Prospective comparison of long-term pain relief rates after first-time microvascular decompression and stereotactic radiosurgery for trigeminal neuralgia

OBJECTIVECommon surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD), stereotactic radiosurgery (SRS), and radiofrequency ablation (RFA). Although the efficacy of each procedure has been described, few studies have directly compared these treatment modalities on pain control for TN. Using a large prospective longitudinal database, the authors aimed to 1) directly compare long-term pain control rates for first-time surgical treatments for idiopathic TN, and 2) identify predictors of pain control.METHODSThe authors reviewed a prospectively collected database for all patients who underwent treatment for TN between 1997 and 2014 at the University of California, San Francisco. Standardized collection of data on preoperative clinical characteristics, surgical procedure, and postoperative outcomes was performed. Data analyses were limited to those patients who received a first-time procedure for treatment of idiopathic TN with > 1 year of follow-up.RESULTSOf 764 surgical procedures performed at the University of California, San Francisco, for TN (364 SRS, 316 MVD, and 84 RFA), 340 patients underwent first-time treatment for idiopathic TN (164 MVD, 168 SRS, and 8 RFA) and had > 1 year of follow-up. The analysis was restricted to patients who underwent MVD or SRS. Patients who received MVD were younger than those who underwent SRS (median age 63 vs 72 years, respectively; p < 0.001). The mean follow-up was 59 ± 35 months for MVD and 59 ± 45 months for SRS. Approximately 38% of patients who underwent MVD or SRS had > 5 years of follow-up (60 of 164 and 64 of 168 patients, respectively). Immediate or short-term (< 3 months) postoperative pain-free rates (Barrow Neurological Institute Pain Intensity score of I) were 96% for MVD and 75% for SRS. Percentages of patients with Barrow Neurological Institute Pain Intensity score of I at 1, 5, and 10 years after MVD were 83%, 61%, and 44%, and the corresponding percentages after SRS were 71%, 47%, and 27%, respectively. The median time to pain recurrence was 94 months (25th–75th quartiles: 57–131 months) for MVD and 53 months (25th–75th quartiles: 37–69 months) for SRS (p = 0.006). A subset of patients who had MVD also underwent partial sensory rhizotomy, usually in the setting of insignificant vascular compression. Compared with MVD alone, those who underwent MVD plus partial sensory rhizotomy had shorter pain-free intervals (median 45 months vs no median reached; p = 0.022). Multivariable regression demonstrated that shorter preoperative symptom duration (HR 1.005, 95% CI 1.001–1.008; p = 0.006) was associated with favorable outcome for MVD and that post-SRS sensory changes (HR 0.392, 95% CI 0.213–0.723; p = 0.003) were associated with favorable outcome for SRS.CONCLUSIONSIn this longitudinal study, patients who received MVD had longer pain-free intervals compared with those who underwent SRS. For patients who received SRS, postoperative sensory change was predictive of favorable outcome. However, surgical decision making depends upon many factors. This information can help physicians counsel patients with idiopathic TN on treatment selection.

Download Full-text

Long-term pain outcomes in elderly patients with trigeminal neuralgia: comparison of first-time microvascular decompression and stereotactic radiosurgery

Neurosurgical FOCUS ◽

10.3171/2020.7.focus20446 ◽

2020 ◽

Vol 49 (4) ◽

pp. E23

Author(s):

Kunal P. Raygor ◽

Anthony T. Lee ◽

Noah Nichols ◽

Doris D. Wang ◽

Mariann M. Ward ◽

...

Keyword(s):

