Results of repeated gamma knife radiosurgery for medically unresponsive trigeminal neuralgia

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 162-164 ◽  
Author(s):  
Bruce E. Pollock ◽  
Robert L. Foote ◽  
Scott L. Stafford ◽  
Michael J. Link ◽  
Deborah A. Gorman ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Facial Pain ◽  
Gamma Knife Radiosurgery ◽  
Neurological Dysfunction ◽  
Content Type ◽  
Additional Surgery ◽  
Facial Numbness ◽  
Fine Print

Object. Gamma knife radiosurgery (GKS) is being increasing performed in the management of patients with medically unresponsive trigeminal neuralgia. The authors report the results of repeated GKS in patients with recurrent facial pain after their initial procedure. Methods. Between April 1997 and December 1999, 100 patients with idiopathic trigeminal neuralgia underwent GKS at the authors' center. To date, 26 patients have required additional surgery because GKS provided no significant pain relief (15 patients) or because they had recurrent facial pain (11 patients). Ten of these patients underwent repeated GKS at a median of 13 months (range 4–27 months). All patients undergoing repeated GKS had a significant reduction in their facial pain after the first procedure (eight were pain free); no patient developed facial numbness or paresthesias. Initially, nine of 10 patients became pain free 1 to 4 weeks following repeated GKS. At a median follow up of 15 months (range 3–32 months), eight patients remained pain free and required no medication. All eight patients with persistent pain relief developed minor neurological dysfunction after repeated GKS (six patients had facial numbness and two had paresthesias). Conclusions. Repeated GKS can be associated with a high rate of pain relief for patients with trigeminal neuralgia who experienced a significant reduction in their facial pain after the first operation. However, every patient with sustained pain relief after the second operation also developed some degree of trigeminal dysfunction. These findings of improved pain relief for patients who develop facial numbness after GKS for trigeminal neuralgia support the experimental data currently available.

Gamma knife radiosurgery for trigeminal neuralgia associated with multiple sclerosis

2002 ◽  
Vol 97 ◽  
pp. 529-532 ◽  
Author(s):  
C. Leland Rogers ◽  
Andrew G. Shetter ◽  
Francisco A. Ponce ◽  
Jeffrey A. Fiedler ◽  
Kris A. Smith ◽  
...  
Keyword(s):  
Multiple Sclerosis ◽  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Maximum Dose ◽  
Gamma Knife Radiosurgery ◽  
Content Type ◽  
Experienced Pain ◽  
The Mean ◽  
Fine Print

Object. The authors assessed the efficacy and complications from gamma knife radiosurgery (GKS) for multiple sclerosis (MS)-associated trigeminal neuralgia (TN). Methods. There were 15 patients with MS-associated TN (MS—TN). Treatment involved three sequential protocols, 70 to 90-Gy maximum dose, using a single 4-mm isocenter targeting the ipsilateral trigeminal nerve at its junction with the pons with the 50% isodose. Pain was appraised by each patient by using Barrow Neurological Institute (BNI) Scores I through IV: I, no pain; II, occasional pain not requiring medication; IIIa, no pain but continued medication; IIIb, some pain, controlled with medication; IV, some pain, not controlled with medication; and V, severe pain/no pain relief. With a mean follow up of 17 months (range 6–38 months), 12 (80%) of 15 patients experienced pain relief. Three patients (20%) reported no relief (BNI Score V). For responders, the mean latency from treatment to the onset of pain relief was 13 days (range 1–61 days). Maximal relief was achieved after a mean latency of 56 days (range 1–157 days). Five patients underwent a second GKS after a mean interval of 534 days (range 231–946 days). The mean maximum dose at this second treatment was 48 Gy. The target was unchanged from the first treatment. All five patients who underwent repeated GKS improved. Complications were limited to delayed facial hypesthesias. Two (13%) of 15 patients experienced onset of numbness after the first GKS, as well as two of five patients following a second GKS. The patients found this mild and not bothersome. Each patient who developed hypesthesias also experienced complete pain relief. Conclusions. Gamma knife radiosurgery is an effective treatment for MS—TN. Radiosurgery carries an acceptable small risk of mild facial hypesthesias, and hypesthesia appears predictive of a favorable outcome.

