy.
| | - Antonio Pontoriero
- Unit of Radiation Oncology, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Giuseppe Iatì
- Unit of Radiation Oncology, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Felice Esposito
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Enrico Nastro Siniscalchi
- Unit of Maxillo-Facial Surgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Salvatore Crimi
- Unit of Maxillo-Facial Surgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Sergio Vinci
- Unit of Neuroradiology, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Anna Brogna
- Unit of Medical Physics, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Francesco De Ponte
- Unit of Maxillo-Facial Surgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Antonino Germanò
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Stefano Pergolizzi
- Unit of Radiation Oncology, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Francesco Tomasello
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
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Pokhrel D, Sood S, McClinton C, Saleh H, Badkul R, Jiang H, Stepp T, Camarata P, Wang F. Linac-based stereotactic radiosurgery (SRS) in the treatment of refractory trigeminal neuralgia: Detailed description of SRS procedure and reported clinical outcomes. J Appl Clin Med Phys 2017; 18:136-143. [PMID: 28300370 PMCID: PMC5689965 DOI: 10.1002/acm2.12057] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 11/28/2016] [Accepted: 01/11/2017] [Indexed: 11/23/2022] Open
Abstract
Purpose/Objectives To present our linac‐based SRS procedural technique for medically and/or surgically refractory trigeminal neuralgia (TN) treatment and simultaneously report our clinical outcomes. Materials and Methods Twenty‐seven refractory TN patients who were treated with a single fraction of 80 Gy to TN. Treatment delivery was performed with a 4 mm cone size using 7‐arc arrangement with differential‐weighting for Novalis‐TX with six MV‐SRS (1000 MU/min) beam and minimized dose to the brainstem. Before each treatment, Winston–Lutz quality assurance (QA) with submillimeter accuracy was performed. Clinical treatment response was evaluated using Barrow Neurological Institute (BNI) pain intensity score, rated from I to V. Results Out of 27 patients, 22 (81%) and 5 (19%) suffered from typical and atypical TN, respectively, and had median follow‐up interval of 12.5 months (ranged: 1–53 months). For 80 Gy prescriptions, delivered total average MU was 19440 ± 611. Average beam‐on‐time was 19.4 ± 0.6 min. Maximum dose and dose to 0.5 cc of brainstem were 13.4 ± 2.1 Gy (ranged: 8.4–15.9 Gy) and 3.6 ± 0.4 Gy (ranged: 3.0–4.9 Gy), respectively. With a median follow‐up of 12.5 months (ranged: 1–45 months) in typical TN patients, the proportion of patients achieving overall pain relief was 82%, of which half achieved a complete pain relief with BNI score of I‐II and half demonstrated partial pain reduction with BNI score of IIIA‐IIIB. Four typical TN patients (18%) had no response to radiosurgery treatment. Of the patients who responded to treatment, actuarial pain recurrence free survival rates were approximately 100%, 75%, and 50% at 12 months, 15 months, and 24 months, respectively. Five atypical TN patients were included, who did not respond to treatment (BNI score: IV–V). However, no radiation‐induced cranial‐toxicity was observed in all patients treated. Conclusion Linac‐based SRS for medically and/or surgically refractory TN is a fast, effective, and safe treatment option for patients with typical TN who had excellent response rates. Patients, who achieve response to treatment, often have durable response rates with moderate actuarial pain recurrence free survival. Longer follow‐up interval is anticipated to confirm our clinical observations.
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Affiliation(s)
- Damodar Pokhrel
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Sumit Sood
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Christopher McClinton
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Habeeb Saleh
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Rajeev Badkul
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Hongyu Jiang
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Timothy Stepp
- Department of Neurosurgery, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Paul Camarata
- Department of Neurosurgery, The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Fen Wang
- Department of Radiation Oncology, The University of Kansas Cancer Center, Kansas City, KS, USA
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Berger I, Nayak N, Schuster J, Lee J, Stein S, Malhotra NR. Microvascular Decompression Versus Stereotactic Radiosurgery for Trigeminal Neuralgia: A Decision Analysis. Cureus 2017; 9:e1000. [PMID: 28280653 PMCID: PMC5325747 DOI: 10.7759/cureus.1000] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Both microvascular decompression (MVD) and stereotactic radiosurgery (SRS) have been demonstrated to be effective in treating medically refractory trigeminal neuralgia. However, there is controversy over which one offers more durable pain relief and the patient selection for each treatment. We used a decision analysis model to calculate the health-related quality of life (QOL) for each treatment. METHODS We searched PubMed and the Cochrane Database of Systematic Reviews for relevant articles on MVD or SRS for trigeminal neuralgia published between 2000 and 2015. Using data from these studies, we modeled pain relief and complication outcomes and assigned QOL values. A sensitivity analysis using a Monte Carlo simulation determined which procedure led to the greatest QOL. RESULTS MVD produced a significantly higher QOL than SRS at a seven-year follow-up. Additionally, MVD patients had a significantly higher rate of complete pain relief and a significantly lower rate of complications and recurrence. CONCLUSIONS With a decision-analytic model, we calculated that MVD provides more favorable outcomes than SRS for the treatment of trigeminal neuralgia.