Adverse Event ◽

Trigeminal Neuralgia ◽

Elderly Patients ◽

Microvascular Decompression ◽

Pain Control ◽

The Elderly ◽

Surgical Treatments ◽

First Time

OBJECTIVECommon surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and stereotactic radiosurgery (SRS). The use of MVD in elderly patients has been described but has yet to be prospectively compared to SRS, which is well-tolerated and noninvasive. The authors aimed to directly compare long-term pain control and adverse event rates for first-time surgical treatments for idiopathic TN in the elderly.METHODSA prospectively collected database was reviewed for TN patients who had undergone treatment between 1997 and 2017 at a single institution. Standardized collection of preoperative demographics, surgical procedure, and postoperative outcomes was performed. Data analysis was limited to patients over the age of 65 years who had undergone a first-time procedure for the treatment of idiopathic TN with at least 1 year of follow-up.RESULTSOne hundred ninety-three patients meeting the study inclusion criteria underwent surgical procedures for TN during the study period (54 MVD, 24 MVD+Rhiz, 115 SRS). In patients in whom an artery was not compressing the trigeminal nerve during MVD, a partial sensory rhizotomy (MVD+Rhiz) was performed. Patients in the SRS cohort were older than those in the MVD and MVD+Rhiz cohorts (mean ± SD, 79.2 ± 7.8 vs 72.9 ± 5.7 and 70.9 ± 4.8 years, respectively; p < 0.0001) and had a higher mean Charlson Comorbidity Index (3.8 ± 1.1 vs 3.0 ± 0.9 and 2.9 ± 1.0, respectively; p < 0.0001). Immediate or short-term postoperative pain-free rates (Barrow Neurological Institute [BNI] pain intensity score I) were 98.1% for MVD, 95.8% for MVD+Rhiz, and 78.3% for SRS (p = 0.0008). At the last follow-up, 72.2% of MVD patients had a favorable outcome (BNI score I–IIIa) compared to 54.2% and 49.6% of MVD+Rhiz and SRS patients, respectively (p = 0.02). In total, 0 (0%) SRS, 5 (9.3%) MVD, and 1 (4.2%) MVD+Rhiz patients developed any adverse event. Multivariate Cox proportional hazards analysis demonstrated that procedure type (p = 0.001) and postprocedure sensory change (p = 0.003) were statistically significantly associated with pain control.CONCLUSIONSIn this study cohort, patients who had undergone MVD had a statistically significantly longer duration of pain freedom than those who had undergone MVD+Rhiz or SRS as their first procedure. Fewer adverse events were seen after SRS, though the MVD-associated complication rate was comparable to published rates in younger patients. Overall, the results suggest that both MVD and SRS are effective options for the elderly, despite their advanced age. Treatment choice can be tailored to a patient’s unique condition and wishes.

Download Full-text

Long-term pain outcomes for recurrent idiopathic trigeminal neuralgia after stereotactic radiosurgery: a prospective comparison of first-time microvascular decompression and repeat stereotactic radiosurgery

Journal of Neurosurgery ◽

10.3171/2018.5.jns172243 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1207-1215 ◽

Cited By ~ 1

Author(s):

Kunal P. Raygor ◽

Doris D. Wang ◽

Mariann M. Ward ◽

Nicholas M. Barbaro ◽

Edward F. Chang

Keyword(s):

Trigeminal Neuralgia ◽

Stereotactic Radiosurgery ◽

San Francisco ◽

Microvascular Decompression ◽

Favorable Outcome ◽

Prospective Comparison ◽

Pain Outcomes ◽

Sensory Changes ◽

First Time

OBJECTIVEMicrovascular decompression (MVD) and stereotactic radiosurgery (SRS) are common surgical treatments for trigeminal neuralgia (TN). Many patients who receive SRS have pain recurrence; the ideal second intervention is unknown. The authors directly compared pain outcomes after MVD and repeat SRS in a population of patients in whom SRS failed as their first-line procedure for TN, and they identified predictors of pain control.METHODSThe authors reviewed a prospectively collected database of patients undergoing surgery for TN between 1997 and 2014 at the University of California, San Francisco (UCSF). Standardized data collection focused on preoperative clinical characteristics, surgical characteristics, and postoperative outcomes. Patients with typical type 1, idiopathic TN with ≥ 1 year of follow-up were included.RESULTSIn total, 168 patients underwent SRS as their first procedure. Of these patients, 90 had residual or recurrent pain. Thirty of these patients underwent a second procedure at UCSF and had ≥ 1 year of follow-up; 15 underwent first-time MVD and 15 underwent repeat SRS. Patients undergoing MVD were younger than those receiving repeat SRS and were more likely to receive ≥ 80 Gy during the initial SRS. The average follow-up was 44.9 ± 33.6 months for MVD and 48.3 ± 45.3 months for SRS. All patients achieved complete pain freedom without medication at some point during their follow-up. At last follow-up, 80% of MVD-treated patients and 33.3% of SRS-treated patients had a favorable outcome, defined as Barrow Neurological Institute Pain Intensity scores of I–IIIa (p < 0.05). Percentages of patients with favorable outcome at 1 and 5 years were 86% and 75% for the MVD cohort and 73% and 27% for the SRS cohort, respectively (p < 0.05). Multivariate Cox proportional hazards analysis demonstrated that performing MVD was statistically significantly associated with favorable outcome (HR 0.12, 95% CI 0.02–0.60, p < 0.01). There were no statistically significant predictors of favorable outcome in the MVD cohort; however, the presence of sensory changes after repeat SRS was associated with pain relief (p < 0.01).CONCLUSIONSPatients who received MVD after failed SRS had a longer duration of favorable outcome compared to those who received repeat SRS; however, both modalities are safe and effective. The presence of post-SRS sensory changes was predictive of a favorable pain outcome in the SRS cohort.

