Linear Accelerator Radiosurgery Using 90 Gray for Essential Trigeminal Neuralgia: Results and Dose Volume Histogram Analysis

Neurosurgery ◽  
2003 ◽  
Vol 53 (4) ◽  
pp. 823-830 ◽  
Author(s):  
Bryan W. Goss ◽  
Leonardo Frighetto ◽  
Antonio A.F. DeSalles ◽  
Zachary Smith ◽  
Timothy Solberg ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Nerve Root ◽  
Linear Accelerator ◽  
Treatment Plan ◽  
Case Series ◽  
Entry Zone ◽  
Root Entry Zone ◽  
Dose Volume ◽  
Facial Numbness

Abstract OBJECTIVE To evaluate treatment of essential trigeminal neuralgia with 90 Gy delivered by a linear accelerator dedicated to radiosurgery. METHODS This is a retrospective case series of 25 patients with essential trigeminal neuralgia treated from March 1999 to March 2001. All were treated with 90 Gy by means of a 5-mm collimator directed to the nerve root entry zone. Patient follow-up (range, 8–52 mo; median, 18 mo) was completed by an uninvolved party. Dose volume histograms of the brainstem were developed for the 20, 30, and 50% isodose lines by means of radiosurgery planning software. RESULTS All patients obtained good to excellent pain relief with treatment. Nineteen (76%) of 25 patients achieved excellent pain relief (pain-free without medication). Six patients (24%) achieved good pain relief (50–90% reduction of pain with or without medication). Median time to pain relief was 2 months. Eight patients (32%) experienced relapse 4 to 13 months after treatment. Eight patients (32%) developed facial numbness, but none developed painful numbness. Mean brainstem volume within the 50% isodose line and occurrence of numbness was statistically significant (P = 0.03). There was no correlation between brainstem volume treated and outcome. CONCLUSION Dedicated linear accelerator-based stereotactic radiosurgery that uses a 5-mm collimator to deliver 90 Gy to the nerve root entry zone is a safe and effective method for the treatment of essential trigeminal neuralgia. Care should be taken to limit brainstem volume included in the 50% isodose line in the treatment plan to avoid facial numbness.

Impact of target location on the response of trigeminal neuralgia to stereotactic radiosurgery

2014 ◽  
Vol 120 (3) ◽  
pp. 716-724 ◽  
Author(s):  
Zhiyuan Xu ◽  
David Schlesinger ◽  
Krisztina Moldovan ◽  
Colin Przybylowski ◽  
Xingwen Sun ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Stereotactic Radiosurgery ◽  
Target Location ◽  
Rank Test ◽  
Root Entry Zone ◽  
Kaplan Meier ◽  
Increased Risk ◽  
Facial Numbness ◽  
The Impact

Object The authors evaluate the impact of target location on the rate of pain relief (PR) in patients with intractable trigeminal neuralgia (TN) undergoing stereotactic radiosurgery (SRS). Methods The authors conducted a retrospective review of 99 patients with idiopathic TN who were identified from a prospectively maintained database and were treated with SRS targeting the dorsal root entry zone with a maximum dose of 80 Gy. Targeting of the more proximal portion of a trigeminal nerve with the 50% isodose line overlapping the brainstem was performed in 36 patients (proximal group). In a matched group, 63 patients received SRS targeting the 20% isodose line tangential to the emergence of the brainstem (distal group). The median follow-up time was 33 months (range 6–124 months). Results The actuarial rate of maintenance of Barrow Neurological Institute (BNI) Pain Score I–IIIa was attained in 89% of patients at 1 year, 81% at 2 years, and 69% at 4 years, respectively, after SRS. Kaplan-Meier analysis revealed that durability of PR was only associated with the proximal location of the radiosurgical target (log-rank test, p = 0.018). Radiosurgery-induced facial numbness (BNI Score II or III) developed in 35 patients, which was significantly more frequent in the proximal group (19 patients [53%] compared with 16 [25%] in the distal group [p = 0.015]). Conclusions The radiosurgical target appears to affect the duration of pain relief in patients with idiopathic trigeminal neuralgia with the target closer to the brainstem affording extended pain relief. However, the proximal SRS target was also associated with an increased risk of mild to moderate facial numbness.