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Affiliation(s)
- Ian Berger
- School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Nikhil Nayak
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - James Schuster
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - John Lee
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Sherman Stein
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Neil R Malhotra
- Neurological Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
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Han KR, Chae YJ, Lee JD, Kim C. Trigeminal nerve block with alcohol for medically intractable classic trigeminal neuralgia: long-term clinical effectiveness on pain. Int J Med Sci 2017; 14:29-36. [PMID: 28138306 PMCID: PMC5278656 DOI: 10.7150/ijms.16964] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/01/2016] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Trigeminal nerve block (Tnb) with alcohol for trigeminal neuralgia (TN) may not be used widely as a percutaneous procedure for medically intractable TN in recent clinical work, because it has been considered having a limited duration of pain relief, a decrease in success rate and increase in complications on repeated blocks. OBJECTIVES To evaluate the clinical outcome of the Tnb with alcohol in the treatment of medically intractable TN. METHODS Six hundred thirty-two patients were diagnosed with TN between March 2000 and February 2010. Four hundred sixty-five out of 632 underwent Tnb with alcohol under a fluoroscope. Pain relief duration were analyzed and compared in the individual branch blocks. Outcomes were compared between patients with and without a previous Tnb with alcohol. RESULTS Tnb with alcohol were performed in a total 710 (1st-465, 2nd-155, 3rd-55, 4th-23, 5th-8, 6th-4) cases for a series of consecutive 465 patients during the study period. Forty hundred sixty two out of the 465 patients experienced immediate complete pain relief (99%) at the first Tnb. Of the 465 patients, 218 patients (46.9%) did not require any further treatment after the first Tnb with alcohol during an entire study period. One hundred fifty nine (34.2 %) out of the 465 patients experienced recurring pain after the first block, among whom 155 patients received subsequent blocks, and the remaining 4 patients decided to take medication. According to the Kaplan-Meier analysis, the probabilities of remaining pain relief for 1, 2, 3, and 5 years after the procedures were 86.2%, 65.5%, 52.5%, and 33.4%, respectively. There was no significant difference in the probability of pain relief duration between patients with and without previous Tnb with alcohol. Median (95% CI) pain relief durations of the first and repeated blocks were 39 (36-51) and 37 (28-54) months, respectively. There was no significant difference in occurrence of complications between patients with and without previous Tnb with alcohol (p <0.076). All the complications recovered spontaneously within 6 months. There was no mortality related to the procedure. CONCLUSIONS Tnb with alcohol for the pain management of TN can provide considerably long lasting pain relief. Repeated Tnb with alcohol has pain relief duration as long as the first block, and seems to produce less complication as well. Tnb with alcohol is a valuable treatment modality of TN as a percutaneous procedure.
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Affiliation(s)
| | - Yun Jeong Chae
- Anesthesiology and Pain medicine, Ajou University Hospital, Suwon Korea
| | - Jung Dong Lee
- Anesthesiology and Pain medicine, Ajou University Hospital, Suwon Korea
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Sharim J, Lo WL, Kim W, Chivukula S, Tenn S, Kaprealian T, Pouratian N. Radiosurgical target distance from the root entry zone in the treatment of trigeminal neuralgia. Pract Radiat Oncol 2016; 7:221-227. [PMID: 28336479 DOI: 10.1016/j.prro.2016.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 12/12/2016] [Accepted: 12/20/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) provides a noninvasive treatment modality for patients with medically refractory trigeminal neuralgia. The root entry zone (REZ) has been proposed to be an ideal stereotactic target because it is partially composed of centrally produced myelin, conferring a theoretical increased sensitivity to irradiation as well as increased susceptibility to neurovascular conflict, making it the site in which nociceptive signals likely arise. The aim of this study is to determine if there is a statistically and clinically significant difference in pain relief or facial hypesthesia following SRS based on distance of the stereotactic isocenter from REZ. METHODS AND MATERIALS Patients undergoing Novalis radiosurgery for the treatment of trigeminal neuralgia with at least 3 months' follow-up were included in this study. Postoperative outcomes were stratified by Barrow Neurological Institute (BNI) score for pain relief and BNI facial numbness score for facial hypesthesia. RESULTS Sixty-seven patients met inclusion criteria and were included in this study. BNI score of I-IIIa was attained in 82% of patients at 3 months and 65% at 1 year following SRS. Distance from isocenter to REZ varied from 0 to 8.6 mm, with a mean of 1.94 ± 1.62 mm. Logistic regression of target-REZ distance against pain relief outcome (patients with score I-IIIa and IIIb-V) was insignificant at 3 months (P = .988), 6 months (P = .925), 9 months (P = .845), and 12 months (P = .547) postoperatively. Furthermore, no significant correlation was found with logistic regression of target-REZ distance with pain relief outcome (patients with score I and score II-IV) (P = .544). CONCLUSIONS The current analysis suggests that distance from REZ does not correlate with degree of postoperative pain relief or facial hypesthesia; thus, targeting specific regions within the trigeminal nerve in relation to these anatomical characteristics may not afford any advantage from this perspective.
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Affiliation(s)
- Justin Sharim
- David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Wei-Lun Lo
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California; Division of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Doctoral Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University and National Health Research Institutes, Taipei, Taiwan
| | - Won Kim
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Srinivas Chivukula
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Stephen Tenn
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Tania Kaprealian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California; Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California; Brain Research Institute, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California; Neuroscience Interdepartmental Program, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.