Download Full-text

Maternal and Fetal Outcomes in Women with Brain Arteriovenous Malformation Rupture during Pregnancy

Cerebrovascular Diseases ◽

10.1159/000513573 ◽

2021 ◽

pp. 1-7

Author(s):

Kimberly L. Yan ◽

Nerissa U. Ko ◽

Steven W. Hetts ◽

Shantel Weinsheimer ◽

Adib A. Abla ◽

...

Keyword(s):

San Francisco ◽

Treatment Strategies ◽

First Trimester ◽

Interventional Treatment ◽

Maternal Outcomes ◽

Fetal Outcomes ◽

Brain Avm ◽

Risk Of Hemorrhage ◽

The University

Background: Sporadic brain arteriovenous malformations (BAVM) are a major cause of hemorrhagic stroke in younger persons. Prior studies have reported contradictory results regarding the risk of hemorrhage during pregnancy, and there are no standard guidelines for the management of pregnant women who present with BAVM rupture. The purpose of this study is to describe maternal and fetal outcomes and treatment strategies in patients with BAVM hemorrhage during pregnancy. Methods: We performed a retrospective review of the University of California, San Francisco Brain AVM Project database for female patients who were pregnant at the time of BAVM hemorrhage between 2000 and 2017. Clinical and angiographic characteristics at presentation, BAVM treatment, and maternal outcomes using modified Rankin scale (mRS) score at presentation and 2-year follow-up were recorded. Fetal outcomes were abstracted from medical records and maternal reports. Results: Sixteen patients presented with BAVM hemorrhage during pregnancy, 81% (n = 13) of whom were in their second or third trimester. Three patients (19%) who were in their first trimester terminated or miscarried pregnancy prior to BAVM intervention. Of the remaining 13 patients, 77% (n = 10) received emergent BAVM treatment at time of hemorrhage prior to delivery, and 85% of patients achieved BAVM obliteration and good maternal outcomes (mRS 0–2) at 2-year follow-up. All patients had uncomplicated deliveries (69% cesarean and 23% vaginal) with no reports of postnatal cognitive or developmental delays in infants at 2-year follow-up. Conclusions: Our study shows good long-term maternal and fetal outcomes in ruptured BAVM patients presenting during pregnancy, the majority who received BAVM interventional treatment prior to delivery.

Download Full-text

Diagnosis, treatment, and misdiagnosis analysis of 28 cases of central nervous system echinococcosis

Chinese Neurosurgical Journal ◽

10.1186/s41016-021-00248-y ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Guojia Du ◽

Yandong Li ◽

Pan Wu ◽

Xin Wang ◽

Riqing Su ◽

...