Gamma knife radiosurgery for trigeminal neuralgia: dose—volume histograms of the brainstem and trigeminal nerve

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 155-158 ◽  
Author(s):  
Ronald Brisman ◽  
R. Mooij
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Trigeminal Nerve ◽  
Maximum Dose ◽  
Gamma Knife Radiosurgery ◽  
Content Type ◽  
Dose Volume Histograms ◽  
Dose Volume ◽  
Fine Print

Object. The purpose of this study was to assess the relationship between the volume of brainstem that receives 20% or more of the maximum dose (VB20) and the volume of the trigeminal nerve that receives 50% or more of the maximum dose (VT50) on clinical outcome following gamma knife radiosurgery (GKS) for trigeminal neuralgia (TN). Methods. Patients with TN were treated with a single 4-mm isocenter with a maximum dose of 75 Gy directed at the trigeminal nerve close to where it leaves the brainstem. The VB20 and VT50, as determined on dose—volume histograms, were correlated with clinical outcomes at 6 and 12 months, laterality, presence of multiple sclerosis (MS), and each other. At 6 months excellent pain relief (no pain or required medicine) was achieved in 27 of 48 patients (p = 0.009) when VB20 was greater than or equal to 20 mm3 and in 25 of 78 when VB20 was less than 20 mm3, when all patients are considered. At 12 months excellent pain relief was achieved in 16 of 32 patients (p = 0.038) when VB20 was greater than or equal to 20 mm3 and in 14 of 52 when VB20 less than 20 mm3, when all patients are considered. When VB20 was less than 20 mm3 in MS patients, five of 21 had an excellent result at 6 months and two of 13 at 12 months. The VB20 was 20 mm3 or more in 38 of 64 on the right side and in eight of 41 on the left side (p < 0.001) in patients with TN and without MS. There is a difference between left and right dose—volume histograms even when the same isodose is placed on the surface of the brainstem. The VB20 was 20 mm3 or more in 45 of 105 patients with TN and without MS but in only three of 21 patients with TN and MS (p = 0.014). There was an inverse relationship between VB20 and VT50 (p = 0.01). Conclusions. Isocenter proximity to the brainstem, as reflected in a higher VB20, is associated with a greater chance of excellent outcome at 6 and 12 months. Worse results in patients with TN and MS may be partly explained by a lower VB20.

Gamma knife radiosurgery for primary management for trigeminal neuralgia

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 159-161 ◽  
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.

Treatment of postherpetic trigeminal neuralgia with the Leksell gamma knife

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 165-168 ◽  
Author(s):  
Dušan Urgošík ◽  
Josef Vymazal ◽  
Vilibald Vladyka ◽  
Roman Liščák
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Postherpetic Neuralgia ◽  
Pain Treatment ◽  
Gamma Knife Radiosurgery ◽  
Intractable Pain ◽  
Neurosurgical Procedures ◽  
Content Type ◽  
Fine Print

Object. Postherpetic neuralgia is a syndrome characterized by intractable pain. Treatment of this pain has not yet been successful. Patients with postherpetic neuralgia will therefore benefit from any progress in the treatment strategy. The authors performed gamma knife radiosurgery (GKS) as a noninvasive treatment for postherpetic trigeminal neuralgia (TN) and evaluated the success rate for pain relief. Methods. Between 1995 and February 1999, six men and 10 women were treated for postherpetic TN; conservative treatment failed in all of them. The median follow up was 33 months (range 8–34 months). The radiation was focused on the root of the trigeminal nerve in the vicinity of the brainstem (maximal dose 70–80 Gy in one fraction, 4-mm collimator). The patients were divided into five groups according to degree of pain relief after treatment. A successful result (excellent, very good, and good) was reached in seven (44%) patients and radiosurgery failed in nine (56%). Pain relief occurred after a median interval of 1 month (range 10 days–6 months). No radiation-related side effects have been observed in these patients. Conclusions. These results suggest that GKS for postherpetic TN is a relatively successful and safe method that can be used in patients even if they are in poor condition. In case this method fails, other treatment options including other neurosurgical procedures are not excluded.

scholarly journals Clinical Outcomes of Gamma Knife Radiosurgery in the Treatment of Patients with Trigeminal Neuralgia

2012 ◽  
Vol 2012 ◽  
pp. 1-13 ◽  
Author(s):  
Ameer L. Elaimy ◽  
Peter W. Hanson ◽  
Wayne T. Lamoreaux ◽  
Alexander R. Mackay ◽  
John J. Demakas ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Pain Control ◽  
Facial Pain ◽  
Gamma Knife Radiosurgery ◽  
Management Approach ◽  
Review Of The Literature ◽  
Facial Numbness ◽  
Sensory Changes

Since its introduction by Leksell, Gamma Knife radiosurgery (GKRS) has become increasingly popular as a management approach for patients diagnosed with trigeminal neuralgia (TN). For this reason, we performed a modern review of the literature analyzing the efficacy of GKRS in the treatment of patients who suffer from TN. For patients with medically refractory forms of the condition, GKRS has proven to be an effective initial and repeat treatment option. Cumulative research suggests that patients treated a single time with GKRS exhibit similar levels of facial pain control when compared to patients treated multiple times with GKRS. However, patients treated on multiple occasions with GKRS are more likely to experience facial numbness and other facial sensory changes when compared to patients treated once with GKRS. Although numerous articles have reported MVD to be superior to GKRS in achieving facial pain relief, the findings of these comparison studies are weakened by the vast differences in patient age and comorbidities between the two studied groups and cannot be considered conclusive. Questions remain regarding optimal GKRS dosing and targeting strategies, which warrants further investigation into this controversial matter.

