Gamma Knife Radiosurgery for Trigeminal Neuralgia

Abstract OBJECTIVE: The purpose of this study was to assess outcomes in patients treated with gamma knife radiosurgery for trigeminal neuralgia. METHODS: From 1997 to 2003, a total of 49 patients with trigeminal neuralgia underwent gamma knife radiosurgery. The trigeminal root entry zone immediately adjacent to the pons was targeted by use of a 4-mm collimator to deliver 40 Gy to the 50% isodose line (maximum dose, 80 Gy). Special care was taken to limit radiation dose to the adjacent pons to 12 Gy. Of the 49 study patients, all had undergone previous medical therapy, 8 (16%) had undergone microvascular decompression, 8 (16%) had undergone percutaneous rhizotomy, 2 (4%) had undergone linear accelerator-based radiosurgery, and 5 (10%) presented with multiple sclerosis. The median duration of symptoms was 6 years. There were 29 female patients (59%) and 20 male patients (41%). Facial pain outcomes were assessed by use of the Barrow Neurological Institute pain score. Other outcomes assessed included recurrence of symptoms and treatment toxicity. The median follow-up period was 49 months. RESULTS: At last evaluation, a total of 27 patients (61%) with idiopathic trigeminal neuralgia reported pain relief (scores of IIIb or less). This included 14 patients (32%) who reported complete pain relief when not receiving medications. Significant recurrence of pain after an initial interval of relief was reported by 10 patients (23%). Mean time to pain recurrence was 9.6 months (range, 2–36 mo). Mild to moderate facial numbness was experienced by 13 patients (29%), whereas 8 (18%) reported mild dysesthesias. CONCLUSION: Gamma knife radiosurgery established durable pain relief in 61% of patients with medically refractory idiopathic trigeminal neuralgia. A longer follow-up period is necessary to fully assess the incidence of late complications and recurrences.

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Repeated Gamma Knife surgery for refractory trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/sup.2006.105.7.99 ◽

2006 ◽

Vol 105 (Supplement) ◽

pp. 99-102 ◽

Cited By ~ 15

Author(s):

Chuan-Fu Huang ◽

Jim-Chao Chuang ◽

Hsien-Tang Tu ◽

Long-Yau Lin

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Prospective Trial ◽

Late Complications ◽

Gamma Knife Surgery ◽

Dose Effect ◽

Duration Of Symptoms ◽

Facial Numbness

ObjectRepeated Gamma Knife surgery (GKS) for trigeminal neuralgia (TN) is an acceptable method for refractory cases but not well established in terms of dose effect and nerve tolerance. The authors report their experience in 28 patients over 3.5 years of follow up.MethodsBetween 1999 and 2004, a total of 28 patients with recurrent or residual TN underwent repeated GKS. The median follow-up periods were 52 and 43 months after the first and repeated procedures, respectively. The entry zone of the trigeminal nerve was targeted using a 4-mm collimator and treated with 40 to 76 Gy as maximal dose. Additive doses ranged between 110 and 152 Gy. The median duration of symptoms was 4.86 years. There were 12 women (46%) and 16 men (54%).At the last evaluation, a total of 19 patients (68%) reported pain relief. Of these patients, 13 were no longer taking pain medications. Significant recurrent or residual pain was noted in nine patients after a median follow up of 12 months (range 6–48 months). New onset of facial numbness was noted in 10 patients. An additive dose above 115 Gy was found to be associated with facial numbness and nonfacial numbness (p = 0.047). No definite additive dose correlation with pain relief was noted (p = 0.23).Conclusions Repeated GKS established durable pain relief in a majority of patients, and a higher additive dose (> 115 Gy) tended to cause facial numbness. However, a prospective trial is needed to fully assess the efficacy and late complications of GKS.