Keyword(s):

Spinal Cord ◽

Central Nervous System ◽

Nervous System ◽

Clinical Features ◽

Multiple Organ ◽

Pathological Examination ◽

Surgical Removal ◽

Surgical Treatments

Abstract Background To explore central nervous system (CNS) involvement in this disease, from the perspectives of diagnosis, treatment, and misdiagnosis Methods Twenty-eight patients with CNS echinococcosis were included in this retrospective study, including 18 males (64.3%) and 10 (35.7%) females. The average age of all the patients were 23.5 years (ranged 4–60 years). Twenty-three (23) patients (82.1%) received the first surgical resection in our hospital. Five (5) patients (17.9%) gave up surgical treatment for multiple-organ hydatidosis and previous surgery history at other hospitals, and albendazole was applied for a long-term (3–6 months) adjunct therapy for the 5 patients. The average follow-up time was 8 years. Results For the 28 patients, 23 cases received surgical treatments, and the diagnosis was confirmed by pathological examinations. The diagnosis of 4 cases of brain echinococcosis and 2 cases of spinal cord echinococcosis could not be confirmed, resulting in a misdiagnosis rate of 21.4% (6/28). For the pathological examination, a total of 17 cases were infected with Echinococcus granulosus (including 2 cases of spinal cord echinococcosis), and 6 cases were infected with Echinococcus alveolaris. Conclusion The diagnosis should be specifically considered in endemic regions. The clinical features of CNS hydatidosis were intracranial space-occupying lesions. For the treatment, the surgical removal of cysts should be necessary. In addition, the adjuvant therapy with drug and intraoperative prophylaxis is also suggested. The misdiagnosis may have resulted from atypical clinical features and radiographic manifestations, as well as the accuracy of hydatid immunologic test.

Download Full-text

Long-term outcomes of pediatric arteriovenous malformations: the 30-year Pittsburgh experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.3.peds19614 ◽

2020 ◽

Vol 26 (3) ◽

pp. 275-282

Author(s):

Michael M. McDowell ◽

Nitin Agarwal ◽

Gordon Mao ◽

Stephen Johnson ◽

Hideyuki Kano ◽

...

Keyword(s):

Multivariate Analysis ◽

Arteriovenous Malformations ◽

Multimodality Treatment ◽

Treatment Choice ◽

University Of Pittsburgh ◽

Poor Outcome ◽

Poor Outcomes ◽

The University

OBJECTIVEThe study of pediatric arteriovenous malformations (pAVMs) is complicated by the rarity of the entity. Treatment choice has often been affected by the availability of different modalities and the experience of the providers present. The University of Pittsburgh experience of multimodality treatment of pAVMs is presented.METHODSThe authors conducted a retrospective cohort study examining 212 patients with pAVM presenting to the University of Pittsburgh between 1988 and 2018, during which patients had access to surgical, endovascular, and radiosurgical options. Univariate analysis was performed comparing good and poor outcomes. A poor outcome was defined as a modified Rankin Scale (mRS) score of ≥ 3. Multivariate analysis via logistic regression was performed on appropriate variables with a p value of ≤ 0.2. Seventy-five percent of the cohort had at least 3 years of follow-up.RESULTSFive patients (2.4%) did not receive any intervention, 131 (61.8%) had GKRS alone, 14 (6.6%) had craniotomies alone, and 2 (0.9%) had embolization alone. Twenty-two (10.4%) had embolization and Gamma Knife radiosurgery (GKRS); 20 (9.4%) had craniotomies and GKRS; 8 (3.8%) had embolization and craniotomies; and 10 (4.7%) had embolization, craniotomies, and GKRS. Thirty-one patients (14.6%) were found to have poor outcome on follow-up. The multivariate analysis performed in patients with poor outcomes was notable for associations with no treatment (OR 18.9, p = 0.02), hemorrhage requiring craniotomy for decompression alone (OR 6, p = 0.03), preoperative mRS score (OR 2.1, p = 0.004), and Spetzler-Martin score (OR 1.8, p = 0.0005). The mean follow-up was 79.7 ± 62.1 months. The confirmed radiographic obliteration rate was 79.4% and there were 5 recurrences found on average 9.5 years after treatment.CONCLUSIONSHigh rates of long-term functional independence (mRS score of ≤ 2) can be achieved with comprehensive multimodality treatment of pAVMs. At this center there was no difference in outcome based on treatment choice when accounting for factors such as Spetzler-Martin grade and presenting morbidity. Recurrences are rare but frequently occur years after treatment, emphasizing the need for long-term screening after obliteration.