Gamma knife radiosurgery for recurrent trigeminal neuralgia

2002 ◽  
Vol 97 ◽  
pp. 536-538 ◽  
Author(s):  
Andrew G. Shetter ◽  
C. Leland Rogers ◽  
Francisco Ponce ◽  
Jeffrey A. Fiedler ◽  
Kris Smith ◽  
...  
Keyword(s):  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
Sensory Loss ◽  
Content Type ◽  
Facial Numbness ◽  
Second Procedure ◽  
Fine Print ◽  
New Onset

Object. Pain may fail to respond or may recur after initial gamma knife radiosurgery (GKS) for trigeminal neuralgia (TN). The authors examined their experience with performing a second GKS procedure in these patients. Methods. Twenty-nine patients underwent repeated GKS for TN at our institution between March 1997 and March 2002. Questionnaires were mailed to patients to assess the degree of their pain relief and the extent of facial numbness. Nineteen patients responded. All patients underwent repeated GKS involving a single 4-mm isocenter directed at the trigeminal nerve as it exited the brainstem (mean maximum dose 23.2 Gy). At a mean follow up of 13.5 months after the second procedure, 10 patients (53%) were pain free and medication free. Four patients (21%) were pain free but elected to continue medication in reduced dose, and two patients (11%) had incomplete but satisfactory pain control and were still taking medication. There was new-onset facial numbness in eight patients (42%), rated as tolerable in all instances. Conclusions. Patients with facial numbness had a greater likelihood of being pain free than those with no sensory loss. The authors observed no cases of corneal anesthesia, keratitis, or deafferentation pain.

Stereotactic gamma knife surgery for trigeminal neuralgia: detailed analysis of treatment response

2005 ◽  
Vol 102 (3) ◽  
pp. 442-449 ◽  
Author(s):  
Rabih G. Tawk ◽  
Mary Duffy-Fronckowiak ◽  
Bryan E. Scott ◽  
Ronald A. Alberico ◽  
Aidnag Z. Diaz ◽  
...  
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Treatment Response ◽  
Gamma Knife ◽  
Gamma Knife Surgery ◽  
Limiting Factors ◽  
Content Type ◽  
Facial Numbness ◽  
Fine Print

Object. The purpose of this study was to assess the durability and completeness of pain relief in patients treated using stereotactic gamma knife surgery (GKS) for trigeminal neuralgia (TN). Methods. Thirty-eight patients with refractory TN were treated with stereotactic GKS. All patients received a prescription radiation dose of 35, 40, or 45 Gy to the 50% isodose surface through a 4-mm collimator helmet. The group was assessed regularly based on physician-directed interviews for a median follow up of 24 months (range 6–27 months). Pain relief was classified as excellent (no pain without medication), good (well-controlled pain with continued medication), fair (decreased but residual pain with continued medication), or poor (unimproved or increased pain with the same or increased medication). Three months after treatment, pain relief was good or excellent in 71% of patients. By 24 months post-GKS, 50% of the original cohort had poor pain relief, 21% continued to have either excellent or good relief, 3% had fair relief, and 26% had not reached the 24-month follow up. Based on their status at the last follow up, 29% of patients had excellent and 16% had good pain relief. Thirty-seven percent experienced facial numbness, which was dose related. In addition, there was a significantly higher rate of complete pain relief in patients who had facial numbness following treatment (p = 0.003). Conclusions. Stereotactic GKS is an effective treatment in patients with TN; however, the durability of pain relief and the time to treatment response are limiting factors. As with other types of ablative treatment, facial numbness is strongly associated with better treatment response.