Petrosal Vein Involvement in Neurovascular Conflict in Trigeminal Neuralgia: Surgical Technique and Clinical Outcomes

2020 ◽  
Author(s):  
Takuro Inoue ◽  
Satoshi Shitara ◽  
Yukihiro Goto ◽  
Mustaqim Prasetya ◽  
Takanori Fukushima
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Trigeminal Nerve ◽  
Nerve Root ◽  
Surgical Techniques ◽  
Main Stem ◽  
Venous Flow ◽  
Petrosal Vein ◽  
Trigeminal Nerve Root ◽  
Facial Numbness

Abstract BACKGROUND Contact of the main stem of the petrosal vein (PV) to the nerve root is a rare cause of trigeminal neuralgia (TGN). The implication of the PV in relation with neurovascular contact (NVC) is not fully understood. OBJECTIVE To assess the operative procedures in microvascular decompression (MVD) in patients with PV involvement in the long-term. METHODS We retrospectively reviewed 34 cases (7.0%) in 485 consecutive MVDs for TGN, whose PV main stem had contact with the trigeminal nerve root (PV-NVC). PV-NVCs were divided into 2 groups: concomitant arterial contact or no concomitant arterial contact. Surgical techniques, outcomes, complications, and recurrence were assessed. RESULTS The anatomical relationship of the PV with the trigeminal nerve root was consistent with preoperative 3-dimensional imaging in all patients. Pain relief was obtained in most patients immediately after surgery (97.1%) by separating the PV from the nerve root. Postoperative facial numbness was noted in 9 patients (26.5%). Symptomatic venous infarctions occurred in 2 patients (5.9%). Recurrence of facial pain occurred in 3 patients (8.8%) with a median 48 mo follow-up period. Re-exploration surgery revealed adhesion being the cause of recurrence. The statistical analyses showed no difference in the surgical outcomes of the 2 groups. CONCLUSION Separating the PV from the nerve root contributes to pain relief in patients with PV conflict regardless of concomitant arteries. Preserving venous flow is crucial to avoid postoperative venous insufficiency.

Primary glioblastoma of the trigeminal nerve root entry zone: case report

2015 ◽  
Vol 122 (1) ◽  
pp. 78-81 ◽  
Author(s):  
Jonathan D. Breshears ◽  
Michael E. Ivan ◽  
Jennifer A. Cotter ◽  
Andrew W. Bollen ◽  
Phillip V. Theodosopoulos ◽  
...  
Keyword(s):  
Case Report ◽  
Trigeminal Nerve ◽  
Nerve Root ◽  
Cranial Nerve ◽  
Entry Zone ◽  
Primary Glioblastoma ◽  
Root Entry Zone ◽  
Trigeminal Nerve Root ◽  
Facial Numbness ◽  
Symptom Progression

Gliomas of the cranial nerve root entry zone are rare clinical entities. There have been 11 reported cases in the literature, including only 2 glioblastomas. The authors report the case of a 67-year-old man who presented with isolated facial numbness and was found to have a glioblastoma involving the trigeminal nerve root entry zone. After biopsy the patient completed treatment with conformal radiation and concomitant temozolomide, and at 23 weeks after surgery he demonstrated symptom progression despite the treatment described. This is the first reported case of a glioblastoma of the trigeminal nerve root entry zone.

Trigeminal Neuralgia and Multiple Sclerosis

Neurosurgery ◽  
1979 ◽  
Vol 5 (6) ◽  
pp. 711-717 ◽  
Author(s):  
Martin L. Lazar ◽  
Joel B. Kirkpatrick
Keyword(s):  
Multiple Sclerosis ◽  
Trigeminal Neuralgia ◽  
Nerve Root ◽  
Superior Cerebellar Artery ◽  
Electron Microscopic ◽  
Entry Zone ◽  
Root Entry Zone ◽  
Cerebellar Artery ◽  
Microsurgical Approach ◽  
Electron Microscopic Demonstration

Abstract Trigeminal neuralgia is unique to humans. The most common cause seems to be an injury to the myelin of the trigeminal nerve root entry zone as it extends for several millimeters lateral to the pons. Jannetta has developed an elegant retromastoid microsurgical approach to this region. He has identified a compression-distortion phenomenon of this nerve root entry zone, usually from an anomalous position of the superior cerebellar artery. Trigeminal neuralgia can also occur in association with multiple sclerosis, when the plaque lies in this same location. The historical evidence for this explanation is reinforced by the electron microscopic demonstration of the plaque in this region in a patient with multiple sclerosis who was suffering from tic douloureux.