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Delayed Development of Aneurysms Following Gamma Knife Surgery for Trigeminal Neuralgia: Report of 2 Cases. World Neurosurg 2016; 99:813.e13-813.e19. [PMID: 27890752 DOI: 10.1016/j.wneu.2016.11.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 11/13/2016] [Accepted: 11/15/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Delayed development of intracranial aneurysms is an extremely rare complication of gamma knife surgery (GKS), with only 6 cases been reported to date. There are no reported cases after GKS performed to treat trigeminal neuralgia (TN). Of the 6 aforementioned cases, none referred to the natural history or pathophysiology of GKS-related intracranial aneurysm formation. CASE DESCRIPTION We treated 2 patients with subarachnoid hemorrhage (SAH) resulting from rupture of an intracranial aneurysm that developed long after GKS. Case 1 involved a 77-year-old man who had undergone GKS to treat recurrent TN after microvascular decompression surgery. At 13 years after the GSK, he developed SAH from a ruptured left anterior inferior cerebellar artery in close vicinity to the left trigeminal nerve. He died from a premature rupture before intervention could be instituted. Case 2 involved a 72-year-old woman who developed SAH at 9 years after undergoing GKS for TN. A ruptured left superior cerebellar artery aneurysm was treated successfully with endovascular occlusion of the parent artery. She recovered well after the surgery, and was discharged to the rehabilitation hospital with a modified Rankin Scale score of 2. CONCLUSION Long-term observations are necessary after GKS performed for TN owing to the possibility of formation of intracranial aneurysms near the irradiated region.
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Kuncz A, Vörös E, Barzó P, Tajti J, Milassin P, Mucsi Z, Elek P, Benedek K, Tarjányi J, Bodosi M. Comparison of Clinical Symptoms and Magnetic Resonance Angiographic (MRA) Results in Patients with Trigeminal Neuralgia and Persistent Idiopathic Facial Pain. Medium-Term Outcome after Microvascular Decompression of Cases with Positive MRA Findings. Cephalalgia 2016; 26:266-76. [PMID: 16472332 DOI: 10.1111/j.1468-2982.2005.01030.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To evaluate whether NC could be demonstrated preoperatively, high-resolution magnetic resonance angiography (MRA) was performed in 287 consecutive patients with TN and persistent idiopathic facial pain (PIFP) on a 0.5-T and a 1-T MR unit. Depending on the clinical symptoms, the TN cases were divided into typical TN and trigeminal neuralgia with non-neuralgic interparoxysmal pain (TNWIP) groups. Microvascular decompression (MVD) was performed in 103 of the MRA-positive cases. The patients were followed up postoperatively for from 1 to 10 years. The clinical symptoms were compared with the imaging results. The value of MRA was assessed on the basis of the clinical symptoms and surgical findings. The outcome of MVD was graded as excellent, good or poor. The clinical symptoms were compared with the type of vascular compression and the outcome of MVD. The MRA image was positive in 161 (56%) of the 287 cases. There were significant differences between the clinical groups: 66.5% of the typical TN group, 47.5% of the TNWIP group and 3.4% of the PIFP group were positive. The quality of the MR unit significantly determined the ratio of positive/negative MRA results. The surgical findings corresponded with the MRA images. Six patients from the MRA-negative group were operated on for selective rhizotomy and no NC was found. Venous compression of the trigeminal nerve was observed in a significantly higher proportion in the background of TNWIP than in that of typical TN on MRA imaging (24.1% and 0.8%, respectively) and also during MVD (31.2% and 1.2%, respectively). Four years following the MVD, 69% of the patients gave an excellent, 23% a good and 8% a poor result. The rate of some kind of recurrence of pain was 20% in the typical TN and 44% in TNWIP group. The rate of recurrence was 57% when pure venous compression was present. The only patient who was operated on from the PIFP group did not react to the MVD. The clinical symptoms and preoperative MRA performed by at least a 1-T MR unit furnish considerable information, which can play a role in the planning of the treatment of TN.
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Affiliation(s)
- A Kuncz
- Department of Neurosurgery, Faculty of Medicine, University of Szeged, Szeged, Hungary.
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Taich ZJ, Goetsch SJ, Monaco E, Carter BS, Ott K, Alksne JF, Chen CC. Stereotactic Radiosurgery Treatment of Trigeminal Neuralgia: Clinical Outcomes and Prognostic Factors. World Neurosurg 2016; 90:604-612.e11. [DOI: 10.1016/j.wneu.2016.02.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 10/22/2022]
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Parikh RR, Goodman RR, Rhome R, Sudentas E, Trichter F, Harrison LB, Choi W. Linear accelerator-based flattening-filter-free stereotactic radiosurgery for trigeminal neuralgia: Feasibility and patient-reported outcomes. Pract Radiat Oncol 2016; 6:e1-7. [DOI: 10.1016/j.prro.2015.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/24/2015] [Accepted: 09/04/2015] [Indexed: 10/23/2022]
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Mousavi SH, Niranjan A, Huang MJ, Laghari FJ, Shin SS, Mindlin JL, Flickinger JC, Lunsford LD. Early radiosurgery provides superior pain relief for trigeminal neuralgia patients. Neurology 2015; 85:2159-65. [DOI: 10.1212/wnl.0000000000002216] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 08/21/2015] [Indexed: 11/15/2022] Open
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Application of MRI and intraoperative CT fusion images with integrated neuronavigation in percutaneous radiofrequency trigeminal rhizotomy. Acta Neurochir (Wien) 2015; 157:1443-8; discussion 1448. [PMID: 26066533 DOI: 10.1007/s00701-015-2459-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Percutaneous radiofrequency trigeminal rhizotomy (RF-TR) has been an effective treatment modality for medically refractory trigeminal neuralgia. Our group has established a protocol for this procedure that includes intraoperative computed tomography (iCT) navigation. The depth of the puncture needle in our protocol was based on cadaveric studies, and anatomical localization was mainly by electric stimulation test. The limitation of the invisibility of the trigeminal cistern on CT imaging and bias from the patient's subjective expression during neurophysiologic stimulation might affect the accuracy of the needle tip and the treatment effect.This study aimed to evaluate the feasibility and preliminary results of the application of magnetic resonance imaging (MRI) and iCT fusion imaging in RF-TR. METHOD The study included 13 patients who received RF-TR with iCT navigation and with recurrence within 3 years. Repeated RF-TR was performed with real-time guidance by MRI and iCT fusion imaging. RESULTS A pain-free or partial satisfactory response was reported with 12 patients (92 %). There was a statistically significant difference in the depth of the needle tip before and after application of MRI and iCT fusion imaging. CONCLUSIONS This preliminary study demonstrated that the application of MRI and iCT fusion could help with anatomical localization of the trigeminal cistern intraoperatively. The improvement in neuronavigation provides a choice in the treatment of recurrent or persistent trigeminal neuralgia after previous intervention. Long-term follow-up of the result is necessary to evaluate the benefit in terms of durability of therapeutic efficacy.