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Gamma knife radiosurgery on the trigeminal ganglion for idiopathic trigeminal neuralgia: Results and review of the literature

Surgical Neurology International ◽

10.25259/sni-134-2019 ◽

2019 ◽

Vol 10 ◽

pp. 89

Author(s):

Salvador Somaza ◽

Eglee M. Montilla ◽

Maria C. Mora

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Trigeminal Ganglion ◽

Gamma Knife Radiosurgery ◽

Latency Period ◽

Satellite Glial Cells ◽

Idiopathic Trigeminal Neuralgia ◽

Collateral Effects

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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Gamma Knife Radiosurgery on the Trigeminal Root Entry Zone for Idiopathic Trigeminal Neuralgia: Results and a Review of the Literature

Yonsei Medical Journal ◽

10.3349/ymj.2020.61.2.111 ◽

2020 ◽

Vol 61 (2) ◽

pp. 111 ◽

Cited By ~ 2

Author(s):

So Hee Park ◽

Jin Woo Chang

Keyword(s):

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Review Of The Literature ◽

Entry Zone ◽

Root Entry Zone ◽

Idiopathic Trigeminal Neuralgia ◽

Trigeminal Root

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Gamma Knife radiosurgery for trigeminal neuralgia: the impact of magnetic resonance imaging–detected vascular impingement of the affected nerve

Journal of Neurosurgery ◽

10.3171/2009.9.jns09196 ◽

2010 ◽

Vol 113 (1) ◽

pp. 53-58 ◽

Cited By ~ 22

Author(s):

Jason P. Sheehan ◽

Dibyendu Kumar Ray ◽

Stephen Monteith ◽

Chun Po Yen ◽

James Lesnick ◽

...

Keyword(s):

Pain Relief ◽

Mr Imaging ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Trigeminal Nerve ◽

Gamma Knife Radiosurgery ◽

Vascular Compression ◽

Pain Intensity Score ◽

The Impact

Object Trigeminal neuralgia is believed to be related to vascular compression of the affected nerve. Radiosurgery has been shown to be reasonably effective for treatment of medically refractory trigeminal neuralgia. This study explores the rate of occurrence of MR imaging–demonstrated vascular impingement of the affected nerve and the extent to which vascular impingement affects pain relief in a population of trigeminal neuralgia patients undergoing Gamma Knife radiosurgery (GKRS). Methods The authors performed a retrospective analysis of 106 cases involving patients treated for typical trigeminal neuralgia using GKRS. Patients with or without single-vessel impingement on CISS MR imaging sequences and with no previous surgery were included in the study. Pain relief was assessed according to the Barrow Neurological Institute (BNI) pain intensity score at the last follow-up. Degree of impingement, nerve diameter preand post-impingement, isocenter placement, and dose to the point of maximum impingement were evaluated in relation to the improvement of BNI score. Results The overall median follow-up period was 31 months. Overall, a BNI pain score of 1 was achieved in 59.4% of patients at last follow-up. Vessel impingement was seen in 63 patients (59%). There was no significant difference in pain relief between those with and without vascular impingement following GKRS (p > 0.05). In those with vascular impingement on MR imaging, the median fraction of vessel impingement was 0.3 (range 0.04–0.59). The median dose to the site of maximum impingement was 42 Gy (range 2.9–79 Gy). Increased dose (p = 0.019) and closer proximity of the isocenter to the site of maximum vessel impingement (p = 0.012) correlated in a statistically significant fashion with improved BNI scores in those demonstrating vascular impingement on the GKRS planning MR imaging Conclusions Vascular impingement of the affected nerve was seen in the majority of patients with trigeminal neuralgia. Overall pain relief following GKRS was comparable in those with and without evidence of vascular compression on MR imaging. In subgroup analysis of those with MR imaging evidence of vessel impingement of the affected trigeminal nerve, pain relief correlated with a higher dose to the point of contact between the impinging vessel and the trigeminal nerve. Such a finding may point to vascular changes affording at least some degree of relief following GKRS for trigeminal neuralgia.

