203 Treatment Options Following Failed Gamma Knife Radiosurgery in Trigeminal Neuralgia: Long Term Outcome with Repeat Radiosurgery vs. Microvascular Decompression

Abstract INTRODUCTION Primary treatment of trigeminal neuralgia with gamma knife radiosurgery (GKRS) is an accepted and effective modality, but is associated with a significant failure rate. Many of the patients ultimately require additional treatment for adequate pain relief. The present paper discusses the long term outcome of this group of patients who are treated with either repeat GKRS or microvascular decompression (MVD) as a secondary procedure. METHODS Using the retrospective database, the clinical data was analyzed of the patients who underwent GKRS at our institute between January 2000 and June 2016. The initial GKRS plan included median prescription dose of 80 Gy at a single iso-center using 4 mm collimator. The patients who did not improve after initial therapy and maximal medication dosage were offered either repeat radiosurgery or MVD. Repeat radiosurgery included a similar plan but a reduced median prescription dose of 40 Gy. Long term pain relief was measured using Marseille's score. Multiple factors including demographic factors, the type of pain, post GKRS facial numbness, treatment interval were analyzed to predict association with the final outcome. RESULTS >In the study preriod, a total of 198 patients underwent GKRS for trigeminal neuralgias. Among these patients 42 (21.2%) patients had treatment failure and required additional treatment. The median interval of subsequent interventions was 16 months (range 2 months to 154 months). Six patients (14.2%) required repeat treatment after 5 years of initial treatment. Out of 42 failed GKRS patients, 15 (35.7%) underwent repeat radiosurgery and 27 (64.3%) underwent MVD. The mean follow up duration was 4.3 years. Overall, 34 patients (81%) improved and had adequate pain relief (Marseille's score III or better) after the second procedure. The rate of adequate pain relief after repeat GKRS and microvascular decompression were 86.6% and 77.7% respectively (P = 0.68). Univariate analysis failed to reveal any significant predictor for pain relief after second treatment. CONCLUSION Repeat GKRS and MVD both are valid treatment options after failed initial radiosurgery, with no difference in long term outcome. Unless specifically indicated, repeat GKRS being noninvasive, may be considered over microvascular decompression.

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Gamma Knife Radiosurgery for Primary and Secondary Trigeminal Neuralgia

Neurosurgery ◽

10.1093/neuros/nyz310_700 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Sunil K Gupta

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Treatment Modality ◽

Pain Control ◽

Treatment Options ◽

Gamma Knife Radiosurgery ◽

Clinical Criteria ◽

Grade Iii

Abstract INTRODUCTION Trigeminal neuralgia has always been a disease of conflict from pathological and management perspectives. Despite advances in the radiological imaging, evidence from autopsy studies, and intraoperative findings, concrete answers are not in sight. GKRS has been a strong contender among available treatment options for the management of trigeminal neuralgia. METHODS All patients were evaluated on clinical criteria, BNI scale for intensity of pain, and facial hypoesthesia (if any) in a protocol-based manner. Only patients with BNI III to V were offered GKRS as a treatment modality. The Marseille point was targeted with a 70 to 90 Gy dose at 50% isodose. Patients were informed about all available treatment options with long-term prognosis and pain control rates. Patients in need of an immediate pain relief, in failed GKRS, and in a severe pain jeopardizing routine life and eating habits were not offered GKRS and were managed with microvascular decompression. RESULTS A total of 108 (65 males, 43 females) patients received GKRS with the Perfexion model since 2009. Eighty-two percent of the patients received GKRS for primary trigeminal neuralgia, while the rest received GKRS for secondary trigeminal neuralgia due to skull base lesions (meningioma, schwannoma, cerebellar AVM, etc). A total of 78% of the patients had preoperative BNI scale IV, while 19% and 3% of the patients had grade III and V scale pain, respectively. Ninety-four percent patients gained BNI scale III intensity pain within 3 mo of GKRS. The 3-yr pain control rate (BNI I-II) could be attained in 81% of the patients. Twelve percent of the patients remained in BNI grade III. Two patients needed redo GKRS for their pain recurrence. CONCLUSION It remains uncontested that MVD provides the best long-term pain-free control in patients of trigeminal neuralgia; however, GKRS remains a valuable feasible option for a selected group of patients. GKRS should be offered as an alternative treatment modality in patients not in urgent need of pain relief. In failed GKRS, authors did not encounter any difficulty in microvascular decompression.