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Helis CA, Lucas JT, Bourland JD, Chan MD, Tatter SB, Laxton AW. Repeat Radiosurgery for Trigeminal Neuralgia. Neurosurgery 2015. [DOI: 10.1227/neu.0000000000000915] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Repeat Gamma Knife radiosurgery (GKRS) is an established option for patients whose pain has recurred after the initial procedure, with reported success rates varying from 68% to 95%. Predictive factors for response to the repeat GKRS are ill-defined.
OBJECTIVE:
This cohort study aimed to report the outcomes and factors predictive of success for patients who have undergone repeated GKRS for trigeminal neuralgia at Wake Forest University Baptist Medical Center.
METHODS:
Between 1999 and 2013, 152 patients underwent repeat GKRS at Wake Forest, 125 of whom were available for long-term follow-up. A retrospective chart review and telephone interviews were conducted to determine background medical history, dosimetric data, outcomes, and adverse effects of the procedure.
RESULTS:
Eighty-four percent of patients achieved at least Barrow Neurological Institute (BNI) IIIb pain relief, with 46% achieving BNI I. The 1-, 3-, and 5-year rates of BNI I pain relief were 63%, 50%, and 37%, respectively. The 1-, 3-, and 5-year rates of BNI IIIb or better pain relief were 74%, 59%, and 46%, respectively. One patient experienced bothersome numbness and 2 patients developed anesthesia dolorosa. The dominant predictive factors for pain relief were facial numbness after the first GKRS and a positive pain response to the first GKRS.
CONCLUSION:
Repeat GKRS is an effective method of treating recurrent trigeminal neuralgia. Patients who have facial numbness after the first treatment and a positive pain response to the first GKRS are significantly more likely to respond well to the second treatment.
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Affiliation(s)
- Corbin A. Helis
- Department of Neurosurgery, Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - John T. Lucas
- Department of Neurosurgery, Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - J. Daniel Bourland
- Department of Neurosurgery, Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Michael D. Chan
- Department of Neurosurgery, Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Stephen B. Tatter
- Department of Neurosurgery, Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Adrian W. Laxton
- Department of Neurosurgery, Radiation Oncology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Daugherty E, Bhavsar S, Hahn SS, Bassano D, Hall W. A successful case of multiple stereotactic radiosurgeries for ipsilateral recurrent trigeminal neuralgia. J Neurosurg 2015; 122:1324-9. [PMID: 25816083 DOI: 10.3171/2014.9.jns13959] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Trigeminal neuralgia is a common pain syndrome primarily managed medically, although many patients require surgical or radiotherapeutic intervention. Stereotactic radiosurgery has become a preferred method of treatment given its high efficacy rates and relatively favorable toxicity profile. However, many patients have refractory pain even after repeat courses of stereotactic radiosurgery. Historically, 2 courses have been the limit in such patients. The authors present a case of multiply recurrent trigeminal neuralgia treated with a third course of radiosurgery in which the patient had successful pain control and no additional toxicity. Meticulous attention to the therapeutic technique allows the continued application of stereotactic radiosurgery in patients.
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Affiliation(s)
| | - Shripal Bhavsar
- 2Department of Radiation Oncology, Integris Cancer Institute, Oklahoma City, Oklahoma
| | | | | | - Walter Hall
- 3Neurosurgery, SUNY Upstate Medical University, Syracuse, New York; and
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Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J, Levivier M, Régis J. Decreased Probability of Initial Pain Cessation in Classic Trigeminal Neuralgia Treated With Gamma Knife Surgery in Case of Previous Microvascular Decompression. Neurosurgery 2015; 77:87-94; discussion 94-5. [DOI: 10.1227/neu.0000000000000739] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Microvascular decompression (MVD) is the reference technique for pharmacoresistant trigeminal neuralgia (TN).
OBJECTIVE:
To establish whether the safety and efficacy of Gamma Knife surgery for recurrent TN are influenced by prior MVD.