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Gamma Knife surgery used as primary and repeated treatment for idiopathic trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/jns/2008/109/12/s27 ◽

2008 ◽

Vol 109 (Supplement) ◽

pp. 179-184 ◽

Cited By ~ 16

Author(s):

Chuan-Fu Huang ◽

Hsien-Tang Tu ◽

Wen-Shan Liu ◽

Shyh-Ying Chiou ◽

Long-Yau Lin

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Surgery ◽

Repeated Treatment ◽

Maximal Dose ◽

Idiopathic Trigeminal Neuralgia ◽

Facial Numbness ◽

The Mean

Object The purpose of this study was to assess the outcome of idiopathic trigeminal neuralgia (TN) treated with Gamma Knife surgery (GKS) as a primary and repeated treatment modality with a mean follow-up of 5.7 years. Methods Between July 1999 and September 2005, a total of 89 patients with idiopathic TN underwent GKS as a primary treatment. The entry zone of the TN was targeted with a 4-mm collimator and treated with a maximal dose of 60–90 Gy (mean 79 Gy). The dose to the pontine margin was always kept < 15 Gy. Twenty patients received repeated GKS for recurrent or residual pain with a maximal dose of 40–76 Gy (mean 52 Gy). For the second procedure, the target was positioned at the same location as the first treatment. Results The mean follow-up period was 68 months (range 32–104 months). Sixty-nine (77.5%) of the 89 patients experienced a favorable response, as follows: 50 (56%) had excellent, 12 (13.5%) had good, and 7 (7.8%) had fair outcomes. The mean time to pain relief was 1.1 months (range 2 days–6 months). No significant correlation, but more likely a tendency, was found between the dose and pain relief (p = 0.08). Also, no correlation was noted for facial numbness (p = 0.77). The mean follow-up period after repeated GKS was 60 months (range 32–87 months). Outcomes after repeated GKS were excellent in 11 patients (55%) and good in 1 (5%). Seven patients experienced facial numbness. No correlation was found between the additive dose and pain relief (p = 0.24) or facial numbness (p = 0.15). Final outcomes of primary and repeated GKS were excellent in 61 (68.5%), good in 13 (14.6%), and fair in 7 (7.9%). In total, 91% of the patients were successfully treated with this method. There was no statistical significance for efficacy between primary and repeated GKS (p = 0.65), but there was a significant difference for facial numbness (p = 0.007). Conclusions Gamma Knife surgery established durable pain relief when used as a primary and repeated surgery. Treatment was successful for a total of 91% of patients at a mean follow-up of 5.7 years, but facial numbness was also relatively higher.

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Results of three or more Gamma Knife radiosurgery procedures for recurrent trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/2020.10.jns202323 ◽

2021 ◽

pp. 1-10

Author(s):

Mihir Gupta ◽

Varun Sagi ◽

Aditya Mittal ◽

Anudeep Yekula ◽

Devan Hawkins ◽

...

Keyword(s):

Pain Relief ◽

Adverse Effects ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Recurrent Pain ◽

The Third ◽

Percutaneous Procedures ◽

Pain Outcomes

OBJECTIVE Gamma Knife radiosurgery (GKRS) is an established surgical option for the treatment of trigeminal neuralgia (TN), particularly for high-risk surgical candidates and those with recurrent pain. However, outcomes after three or more GKRS treatments have rarely been reported. Herein, the authors reviewed outcomes among patients who had undergone three or more GKRS procedures for recurrent TN. METHODS The authors conducted a multicenter retrospective analysis of patients who had undergone at least three GKRS treatments for TN between July 1997 and April 2019 at two different institutions. Clinical characteristics, radiosurgical dosimetry and technique, pain outcomes, and complications were reviewed. Pain outcomes were scored on the Barrow Neurological Institute (BNI) scale, including time to pain relief (BNI score ≤ III) and recurrence (BNI score > III). RESULTS A total of 30 patients were identified, including 16 women and 14 men. Median pain duration prior to the first GKRS treatment was 10 years. Three patients (10%) had multiple sclerosis. Time to pain relief was longer after the third treatment (p = 0.0003), whereas time to pain recurrence was similar across each of the successive treatments (p = 0.842). Complete or partial pain relief was achieved in 93.1% of patients after the third treatment. The maximum pain relief achieved after the third treatment was significantly better among patients with no prior percutaneous procedures (p = 0.0111) and patients with shorter durations of pain before initiation of GKRS therapy (p = 0.0449). New or progressive facial sensory dysfunction occurred in 29% of patients after the third GKRS treatment and was reported as bothersome in 14%. One patient developed facial twitching, while another experienced persistent lacrimation. No statistically significant predictors of adverse effects following the third treatment were found. Over a median of 39 months of follow-up, 77% of patients maintained complete or partial pain relief. Three patients underwent a fourth GKRS treatment, including one who ultimately received five treatments; all of them reported sustained pain relief at the extended follow-up. CONCLUSIONS The authors describe the largest series to date of patients undergoing three or more GKRS treatments for refractory TN. A third treatment may produce outcomes similar to those of the first two treatments in terms of long-term pain relief, recurrence, and adverse effects.