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MICROVASCULAR DECOMPRESSION FOR TRIGEMINAL NEURALGIA IN THE ELDERLY

Neurosurgery ◽

10.1227/01.neu.0000350859.27751.90 ◽

2009 ◽

Vol 65 (3) ◽

pp. 477-482 ◽

Cited By ~ 46

Author(s):

Thomas Günther ◽

Venelin M. Gerganov ◽

Lennart Stieglitz ◽

Wolf Ludemann ◽

Amir Samii ◽

...

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

The Elderly ◽

Safe Procedure ◽

Term Outcome ◽

Long Term Outcome ◽

Younger Patients ◽

The Mean

Abstract OBJECTIVE Multiple studies have proved that microvascular decompression (MVD) is the treatment of choice in cases of medically refractory trigeminal neuralgia (TN). In the elderly, however, the surgical risks related to MVD are assumed to be unacceptably high and various alternative therapies have been proposed. We evaluated the outcomes of MVD in patients aged older than 65 years of age and compared them with the outcomes in a matched group of younger patients. The focus was on procedure-related morbidity rate and long-term outcome. METHODS This was a retrospective study of 112 patients with TN operated on consecutively over 22 years. The main outcome measures were immediate and long-term postoperative pain relief and neurological status, especially function of trigeminal, facial, and cochlear nerves, as well as surgical complications. A questionnaire was used to assess long-term outcome: pain relief, duration of a pain-free period, need for pain medications, time to recurrence, pain severity, and need for additional treatment. RESULTS The mean age was 70.35 years. The second and third branches of the trigeminal nerve were most frequently affected (37.3%). The mean follow-up period was 90 months (range, 48–295 months). Seventy-five percent of the patients were completely pain free, 11% were never pain free, and 14% experienced recurrences. No statistically significant differences existed in the outcome between the younger and older patient groups. Postoperative morbidity included trigeminal hypesthesia in 6.25%, hypacusis in 5.4%, and complete hearing loss, vertigo, and partial facial nerve palsy in 0.89% each. Cerebrospinal fluid leak and meningitis occurred in 1 patient each. There were no mortalities in both groups. CONCLUSION MVD for TN is a safe procedure even in the elderly. The risk of serious morbidity or mortality is similar to that in younger patients. Furthermore, no significant differences in short- and long-term outcome were found. Thus, MVD is the treatment of choice in patients with medically refractory TN, unless their general condition prohibits it.

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Predictors of long-term success after microvascular decompression for trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/2008.9.17660 ◽

2009 ◽

Vol 110 (4) ◽

pp. 620-626 ◽

Cited By ~ 60

Author(s):

Jonathan P. Miller ◽

Stephen T. Magill ◽

Feridun Acar ◽

Kim J. Burchiel

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Excellent Result ◽

Preoperative Pain ◽

Term Outcome ◽

Long Term Outcome

Object Microvascular decompression (MVD) is an effective treatment for trigeminal neuralgia (TN). However, many patients do not experience complete pain relief, and relapse can occur even after an initial excellent result. This study was designed to identify characteristics associated with improved long-term outcome after MVD. Methods One hundred seventy-nine consecutive patients who had undergone MVD for TN at the authors' institution were contacted, and 95 were enrolled in the study. Patients provided information about preoperative pain characteristics including preponderance of shock-like (Type 1 TN) or constant (Type 2 TN) pain, preoperative duration, trigger points, anticonvulsant therapy response, memorable onset, and pain-free intervals. Three groups were defined based on outcome: 1) excellent, pain relief without medication; 2) good, mild or intermittent pain controlled with low-dose medication; and 3) poor, severe persistent pain or need for additional surgical treatment. Results Type of TN pain (Type 1 TN vs Type 2 TN) was the only significant predictor of outcome after MVD. Results were excellent, good, and poor for Type 1 TN versus Type 2 TN patients in 60 versus 25%, 24 versus 39%, and 16 versus 36%, respectively. Among patients with each TN type, there was a significant trend toward better outcome with greater proportional contribution of Type 1 TN (lancinating) symptoms (p < 0.05). Conclusions Pain relief after MVD is strongly correlated with the lancinating pain component, and therefore type of TN pain is the best predictor of long-term outcome after MVD. Application of this information should be helpful in the selection of TN patients likely to benefit from MVD.