METHODS:
Between July 1992 and November 2010, 54 of 737 patients (45 of 497 with >1 year of follow-up) had a history of MVD (approximately half also with previous ablative procedure) and were operated on with Gamma Knife surgery for TN in the Timone University Hospital. A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range, 3.9–11.9 mm) anterior to the emergence of the nerve. A median maximum dose of 85 Gy (range, 70–90 Gy) was delivered.
RESULTS:
The median follow-up time was 39.5 months (range, 14.1–144.6 months). Thirty-five patients (77.8%) were initially pain free in a median time of 14 days (range, 0–180 days), much lower compared with our global population of classic TN (P = .01). Their actuarial probabilities of remaining pain-free without medication at 3, 5, 7, and 10 years were 66.5%, 59.1%, 59.1%, and 44.3%. The hypoesthesia actuarial rate at 1 year was 9.1% and remained stable until 12 years (median, 8 months).
CONCLUSION:
Patients with previous MVD showed a significantly lower probability of initial pain cessation compared with our global population with classic TN (P = .01). The toxicity was low (only 9.1% hypoesthesia); furthermore, no patient reported bothersome hypoesthesia. However, the probability of maintaining pain relief without medication was 44.3% at 10 years, similar to our global series of classic TN (P = .85).
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Affiliation(s)
- Constantin Tuleasca
- Functional and Stereotactic Neurosurgery Unit, Centre Hospitalier Universitaire La Timone, Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, INSERM U 751, Marseille, France
- Signal Processing Laboratory (LTS 5), Swiss Federal Institute of Technology, Lausanne, Switzerland
- Medical Image Analysis Laboratory, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- Centre Hospitalier Universitaire Vaudois, Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland
- University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Romain Carron
- Functional and Stereotactic Neurosurgery Unit, Centre Hospitalier Universitaire La Timone, Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, INSERM U 751, Marseille, France
| | - Noémie Resseguier
- University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Anne Donnet
- Department of Neurology, Clinical Neuroscience Federation, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, Marseille, France
| | - Philippe Roussel
- Department of Neurology, Clinical Neuroscience Federation, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, Marseille, France
| | - Jean Gaudart
- Department of Public Health and Medical Information, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, UMR 912 (INSERM-IRD-Université de la Méditerranée), Marseille, France
| | - Marc Levivier
- Centre Hospitalier Universitaire Vaudois, Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland
- University of Lausanne, Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Jean Régis
- Functional and Stereotactic Neurosurgery Unit, Centre Hospitalier Universitaire La Timone, Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, INSERM U 751, Marseille, France
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Somaza S, Hurtado W, Montilla E, Ghaleb J. Gamma knife radiosurgery to the trigeminal ganglion for treatment of trigeminal neuralgia secondary to vertebrobasilar ectasia. Surg Neurol Int 2015; 5:S580-5. [PMID: 25593782 PMCID: PMC4287894 DOI: 10.4103/2152-7806.148056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 09/09/2014] [Indexed: 11/17/2022] Open
Abstract
Background: We report the result obtained using Gamma knife stereotactic radiosurgery on the trigeminal ganglion (TG) in a patient with trigeminal neuralgia (TN) secondary to vertebrobasilar ectasia (VBE). Case Description: Retrospective review of medical records corresponding to one patient with VBE-related trigeminal pain treated with radiosurgery. Because of the impossibility of visualization of the entry zone or the path of trigeminal nerve through the pontine cistern, we proceeded with stereotactic radiosurgery directed to the TG. The maximum radiation dose was 86 Gy with a 8-mm and a 4-mm collimator. The follow-up period was 24 months. The pain disappeared in 15 days, passing from Barrow Neurological Institute (BNI) grade V to BNI grade IIIa in 4 months and then to grade I. The patient did not experience noticeable subjective facial numbness. Conclusions: This experience showed that Gamma knife radiosurgery was effective in the management of VBE-related trigeminal pain, using the TG as radiosurgical target.
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Affiliation(s)
- Salvador Somaza
- Unit of Gamma Knife Radiosurgery, CDD Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Wendy Hurtado
- Unit of Gamma Knife Radiosurgery, CDD Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Eglee Montilla
- Unit of Gamma Knife Radiosurgery, CDD Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
| | - Jose Ghaleb
- Unit of Gamma Knife Radiosurgery, CDD Las Mercedes, Hospital de Clinicas Caracas, Caracas, Venezuela
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Tempel ZJ, Chivukula S, Monaco EA, Bowden G, Kano H, Niranjan A, Chang EF, Sneed PK, Kaufmann AM, Sheehan J, Mathieu D, Lunsford LD. The results of a third Gamma Knife procedure for recurrent trigeminal neuralgia. J Neurosurg 2015; 122:169-79. [DOI: 10.3171/2014.9.jns132779] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Gamma Knife radiosurgery (GKRS) is the least invasive treatment option for medically refractory, intractable trigeminal neuralgia (TN) and is especially valuable for treating elderly, infirm patients or those on anticoagulation therapy. The authors reviewed pain outcomes and complications in TN patients who required 3 radiosurgical procedures for recurrent or persistent pain.
METHODS
A retrospective review of all patients who underwent 3 GKRS procedures for TN at 4 participating centers of the North American Gamma Knife Consortium from 1995 to 2012 was performed. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes.