Download Full-text

Two new records of flowering plants from Lesotho

Bothalia ◽

10.4102/abc.v47i1.2099 ◽

2017 ◽

Vol 47 (2) ◽

Cited By ~ 1

Author(s):

Khotso Kobisi ◽

Lerato S. Kose ◽

Annah Moteetee

Keyword(s):

National Park ◽

New Records ◽

Field Trips ◽

Flowering Plants ◽

Plant Identification ◽

The Family ◽

National University ◽

The University ◽

First Time

Background: A number of books, articles and checklists have been published on Lesotho’s flora. The species presented here have been recorded for South Africa but have not previously been recorded for Lesotho.Objectives: As part of a study aimed at updating biodiversity records of the southern parts of Lesotho (Qacha’s Nek and Quthing districts), with the main focus of compiling a checklist for the Sehlabethebe National Park, this report presents plant species that have until now not been recorded for the Lesotho flora.Method: Several field trips were undertaken between 2004 and 2009. Plant identification was done based on observation and photographic records. After the compilation of the checklist, it became clear that two of the species observed had not been previously recorded for Lesotho. A follow-up trip was carried out in February 2016, during which plant specimens of the presumed new records were collected and deposited at the National University of Lesotho Herbarium (ROML) [and the University of Johannesburg Herbarium (JRAU)]. Plant identification was confirmed by experts in the family Apocynaceae.Results: Two species not previously recorded for Lesotho, namely Ceropegia africana subsp. barklyi and Duvalia caespitosa subsp. caespitosa, were found during the exploration of the southern parts of Lesotho which included the Sehlabathebe National Park.Conclusions: The fact that two species have been recorded in Lesotho for the first time clearly indicates that documentation of the flora of Lesotho needs to be updated. This work is therefore regarded as complementary to previous publications on the Lesotho flora.

Download Full-text

Mid-term Outcome Of Surgical Treatment In Pediatric Patients With Ebstein's Anomaly: A Single-center Cohort Study.

10.21203/rs.3.rs-42297/v1 ◽

2020 ◽

Author(s):

Jia-chen Li ◽

Xian-chao Jiang ◽

Si-meng Zhang ◽

Jin-yang Liu ◽

Ya-juan Zhang ◽

...

Keyword(s):

Surgical Treatment ◽

Reoperation Rate ◽

Term Effect ◽

Ebstein’S Anomaly ◽

Biventricular Repair ◽

Ebstein's Anomaly ◽

Long Term Follow Up ◽

Surgical Treatments

Abstract Background: Ebstein’s anomaly is a malformation of the tricuspid valve and myopathy of the right ventricle. Surgery is now the main treatment for the defect. To summarize our surgical results and experience based on patients with Ebstein’s anomaly who were under 7 years of age and treated with different surgical treatments.Materials and Methods: From January 2010 to December 2019, 80 patients under 7 years old who were diagnosed of Ebstein’s anomaly and underwent different surgical treatments were consecutively enrolled and followed up in detail. Results: The median age of the 80 patients at the time of surgery was 3.63 years. Sixty-four (80.00%) patients underwent biventricular repair while 13 (16.25%) underwent 1.5-ventricle repair. With the median follow-up 27.50 months, the long-term survival of the total cohort, 1.5-ventricular repair and biventricular repair was 82.35%, 91.67% and 100%, respectively. The long-term freedom from reoperation rate was 97.50%, 92.31% and 98.44%, respectively. Mild, moderate and severe TR before surgery occurred in 6 (7.50%), 18 (22.50%) and 56 (70.00%), respectively. The early outcomes of 78 patients were 65 (83.33%), 11 (14.11%) and 2 (2.56%); the mid-term outcomes of 72 patients were 49 (68.06%), 19 (26.38%) and 4 (5.56%). Both early and long-term valve regurgitation were significantly decreased (p< 0.001) compared with preoperative condition. No more severe regurgitation occurred (p=0.404), though some early mild regurgitation became acceptable moderate regurgitation during long-term follow-up (p=0.036). Compared with Carpentier procedure, cone procedure had better long-term effect, while the effect of whole-valve technique needed more operation and long-term follow-up.Conclusion: The reoperation rate and mid-term mortality of surgical treatment for Ebstein’s anomaly were both low, tricuspid regurgitation was significantly improved during mid-term follow up. Cone procedure had the best mid-term effect among anatomic repair.