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Long-Term Outcome after Aggressive Surgical Resection of Clival Chordomas and Gamma Knife Radiosurgery for Recurrences

Skull Base ◽

10.1055/s-2007-983997 ◽

2007 ◽

Vol 17 (S 1) ◽

Author(s):

Kiyoshi Saito ◽

Tetsuya Nagatani ◽

Yuri Aimi ◽

Masahiro Ichikawa ◽

Jun Yoshida

Keyword(s):

Surgical Resection ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Term Outcome ◽

Long Term Outcome

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The long-term outcome of microvascular decompression for trigeminal neuralgia

British Journal of Neurosurgery ◽

10.3109/02688690903370289 ◽

2010 ◽

Vol 24 (1) ◽

pp. 18-25 ◽

Cited By ~ 66

Author(s):

Zaid Sarsam ◽

Marta Garcia-Fiñana ◽

Turo J. Nurmikko ◽

Thelekat R. K. Varma ◽

Paul Eldridge

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Term Outcome ◽

Long Term Outcome

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Commentary: Development and Evaluation of a Preoperative Trigeminal Neuralgia Scoring System to Predict Long-Term Outcome Following Microvascular Decompression

Neurosurgery ◽

10.1093/neuros/nyz446 ◽

2019 ◽

Vol 87 (1) ◽

pp. E12-E13

Author(s):

Xiaofei Zhou ◽

Jonathan Pace ◽

Jonathan Miller

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Scoring System ◽

Term Outcome ◽

Long Term Outcome

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4035 Astrocyte LDLR-Related Protein 1 Increases Cytokine Sensitivity – The Role of Glia in Recovery after Brain Damage

Journal of Clinical and Translational Science ◽

10.1017/cts.2020.56 ◽

2020 ◽

Vol 4 (s1) ◽

pp. 3-3

Author(s):

Sadiya Ahmad ◽

Pamela Reed ◽

Shane Sprauge ◽

Naomi Sayre

Keyword(s):

Plasma Membrane ◽

Treatment Options ◽

Significant Loss ◽

Null Mouse ◽

Dependent Manner ◽

Related Protein ◽

Stroke Patients ◽

Term Outcome ◽

Long Term Outcome

OBJECTIVES/GOALS: The limited treatment options for ischemic stroke patients have resulted in stroke being a leading cause of death and the primary cause of long-term disability in the U.S. Finding effective treatment options requires a better fundamental understanding of the ongoing processes that contribute to poor long-term outcome. METHODS/STUDY POPULATION: Expression of Apolipoprotein E4 predisposes stroke patients to poor long-term outcome. This study aims to test one possible mechanism by which ApoE4 contributes to cognitive decline after stroke. Here, we examine the effect of a major ApoE4 receptor, low-density lipoprotein receptor related protein 1 (LRP1) on sensitivity to stress in astrocytes. LRP1 binds and moves extracellular ligands and plasma membrane proteins into the endocytic system. Others have shown that LRP1 regulates cell-surface TNF receptor (TNFR1) in non-astrocytic cells. We propose That LRP1 similarly regulates TNFR1 in the central nervous system to attenuate inflammatory response after stroke. Studies have shown that ApoE4 slows the recycling of endocytic LDL receptors. We hypothesize that ApoE4 inhibits the ability of LRP1 to remove TNFR1 from the plasma membrane. This is expected to increase cytokine sensitivity, resulting in worse outcome after stroke. We investigated the effect of LRP1 on astrocyte TNFα signaling and response in immortalized ApoE null mouse astrocytes subjected to lentiviral-mediated knockdown of LRP1. The astrocyte response to TNFα stimulation was tested in a time dependent manner using Western blotting of NFkB pathway components, which are the downstream mediators of TNFα signaling. We also tested astrocyte viability after prolonged TNFα stimulation using Alamar Blue reagent. We found that LRP1 deficient cells have increased phosphorylation of NFkB upon TNFα stimulation, and that loss of LRP1 resulted in significant loss of astrocyte viability after prolonged stimulation. RESULTS/ANTICIPATED RESULTS: Altogether, our results indicate that loss of LRP1 renders astrocytes more sensitive to TNFα. Future experiments will focus on testing the influence of LRP1 on recovery after middle cerebral artery occlusion in mice. DISCUSSION/SIGNIFICANCE OF IMPACT: These studies will elucidate how astrocyte-LRP1 contributes to outcome after stroke, and helps us to understand one potential way that ApoE4 exerts pathological effects. A better understanding of the long-term processes after stroke will allow identification of therapies which improve the morbidity and mortality associated with stroke. CONFLICT OF INTEREST DESCRIPTION: NA.

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