CYBERKNIFE RADIOSURGERY AS A FIRST TREATMENT FOR IDIOPATHIC TRIGEMINAL NEURALGIA

Neurosurgery ◽  
2009 ◽  
Vol 64 (suppl_2) ◽  
pp. A96-A101 ◽  
Author(s):  
Laura Fariselli ◽  
Carlo Marras ◽  
Michela De Santis ◽  
Marcello Marchetti ◽  
Ida Milanesi ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Pain Control ◽  
Root Entry Zone ◽  
Successful Treatment Outcome ◽  
Robotic Radiosurgery ◽  
Idiopathic Trigeminal Neuralgia ◽  
Facial Numbness ◽  
Cyberknife Radiosurgery

Abstract OBJECTIVE To report the level of effectiveness and safety, in our experience, of CyberKnife (Accuray, Inc., Sunnyvale, CA) robotic radiosurgery as a first-line treatment against pharmacologically refractory trigeminal neuralgia. METHODS We treated 33 patients with the frameless CyberKnife system as a monotherapy. The retrogasserian portion of the trigeminal nerve (a length of 4 mm, 2–3 mm anterior to the root entry zone) was targeted. Doses of 55 to 75 Gy were prescribed to the 100% isodose line, according to a dose escalation protocol. The patients were evaluated for the level of pain control, time to pain relief, hypesthesia, and time to pain recurrence. RESULTS The median age was 74 years. All but 2 patients (94%) achieved a successful treatment outcome. The follow-up period was 9 to 37 months (mean, 23 months). The Barrow Neurological Institute Pain Intensity Scale (BPS) score before radiosurgery was III in 2 patients (6%), IV in 8 patients (24%), and V in 23 patients (70%). The time to pain relief was 1 to 180 days (median, 30 days). No facial numbness was observed. Only 1 patient developed a transitory dysesthesia of the tongue. After treatment, the BPS score was I, II, or III in 31 patients (97%). Pain recurred in 33% (11 patients) at a mean of 9 months (range, 1–43 months). Three patients with recurrences had low pain control by medication (BPS score, IV), and 1 patient (BPS score, V) needed a radiofrequency lesioning (BPS score, I at 12 months). CONCLUSION CyberKnife radiosurgery for trigeminal neuralgia allows pain relief at safe doses and is suggested for pharmacologically refractory trigeminal neuralgia. Higher prescribed doses were not associated with improvement in pain relief or recurrence rate.

scholarly journals Basilar artery dolichoectasia an unusual and rare cause of secondary trigeminal neuralgia: a clinical report

2020 ◽  
Vol 24 (1) ◽  
Author(s):  
Zafar Ali Khan Ali Khan ◽  
Shammas Raza Khan Raza Khan ◽  
Tariq Mehmood ◽  
Chaudhary Umar Asghar ◽  
Naseer Ahmed
Keyword(s):  
Trigeminal Neuralgia ◽  
Trigeminal Nerve ◽  
Basilar Artery ◽  
Nerve Root ◽  
Neurological Deficits ◽  
Clinical Report ◽  
Entry Zone ◽  
Root Entry Zone ◽  
Trigeminal Nerve Root ◽  
Corneal Reflex

Objective: Patients with Trigeminal Neuralgia often consults a dentist for relief of their symptoms as the pain seems to be arising from teeth and allied oral structures. Basilar artery Dolichoectasia is an unusual and very rare cause of secondary Trigeminal Neuralgia as it compresses the Trigeminal nerve Root Entry Zone. Case reports: We report three cases of Trigeminal Neuralgia caused by Basilar artery Dolichoectasia compression. The corneal reflex was found absent in all three of the cases along with mild neurological deficits in one case. Multiplanar T1/T2W images through the brain disclosed an aberrant, cirsoid (S-shaped) and torturous Dolichoectasia of basilar artery offending the Trigeminal nerve Root Entry Zone. Discussion: Based on these findings we propose a protocol for general dentist for diagnosis of patients with trigeminal neuralgia and timely exclusion of secondary intracranial causes. Conclusion: General dentists and oral surgeons ought to consider this diagnosis in patients presenting with chronic facial pain especially pain mimicking neuralgia with loss of corneal reflex or other neurosensory deficit on the face along with nighttime pain episodes. Timely and accurate diagnosis and prompt referral to a concerned specialist can have an enormous impact on patient survival rate in such cases. KEYWORDS Basilar artery; Cirsoid dolichoectasia; Corneal reflex; Trigeminal neuralgia.