Download Full-text

Recent advances in understanding urethral lichen sclerosus

F1000Research ◽

10.12688/f1000research.7120.1 ◽

2016 ◽

Vol 5 ◽

pp. 96 ◽

Cited By ~ 5

Author(s):

Altaf Mangera ◽

Nadir Osman ◽

Christopher R. Chapple

Keyword(s):

Natural History ◽

Male Genitalia ◽

Lichen Sclerosus ◽

Recent Advances ◽

History Of ◽

Surgical Treatments ◽

Term Data

Lichen sclerosus affecting the male genitalia is a poorly understood but potentially devastating condition. The natural history of the condition is beginning to be understood better with longer follow-up of patients. Recent long-term data suggest that circumcision for lichen sclerosus limited to the prepuce may not be curative as was once thought. In addition, surgical treatments should be followed up for longer periods as recurrences may occur after urethroplasty and perineal urethrostomy.

Download Full-text

Gamma Knife surgery for trigeminal schwannoma

Journal of Neurosurgery ◽

10.3171/jns.2007.106.5.839 ◽

2007 ◽

Vol 106 (5) ◽

pp. 839-845 ◽

Cited By ~ 44

Author(s):

Jason Sheehan ◽

Chun Po Yen ◽

Yasser Arkha ◽

David Schlesinger ◽

Ladislau Steiner

Keyword(s):

Gamma Knife ◽

Gamma Knife Surgery ◽

Long Term Results ◽

University Of Virginia ◽

Trigeminal Schwannoma ◽

The Mean ◽

The University ◽

Lost To Follow Up

Object Trigeminal schwannomas are rare intracranial tumors. In the past, resection and radiation therapy were the mainstays of their treatment. More recently, neurosurgeons have begun to use radiosurgery in the treatment of trigeminal schwannomas because of its successful use in the treatment of vestibular schwannomas. In this article the authors evaluate the radiological and clinical outcomes in a series of patients in whom Gamma Knife surgery (GKS) was used to treat trigeminal schwannomas. Methods Twenty-six patients with trigeminal schwannomas underwent GKS at the University of Virginia Lars Lek-sell Gamma Knife Center between 1989 and 2005. Five of these patients had neurofibromatosis and one patient was lost to follow up. The median tumor volume was 3.96 cm3, and the mean follow-up period was 48.5 months. The median prescription radiation dose was 15 Gy, and the median prescription isodose configuration was 50%. There was clinical improvement in 18 patients (72%), a stable lesion in four patients (16%), and worsening of the disease in three patients (12%). On imaging, the schwannomas shrank in 12 patients (48%), remained stable in 10 patients (40%), and increased in size in three patients (12%). These results were comparable for primary and adjuvant GKSs. No tumor growth following GKS was observed in the patients with neurofibromatosis. Conclusions Gamma Knife surgery affords a favorable risk-to-benefit profile for patients harboring trigeminal schwannomas. Larger studies with open-ended follow-up review will be necessary to determine the long-term results and complications of GKS in the treatment of trigeminal schwannomas.

Download Full-text

Cody’s Books

LOGOS ◽

10.1163/18784712-02904003 ◽

2018 ◽

Vol 29 (4) ◽

pp. 14-25

Author(s):

David Emblidge

Keyword(s):

San Francisco ◽

Social Protest ◽

Left Wing ◽

Protest Movements ◽

Chain Stores ◽

Street Violence ◽

The Social ◽

The 1960S ◽

The University

Cody’s Books, in Berkeley, California, had its roots during the mid-1950s in the left-wing sympathies of its founders, the husband–wife team of Fred and Patricia Cody. Serving the University of California nearby, the much admired bookstore became a hangout and haven for intellectually curious students and faculty. In the social protest movements of the 1960s, the store functioned as a refuge from street violence as students and police clashed outside. When long-term employee Andy Ross bought the shop upon the Codys’ retirement, it was a thriving business but soon ran into challenges from encroaching chain stores and the emergence of online shopping. Ross responded variously: sometimes with ambitious, effective bookselling tactics, sometimes with ineffective resentment towards consumers who had abandoned the store. Attempts to survive through risky refinancing and the infusion of foreign investment money to support expansion into San Francisco all backfired. The last Cody’s branch closed ignominiously in 2008.

Download Full-text