RESULTS
Seventeen patients were identified; 7 were male and 10 were female. The mean age at the time of last GKRS was 79.6 years (range 51.2–95.6 years). The TN was Type I in 16 patients and Type II in 1 patient. No patient suffered from multiple sclerosis. Eight patients (47.1%) reported initial complete pain relief (BNI Score I) following their third GKRS and 8 others (47.1%) experienced at least partial relief (BNI Scores II–IIIb). The average time to initial response was 2.9 months following the third GKRS. Although 3 patients (17.6%) developed new facial sensory dysfunction following primary GKRS and 2 patients (11.8%) experienced new or worsening sensory disturbance following the second GKRS, no patient sustained additional sensory disturbances after the third procedure. At a mean follow-up of 22.9 months following the third GKRS, 6 patients (35.3%) reported continued Score I complete pain relief, while 7 others (41.2%) reported pain improvement (BNI Scores II–IIIb). Four patients (23.5%) suffered recurrent TN following the third procedure at a mean interval of 19.1 months.
CONCLUSIONS
A third GKRS resulted in pain reduction with a low risk of additional complications in most patients with medically refractory and recurrent, intractable TN. In patients unsuitable for other microsurgical or percutaneous strategies, especially those receiving long-term oral anticoagulation or antiplatelet agents, GKRS repeated for a third time was a satisfactory, low risk option.
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Affiliation(s)
- Zachary J. Tempel
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | | | - Edward A. Monaco
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Greg Bowden
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Hideyuki Kano
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Ajay Niranjan
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | | | - Penny K. Sneed
- 4Radiation Oncology, University of California, San Francisco, California
| | - Anthony M. Kaufmann
- 5Department of Neurological Surgery, University of Manitoba Health Sciences Centre, Winnipeg, Manitoba; and
| | - Jason Sheehan
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David Mathieu
- 7Department of Neurological Surgery, Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - L. Dade Lunsford
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
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Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J, Levivier M, Régis J. Repeat Gamma Knife surgery for recurrent trigeminal neuralgia: long-term outcomes and systematic review. J Neurosurg 2014; 121 Suppl:210-21. [DOI: 10.3171/2014.8.gks141487] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThe purpose of this study was to establish the safety and efficacy of repeat Gamma Knife surgery (GKS) for recurrent trigeminal neuralgia (TN).MethodsUsing the prospective database of TN patients treated with GKS in Timone University Hospital (Marseille, France), data were analyzed for 737 patients undergoing GKS for TN Type 1 from July 1992 to November 2010. Among the 497 patients with initial pain cessation, 34.4% (157/456 with ≥ 1-year follow-up) experienced at least 1 recurrence. Thirteen patients (1.8%) were considered for a second GKS, proposed only if the patients had good and prolonged initial pain cessation after the first GKS, with no other treatment alternative at the moment of recurrence. As for the first GKS, a single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4–14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 90 Gy (range 70–90 Gy) was delivered. Data for 9 patients with at least 1-year followup were analyzed. A systematic review of literature was also performed, and results are compared with those of the Marseille study.ResultsThe median time to retreatment in the Marseille study was 72 months (range 12–125 months) and in the literature it was 17 months (range 3–146 months). In the Marseille study, the median follow-up period was 33.9 months (range 12–96 months), and 8 of 9 patients (88.9%) had initial pain cessation with a median of 6.5 days (range 1–180 days). The actuarial rate for new hypesthesia was 33.3% at 6 months and 50% at 1 year, which remained stable for 7 years. The actuarial probabilities of maintaining pain relief without medication at 6 months and 1 year were 100% and 75%, respectively, and remained stable for 7 years. The systematic review analyzed 20 peer-reviewed studies reporting outcomes for repeat GKS for recurrent TN, with a total of 626 patients. Both the selection of the cases for retreatment and the way of reporting outcomes vary widely among studies, with a median rate for initial pain cessation of 88% (range 60%–100%) and for new hypesthesia of 33% (range 11%–80%).ConclusionsResults from the Marseille study raise the question of surgical alternatives after failed GKS for TN. The rates of initial pain cessation and recurrence seem comparable to, or even better than, those of the first GKS, according to different studies, but toxicity is much higher, both in the Marseille study and in the published data. Neither the Marseille study data nor literature data answer the 3 cardinal questions regarding repeat radiosurgery in recurrent TN: which patients to retreat, which target is optimal, and which dose to use.
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Affiliation(s)
- Constantin Tuleasca
- 1INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit
- 4Signal Processing Laboratory (LTS 5), École polytechnique fédérale de Lausanne
- 5Medical Image Analysis Laboratory
- 6Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois; and
- 7Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Romain Carron
- 1INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit
| | - Noémie Resseguier
- 2Department of Public Health and Medical Information and UMR 912 (INSERM-IRD–Université de laMéditerranée); and
| | - Anne Donnet
- 3Department of Neurology, Clinical Neuroscience Federation, Centre Hospitalier Universitaire La Timone Assistance Publique–Hôpitaux de Marseille, France
| | - Philippe Roussel
- 1INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit
| | - Jean Gaudart
- 2Department of Public Health and Medical Information and UMR 912 (INSERM-IRD–Université de laMéditerranée); and
| | - Marc Levivier
- 6Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois; and
- 7Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Jean Régis
- 1INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit
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Raval AB, Salluzzo J, Dvorak T, Price LL, Mignano JE, Wu JK. Salvage Gamma Knife Radiosurgery after failed management of bilateral trigeminal neuralgia. Surg Neurol Int 2014; 5:160. [PMID: 25525553 PMCID: PMC4258705 DOI: 10.4103/2152-7806.145201] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/13/2014] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The incidence of bilateral trigeminal neuralgia (TN) is 1-6% of total number of TN cases. Gamma Knife Radiosurgery (GKRS) is effective in treating unilateral TN; however, outcomes of bilateral TN treated by GKRS have not been well evaluated. The purpose of this study is to evaluate the long-term GKRS outcomes of bilateral TN at our institution and compare with our published treatment outcomes of unilateral TN. METHODS Between 2000 and 2006, eight patients with bilateral TN were treated with GKRS. Data available on seven patients were collected. Facial pain outcomes were defined using the Barrow Neurological Institute pain intensity scale. Outcomes and toxicities were compared to published outcomes of unilateral TN patients treated with GKRS at our institution. RESULTS The incidence of bilateral TN in our series is 2.3%. Treatment outcomes were excellent in 5/14, good in 1/14, and poor in 8/14. Median follow-up time was 58 months. Median time-to-failure was 38 months. Pain control rate was 80% at 12 months and 65% at 36 months. Bothersome side effects were seen in 4/14 nerves treated. Compared with our long-term unilateral TN cohort, there was no statistically significant difference in outcome, time-to-failure, or rate of toxicity. CONCLUSION Bilateral TN is rare, and effective treatment is crucial to improve the quality of life of those afflicted. Salvage GKRS is a reasonable treatment modality for individuals with bilateral TN.