Linear Accelerator Radiosurgery for Trigeminal Neuralgia

Neurosurgery ◽  
2005 ◽  
Vol 57 (6) ◽  
pp. 1193-1200 ◽  
Author(s):  
Gregory M. Richards ◽  
Kristin A. Bradley ◽  
Wolfgang A. Tomé ◽  
Søren M. Bentzen ◽  
Daniel K. Resnick ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Linear Accelerator ◽  
Response Duration ◽  
Pain Scale ◽  
Treatment Delivery ◽  
Idiopathic Trigeminal Neuralgia ◽  
Facial Numbness ◽  
Effective Pain Relief ◽  
Mean Time

Abstract OBJECTIVE: To report the clinical outcomes following treatment of trigeminal neuralgia with linear accelerator-based radiosurgery. METHODS: Twenty-eight patients with medication refractory idiopathic trigeminal neuralgia were treated with a single fraction of 80 Gy to the trigeminal nerve root. For treatment delivery, a 4-mm collimator and a 7-arc technique were delivered using a stereotactic floor stand system with an isocenter stability of 0.2 ± 0.1 mm to minimize dose to the brainstem. Treatment delivery time was approximately 55 minutes. RESULTS: With a median follow-up of 12 months (range, 1–40 mo), 57% of patients achieved complete pain relief and 75% (exact 95% confidence interval, 55 to 89%) had their pain reduced to 3 or less on a 10-point pain scale. Median time to pain relief was 1 month. Four patients did not respond to treatment. The actuarial mean time to pain recurrence in responders was 14 months, and the actuarial mean response duration in major to complete responders was 16 months. Women had significantly longer mean time to pain recurrence than men (16 versus 7 months; P = 0.05). Three patients reported new mild facial numbness after radiosurgery and one patient developed neurotrophic keratopathy. CONCLUSION: Linear accelerator-based radiosurgery for medication refractory trigeminal neuralgia provides effective pain relief with a low complication rate.

Linear accelerator–based radiosurgery for trigeminal neuralgia: comparative outcomes of frame-based and mask-based techniques

2021 ◽  
pp. 1-10
Author(s):  
Jenny C. Kienzler ◽  
Stephen Tenn ◽  
Srinivas Chivukula ◽  
Fang-I Chu ◽  
Hiro D. Sparks ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Pain Control ◽  
Linear Accelerator ◽  
Initial Response ◽  
Time To Recurrence ◽  
Facial Numbness ◽  
The Mean

OBJECTIVE Precise and accurate targeting is critical to optimize outcomes after stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN). The aim of this study was to compare the outcomes after SRS for TN in which two different techniques were used: mask-based 4-mm cone versus frame-based 5-mm cone. METHODS The authors performed a retrospective review of patients who underwent SRS for TN at their institution between 1996 and 2019. The Barrow Neurological Institute (BNI) pain score and facial hypesthesia scale were used to evaluate pain relief and facial numbness. RESULTS A total of 234 patients were included in this study; the mean age was 67 years. In 97 patients (41.5%) radiation was collimated by a mask-based 4-mm cone, whereas a frame-based 5-mm cone was used in the remaining 137 patients (58.5%). The initial adequate pain control rate (BNI I–III) was 93.4% in the frame-based 5-mm group, compared to 87.6% in the mask-based 4-mm group. This difference between groups lasted, with an adequate pain control rate at ≥ 24 months of 89.9% and 77.8%, respectively. Pain relief was significantly different between groups from initial response until the last follow-up (≥ 24 months, p = 0.02). A new, permanent facial hypesthesia occurred in 30.3% of patients (33.6% in the frame-based 5-mm group vs 25.8% in the mask-based 4-mm group). However, no significant association between the BNI facial hypesthesia score and groups was found. Pain recurrence occurred earlier (median time to recurrence 12 months vs 29 months, p = 0.016) and more frequently (38.1% vs 20.4%, p = 0.003) in the mask-based 4-mm than in the frame-based 5-mm group. CONCLUSIONS Frame-based 5-mm collimator SRS for TN resulted in a better long-term pain relief with similar toxicity profiles to that seen with mask-based 4-mm collimator SRS.