Unusual causes of trigeminal neuralgia treated by gamma knife radiosurgery

2002 ◽  
Vol 97 ◽  
pp. 533-535 ◽  
Author(s):  
Jin Woo Chang ◽  
Jae Young Choi ◽  
Young Sul Yoon ◽  
Yong Gou Park ◽  
Sang Sup Chung
Keyword(s):  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Fourth Ventricle ◽  
Gamma Knife Radiosurgery ◽  
Brain Magnetic Resonance Imaging ◽  
Resonance Imaging ◽  
Segmental Demyelination ◽  
Content Type ◽  
Clinical Responses ◽  
Fine Print

✓ The purpose of this paper was to present two cases of secondary trigeminal neuralgia (TN) with an unusual origin and lesion location. In two cases TN was caused by lesions along the course of the trigeminal nerve within the pons and adjacent to the fourth ventricle. Both cases presented with typical TN. Brain magnetic resonance imaging revealed linear or wedge-shaped lesions adjacent to the fourth ventricle, extending anterolaterally and lying along the pathway of the intraaxial trigeminal fibers. The involvement of the nucleus of the spinal trigeminal tract and of the principal sensory trigeminal nucleus with segmental demyelination are suggested as possible causes for trigeminal pain in these cases. It is postulated that these lesions are the result of an old viral neuritis. The patients underwent gamma knife radiosurgery and their clinical responses have been encouraging to date.

Gamma knife surgery with a dose of 75 to 76.8 Gray for trigeminal neuralgia

2004 ◽  
Vol 100 (5) ◽  
pp. 848-854 ◽  
Author(s):  
Ronald Brisman
Keyword(s):  
Pain Relief ◽  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Gamma Knife Surgery ◽  
Recurrent Pain ◽  
Content Type ◽  
Kaplan Meier ◽  
Uniform Manner ◽  
Second Procedure ◽  
Fine Print

Object. The author presents a large series of patients with idiopathic trigeminal neuralgia (TN) who were treated with gamma knife surgery (GKS), at a maximum dose of 75 to 76.8 Gy, and followed up in a nearly uniform manner for up to 4.6 years. Methods. Two hundred ninety-three patients were treated and followed up for at least 6 months (range 0.4–4.6 years, median 1.9 years). At the final follow-up review, there was complete (100%) pain relief without medicines in 64 patients (21.8%), 90% or greater relief with or without small doses of medicines in 86 (29.4%), between 75 and 89% relief in 31 (10.6%), between 50 and 74% relief in 19 (6.5%), and less than 50% relief in 23 patients (7.8%). Recurrent pain requiring a second procedure occurred in 70 patients (23.9%). Kaplan—Meier analysis showed that 100%, 90% or greater, and 50% or greater pain relief was obtained and maintained for 3.5 to 4.1 years in 5.6 , 23.7, and 50.4% patients, respectively. Of 31 patients who described pain relief ranging from 75 to 89%, 80% of patients described it as good and 10% as excellent; of 17 patients who reported between 50 and 74% pain relief, 53% described it as good and none as excellent (p = 0.014). Dysesthesia scores greater than 5 (scale of 0–10, in which a score of 10 represents excruciating pain) occurred in four (3.2%) of 126 patients who had not undergone prior surgery; all these patients obtained either good or excellent relief from TN pain. There were 36 patients in whom the TN had atypical features; these patients were less likely to attain at least 50% or at least 90% pain relief compared with those without atypical TN features (p = 0.001). Conclusions. Gamma knife surgery is a safe and effective way to relieve TN. Patients who attain between 75 and 89% pain relief are much more likely to describe this outcome as good or excellent than those who attain between 50 and 74% pain relief.

Acute symptoms after gamma knife radiosurgery

2002 ◽  
Vol 97 ◽  
pp. 631-634 ◽  
Author(s):  
E. J. St. George ◽  
J. Kudhail ◽  
J. Perks ◽  
P. N. Plowman
Keyword(s):  
Adverse Events ◽  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
Neurological Dysfunction ◽  
Content Type ◽  
Lesion Type ◽  
Patient Groups ◽  
Pin Site ◽  
Fine Print

Object. The purpose of this study was to examine the widely held assumption that early-onset symptoms after gamma knife radiosurgery (GKS) are uncommon. The study was designed to include all types of morbidity and not just those that lead to neurological dysfunction. It was hoped that the results of the study could lead to a more rational follow-up protocol. Methods. Data regarding adverse events were collected prospectively (within 2–3 weeks post-GKS) by telephone interview from 47 of the first 65 patients who could be reached. Immediate adverse events were defined as any new or unexpected symptom developing within 2 weeks of treatment and were graded as mild, moderate, or severe. Two thirds of all patients complained of new adverse symptoms; three patients required prolonged hospitalization, although in one case this was not related to the radiosurgery. The majority of symptomatic patients (91%) experienced mild or moderate complications. More than 50% of patients had headache. One third described pin site—related complications and one fifth suffered from nausea/vomiting or marked tiredness. Patients with moderate symptoms had a larger mean tumor volume and higher radiation dose than other patient groups. Prior radiation therapy, lesion type, or the posttreatment administration of steroid agents did not significantly influence the development of acute symptoms. Conclusions. Acute adverse events following GKS are not uncommon if all types of morbidity are considered. An increased appreciation of these other complications may improve posttreatment care.

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