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CYBERKNIFE RADIOSURGERY AS A FIRST TREATMENT FOR IDIOPATHIC TRIGEMINAL NEURALGIA

Neurosurgery ◽

10.1227/01.neu.0000341714.55023.8f ◽

2009 ◽

Vol 64 (suppl_2) ◽

pp. A96-A101 ◽

Cited By ~ 42

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.

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Gamma knife radiosurgery using 90 Gy for trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/jns.2000.93.supplement_3.0152 ◽

2000 ◽

Vol 93 (supplement_3) ◽

pp. 152-154 ◽

Cited By ~ 70

Author(s):

Bradley Nicol ◽

William F. Regine ◽

Claire Courtney ◽

Ali Meigooni ◽

Michael Sanders ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Complete Relief ◽

Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Good Pain Control ◽

Fine Print

Object. The purpose of this paper was to assess the treatment of trigeminal neuralgia (TN) with the higher than normal dose of 90 Gy. Methods. Forty-two patients with typical TN were treated over a 3-year period with gamma knife radiosurgery. Every patient received a maximum dose of 90 Gy in a single 4-mm isocenter targeted to the root entry zone of the trigeminal nerve. Thirty of 42 patients had undergone no prior treatments. The median follow-up period was 14 months (range 2–30 months). Thirty-one patients (73.8%) achieved complete relief of pain. Nine patients (21.4%) obtained good pain control. Complications were limited to increased facial paresthesia in seven patients (16.7%) and dysgeusia in four patients (9.5%). Conclusions. The authors conclude that the use of 90 Gy is a safe and effective dose for the treatment of TN.

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Gamma knife radiosurgery for primary management for trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/jns.2000.93.supplement_3.0159 ◽

2000 ◽

Vol 93 (supplement_3) ◽

pp. 159-161 ◽

Cited By ~ 65

Author(s):

Ronald Brisman

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Content Type ◽

Group A ◽

Group B ◽

Primary Management ◽

Fine Print

Object. The purpose of this study was to assess the efficacy of gamma knife radiosurgery (GKS) as the primary rather than secondary management for trigeminal neuralgia. Methods. Eighty-two patients underwent GKS as their first neurosurgical intervention (Group A), and 90 patients underwent GKS following a different procedure (Group B). All GKS patients were treated with a maximum dose of 75 Gy. The single 4-mm isocenter was placed close to the junction of the trigeminal nerve and the brainstem. Six-month follow up was available for 126 patients and 12-month follow up for 84 patients. Excellent (no pain and no medicine) or good (at least 50% reduction in pain and less medicine) relief was more likely to occur in Group A than in Group B patients 6 and 12 months following GKS for trigeminal neuralgia (p = 0.058). Excellent or good results were also more likely in patients with trigeminal neuralgia without multiple sclerosis (MS) (p = 0.042). The number and type of procedures performed prior to GKS, the interval between the last procedure and GKS, and the interval from first symptom to GKS (within Groups A and B) did not affect 6-month outcome. The interval between first symptom and GKS was shorter in Group A patients without MS (87 months) than in Group B (148 months; p < 0.004). There were no significant differences between Group A and B patients with regard to sex, age, or laterality. Conclusions. Patients with trigeminal neuralgia who are treated with GKS as primary management have better pain relief than those treated with GKS as secondary management. Patients are more likely to have pain relief if they do not have MS.

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