Dedicated linear accelerator radiosurgery for the treatment of trigeminal neuralgia

2003 ◽  
Vol 99 (3) ◽  
pp. 511-516 ◽  
Author(s):  
Zachary A. Smith ◽  
Antonio A. F. De Salles ◽  
Leonardo Frighetto ◽  
Bryan Goss ◽  
Steve P. Lee ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Linear Accelerator ◽  
Facial Pain ◽  
Content Type ◽  
Excellent Outcome ◽  
Linac Radiosurgery ◽  
Root Entry Zone ◽  
Fine Print

Object. In this study the authors evaluate the efficacy of and complications associated with dedicated linear accelerator (LINAC) radiosurgery for trigeminal neuralgia (TN). Methods. Between August 1995 and February 2001, 60 patients whose median age was 66.1 years (range 45–88 years) were treated with dedicated LINAC radiosurgery for TN. Forty-one patients (68.3%) had essential TN, 12 (20%) had secondary facial pain, and seven (11.7%) had atypical features. Twenty-nine patients (48.3%) had undergone previous surgical procedures. Radiation doses varied between 70 and 90 Gy (mean 83.3 Gy) at the isocenter, with the last 35 patients (58.3%) treated with a 90-Gy dose. A 5-mm collimator was used in 45 patients (75%) and a 7.5-mm collimator in 15 patients (25%). Treatment was focused at the nerve root entry zone. At last follow up (mean follow-up period 23 months, range 2–70 months), 36 (87.8%) of the 41 patients with essential TN had sustained significant pain relief (good plus excellent results). Twenty-three patients (56.1%) were pain free without medication (excellent outcome), 13 (31.7%) had a 50 to 90% reduction in pain with or without medication (good outcome), and five (12.2%) had minor improvement or no relief. Of 12 patients with secondary facial pain, significant relief was sustained in seven patients (58.3%); worse results were found with atypical pain. Fifteen (25%) of the 60 patients experienced new numbness postprocedure; no other significant complications were found. Pain relief was experienced at a mean of 2.7 months (range 0–12 months). Conclusions. Dedicated LINAC radiosurgery is a precise and effective treatment for TN.

scholarly journals Characteristics and management of the offending veins in microvascular decompression surgery for trigeminal neuralgia

2020 ◽  
Author(s):  
Hidetoshi Kasuya ◽  
Shigeru Tani ◽  
Yuichi Kubota ◽  
Suguru Yokosako ◽  
Hidenori Ohbuchi ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Decompression Surgery ◽  
Venous Infarction ◽  
Middle Cerebellar Peduncle ◽  
Root Entry Zone ◽  
Complete Pain Relief ◽  
Facial Numbness ◽  
Cerebellar Peduncle

Abstract The optimal technique of microvascular decompression (MVD) for trigeminal neuralgia (TN) caused by venous conflict remains unclear. The objectives of this study are to characterize the offending veins identified during MVD for TN and to evaluate intraoperative technique applied for their management. From 2007 till 2019, 308 MVD surgeries were performed in 288 consecutive patients with TN, and in 58 of them, pure venous conflict was identified. In 44 patients, the offending vein was interrupted, as was done for small veins arising from the cisternal trigeminal nerve (CN V) or its root entry zone (REZ) causing their stretching (19 cases), small veins on the surface of REZ (9 cases), transverse pontine vein (TPV) compressing REZ or distal CN V (12 cases), and superior petrosal vein (SPV) using flow conversion technique (4 cases). In 14 other cases, the offending vein was relocated, as was done for the SPV or the vein of cerebellopontine fissure (8 cases), TPV (3 cases), and the vein of middle cerebellar peduncle (3 cases). Complete pain relief after surgery was noted in 49 patients (84%). No one patient experienced major neurological deterioration. Postoperative facial numbness developed in 14 patients (24%), and in 8 of them, it was permanent. In 14 patients, MRI demonstrated venous infarction of the middle cerebellar peduncle, which was associated with the presence of any (P = 0.0180) and permanent (P = 0.0002) facial numbness. Ten patients experienced pain recurrence. Thus, 39 patients (67%) sustained complete pain relief at the last follow-up (median, 48 months), which was significantly associated with the presence of any (P = 0.0228) and permanent (P = 0.0427) postoperative facial numbness. In conclusion, in cases of TN, small offending veins arising from REZ and/or distal CN V and causing their stretching may be coagulated and cut. In many cases, TPV can be also interrupted safely or considered as collateral way for blood outflow. The main complication of such procedures is facial numbness, which is associated with the venous infarction of middle cerebellar peduncle and long-term complete pain relief.

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