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Affiliation(s)
- Ami B. Raval
- Department of Neurosurgery, Healthcare Associates in Medicine, Staten Island, NY 10304, USA
| | - Jennifer Salluzzo
- Department of General Surgery, Hospital of St. Raphael, New Haven, CT 06510, USA
| | - Tomas Dvorak
- Department of Radiation Oncology, MD Anderson Cancer Center, Orlando, FL 32806, USA
| | - Lori Lyn Price
- Biostatistics Research Center, Institute of Clinical Research and Health Policy Studies, Boston, MA 02111, USA
| | - John E. Mignano
- Department of Radiation Oncology, Boston Gamma Knife Center, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Julian K. Wu
- Department of Neurosurgery, Boston Gamma Knife Center, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
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Cheng JS, Lim DA, Chang EF, Barbaro NM. A review of percutaneous treatments for trigeminal neuralgia. Neurosurgery 2014; 10 Suppl 1:25-33; discussion 33. [PMID: 24509496 DOI: 10.1227/neu.00000000000001687] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Common treatments for trigeminal neuralgia include percutaneous techniques, microvascular decompression, and Gamma Knife radiosurgery. Although microvascular decompression is considered the gold standard for treatment, percutaneous techniques remain an effective option for select patients. OBJECTIVE To review the historical development, advantages, and limitations of the most common percutaneous procedures for trigeminal neuralgia: balloon compression (BC), glycerol rhizotomy (GR), and radiofrequency thermocoagulation (RF). METHODS Publications reporting clinical outcomes after BC, GR, and RF were reviewed and included. Operative technique was based on the experience of the primary surgeon and senior author. RESULTS All 3 percutaneous techniques (BC, GR, and RF) provide effective pain relief but differ in method and specificity of nerve injury. BC selectively injures larger pain fibers while sparing small fibers and does not require an awake, cooperative patient. Pain control rates up to 91% at 6 months and 66% at 3 years have been reported. RF allows somatotopic nerve mapping and selective division lesioning and provides pain relief in up to 97% of patients initially and 58% at 5 years. Multiple treatments improve outcomes but carry significant morbidity risk. GR offers similar pain-free outcomes of 90% at 6 months and 54% at 3 years but with higher complication rates (25% vs. 16%) compared with BC. Advantages of percutaneous techniques include shorter procedure duration, minimal anesthesia risk, and in the case of GR and RF, immediate patient feedback. CONCLUSION Percutaneous treatments for trigeminal neuralgia remain safe, simple, and effective for achieving good pain control while minimizing procedural risk.
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Affiliation(s)
- Jason S Cheng
- *Department of Neurological Surgery, ‡Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, and §Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, California; ¶Department of Neurological Surgery, Indiana University School of Medicine, and Goodman Campbell Brain and Spine, Indianapolis, Indiana
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Tuleasca C, Carron R, Resseguier N, Donnet A, Roussel P, Gaudart J, Levivier M, Régis J. Trigeminal neuralgia related to megadolichobasilar artery compression: a prospective series of twenty-nine patients treated with gamma knife surgery, with more than one year of follow-up. Stereotact Funct Neurosurg 2014; 92:170-7. [PMID: 24943284 DOI: 10.1159/000362172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/11/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Trigeminal neuralgia (TN) secondary to megadolichobasilar artery (MBA) compression is considerably difficult to manage surgically. OBJECTIVE This study aims to evaluate the safety/efficacy of Gamma Knife surgery (GKS) in this special group of patients. METHODS Between July 1992 and November 2010, 29 patients with >1 year of follow-up presenting with MBA compression were treated with GKS at Timone University Hospital. Radiosurgery was performed using a Gamma Knife (model B, C or Perfexion). A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 9.1 mm (range: 6-18.2 mm) from the emergence. RESULTS The median follow-up period was 46.1 months (range: 12.9-157.9 months). Initially, all patients (100%) were pain free; the average time to complete pain relief was 13.5 days (range: 0-240 days). Their actuarial probability of remaining pain free without medication at 0.5, 1 and 2 years was 93.1, 79.3 and 75.7%, respectively, and remained stable until 13 years after treatment. The actuarial probability of hypoesthesia onset at 6 months was 4.3%; at 1 year it reached 13% and remained stable until 13 years after treatment. CONCLUSIONS GKS proved to be reasonably safe and effective on a long-term basis as a first- and/or second-line surgical treatment for TN due to MBA compression.
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Affiliation(s)
- Constantin Tuleasca
- Functional and Stereotactic Neurosurgery Unit, INSERM U751, Centre Hospitalier Universitaire La Timone Assistance Publique-Hôpitaux de Marseille, Marseille, France
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Baschnagel AM, Cartier JL, Dreyer J, Chen PY, Pieper DR, Olson RE, Krauss DJ, Maitz AH, Grills IS. Trigeminal neuralgia pain relief after gamma knife stereotactic radiosurgery. Clin Neurol Neurosurg 2014; 117:107-111. [DOI: 10.1016/j.clineuro.2013.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 12/05/2013] [Accepted: 12/08/2013] [Indexed: 10/25/2022]
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Karam SD, Tai A, Wooster M, Rashid A, Chen R, Baig N, Jay A, Harter KW, Randolph-Jackson P, Omogbehin A, Aulisi EF, Jacobson J. Trigeminal neuralgia treatment outcomes following Gamma Knife radiosurgery with a minimum 3-year follow-up. ACTA ACUST UNITED AC 2013; 3:125-130. [PMID: 24955219 PMCID: PMC4052001 DOI: 10.1007/s13566-013-0134-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 11/10/2013] [Indexed: 11/26/2022]
Abstract
Objective Effective short-term outcomes have been well documented for trigeminal neuralgia (TN) patients treated with Gamma Knife radiosurgery (GKRS) with reported success rates of 70–90 % with median follow-up intervals of 19–75 months. Fewer series, however, have described uniform long-term follow-up data. In this study, we report our long-term institutional outcomes in patients treated with GKRS after a minimum follow-up of 36 months. Methods Thirty-six consecutive patients with medically intractable TN received a median radiation dose of 45 Gy applied with a single 4-mm isocenter to the affected trigeminal nerve. Follow-up data were obtained by clinical examination and telephone questionnaire. Outcome results were categorized based on the Barrow Neurological Institute (BNI) pain scale with BNI I–III considered to be good outcomes and BNI IV–V considered as treatment failure. BNI facial numbness score was used to assess treatment complications. Results The incidence of early pain relief was high (80.5 %) and relief was noted in an average of 1.6 months after treatment. At minimum follow-up of 3 years, 67 % were pain free (BNI I) and 75 % had good treatment outcome. At a mean last follow-up of 69 months, 32 % were free from any pain and 63 % were free from severe pain. Bothersome posttreatment facial numbness was reported in 11 % of the patients. A statistically significant correlation was found between age and recurrence of any pain with age >70 predicting a more favorable outcome after radiosurgery. Conclusion The success rate of GKRS for treatment of medically intractable TN declines over time with 32 % reporting ideal outcome and 63 % reporting good outcome. Patients older than age 70 are good candidates for radiosurgery. This data should help in setting realistic expectations for weighing the various available treatment options.
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Affiliation(s)
- Sana D. Karam
- Department of Radiation Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Rd., NW, Washington, DC 20007 USA
| | - Alexander Tai
- Department of Radiation Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Rd., NW, Washington, DC 20007 USA
| | - Margaux Wooster
- Department of Radiation Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Rd., NW, Washington, DC 20007 USA
| | - Abdul Rashid
- Department of Radiation Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Rd., NW, Washington, DC 20007 USA
| | - Rosanna Chen
- Department of Radiation Oncology, Medstar Washington Hospital Center, Washington, DC USA
| | - Nimrah Baig
- Department of Radiation Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Rd., NW, Washington, DC 20007 USA
| | - Ann Jay
- Department of Radiology, Medstar Georgetown University Hospital, Washington, DC USA
| | - K. William Harter
- Department of Radiation Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Rd., NW, Washington, DC 20007 USA
| | | | - Adedamola Omogbehin
- Department of Radiation Oncology, Medstar Washington Hospital Center, Washington, DC USA
| | - Edward F. Aulisi
- Department of Neurosurgery, Medstar Washington Hospital Center, Washington, DC USA
| | - Jeff Jacobson
- Department of Neurosurgery, Medstar Washington Hospital Center, Washington, DC USA
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Collet C, Haen P, Laversanne S, Brignol L, Thiéry G. Trigeminal neuralgia: a new therapy? Med Hypotheses 2013; 81:1088-9. [PMID: 24199950 DOI: 10.1016/j.mehy.2013.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 09/16/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
Abstract
Trigeminal neuralgia (TN) is a rare form of neuropathic pain that results in sudden, unilateral and recurrent pains in the distribution of one or more branches of the trigeminal nerve. The aetiology of TN remains unclear and several theories have been proposed. Many medical and surgical methods have been applied with only partial effectiveness and several side effects. New hypotheses and therapeutic methods are urgently needed. Using evidence presented in a literature review and in our own case report, we hypothesize that pain resulting from trigeminal neuralgia can be caused by demyelinating lesions in the trigger zone. These lesions can be repaired through the injection of fat containing Adipose-Derived Stem Cells (ADSC).
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Affiliation(s)
- C Collet
- Service de Chirurgie Maxillo-faciale, Stomatologie et Plastique de la face, Hôpital d'Instruction des Armées Laveran Marseille, France.
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