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.

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 in the management of cavernous sinus meningiomas

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 68-73 ◽  
Author(s):  
Pierre-Hugues Roche ◽  
Jean Régis ◽  
Henry Dufour ◽  
Henri-Dominique Fournier ◽  
Christine Delsanti ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Tumor Growth ◽  
Gamma Knife ◽  
Cavernous Sinus ◽  
Gamma Knife Radiosurgery ◽  
Surgical Removal ◽  
Content Type ◽  
Cavernous Sinus Meningioma ◽  
The Mean ◽  
Fine Print

Object. The authors sought to assess the functional tolerance and tumor control rate of cavernous sinus meningiomas treated by gamma knife radiosurgery (GKS). Methods. Between July 1992 and October 1998, 92 patients harboring benign cavernous sinus meningiomas underwent GKS. The present study is concerned with the first 80 consecutive patients (63 women and 17 men). Gamma knife radiosurgery was performed as an alternative to surgical removal in 50 cases and as an adjuvant to microsurgery in 30 cases. The mean patient age was 49 years (range 6–71 years). The mean tumor volume was 5.8 cm3 (range 0.9–18.6 cm3). On magnetic resonance (MR) imaging the tumor was confined in 66 cases and extensive in 14 cases. The mean prescription dose was 28 Gy (range 12–50 Gy), delivered with an average of eight isocenters (range two–18). The median peripheral isodose was 50% (range 30–70%). Patients were evaluated at 6 months, and at 1, 2, 3, 5, and 7 years after GKS. The median follow-up period was 30.5 months (range 12–79 months). Tumor stabilization after GKS was noted in 51 patients, tumor shrinkage in 25 patients, and enlargement in four patients requiring surgical removal in two cases. The 5-year actuarial progression-free survival was 92.8%. No new oculomotor deficit was observed. Among the 54 patients with oculomotor nerve deficits, 15 improved, eight recovered, and one worsened. Among the 13 patients with trigeminal neuralgia, one worsened (contemporary of tumor growing), five remained unchanged, four improved, and three recovered. In a patient with a remnant surrounding the optic nerve and preoperative low vision (3/10) the decision was to treat the lesion and deliberately sacrifice the residual visual acuity. Only one transient unexpected optic neuropathy has been observed. One case of delayed intracavernous carotid artery occlusion occurred 3 months after GKS, without permanent deficit. Another patient presented with partial complex seizures 18 months after GKS. All cases of tumor growth and neurological deficits observed after GKS occurred before the use of GammaPlan. Since the initiation of systematic use of stereotactic MR imaging and computer-assisted modern dose planning, no more side effects or cases of tumor growth have occurred. Conclusions. Gamma knife radiosurgery was found to be an effective low morbidity—related tool for the treatment of cavernous sinus meningioma. In a significant number of patients, oculomotor functional restoration was observed. The treatment appears to be an alternative to surgical removal of confined enclosed cavernous sinus meningioma and should be proposed as an adjuvant to surgery in case of extensive meningiomas.

Gamma knife radiosurgery for craniopharyngiomas

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 47-56 ◽  
Author(s):  
Wen-Yuh Chung ◽  
David Hung-Chi Pan ◽  
Cheng-Ying Shiau ◽  
Wan-Yuo Guo ◽  
Ling-Wei Wang
Keyword(s):  
Clinical Outcome ◽  
Gamma Knife ◽  
Tumor Volume ◽  
Gamma Knife Radiosurgery ◽  
Tumor Control ◽  
Content Type ◽  
Stereotactic Aspiration ◽  
Cystic Component ◽  
The Mean ◽  
Fine Print

Object. The goal of this study was to elucidate the role of gamma knife radiosurgery (GKS) and adjuvant stereotactic procedures by assessing the outcome of 31 consecutive patients harboring craniopharyngiomas treated between March 1993 and December 1999. Methods. There were 31 consecutive patients with craniopharyngiomas: 18 were men and 13 were women. The mean age was 32 years (range 3–69 years). The mean tumor volume was 9 cm3 (range 0.3–28 cm3). The prescription dose to the tumor margin varied from 9.5 to 16 Gy. The visual pathways received 8 Gy or less. Three patients underwent stereotactic aspiration to decompress the cystic component before GKS. The tumor response was classified by percentage reduction of tumor volume as calculated based on magnetic resonance imaging studies. Clinical outcome was evaluated according to improvement and dependence on replacement therapy. An initial postoperative volume increase with enlargement of a cystic component was found in three patients. They were treated by adjuvant stereotactic aspiration and/or Ommaya reservoir implantation. Tumor control was achieved in 87% of patients and 84% had fair to excellent clinical outcome in an average follow-up period of 36 months. Treatment failure due to uncontrolled tumor progression was seen in four patients at 26, 33, 49, and 55 months, respectively, after GKS. Only one patient was found to have a mildly restricted visual field; no additional endocrinological impairment or neurological deterioration could be attributed to the treatment. There was no treatment-related mortality. Conclusions. Multimodality management of patients with craniopharyngiomas seemed to provide a better quality of patient survival and greater long-term tumor control. It is suggested that GKS accompanied by adjuvant stereotactic procedures should be used as an alternative in treating recurrent or residual craniopharyngiomas if further microsurgical excision cannot promise a cure.

Gamma knife radiosurgery for uveal melanomas: an 8-year experience

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 184-188 ◽  
Author(s):  
Gerald Langmann ◽  
Gerhard Pendl ◽  
Georg Papaefthymiou ◽  
Helmuth Guss ◽  
Keyword(s):  
Gamma Knife ◽  
Ciliary Body ◽  
Tumor Regression ◽  
Gamma Knife Radiosurgery ◽  
Neovascular Glaucoma ◽  
Content Type ◽  
Prescription Dose ◽  
The Mean ◽  
Fine Print ◽  
Uveal Melanomas

Object. The authors report their experience using gamma knife radiosurgery (GKS) to treat uveal melanomas. Methods. Between 1992 and 1998, 60 patients were treated with GKS at a prescription dose between 45 Gy and 80 Gy. The mean diameter of the tumor base was 12.2 mm (range 3–22 mm). The mean height of the tumor prominence was 6.7 mm (range 3–12 mm). The eye was immobilized. The follow-up period ranged from 16 to 94 months. Tumor regression was achieved in 56 (93%) of 60 patients. There were four recurrences followed by enucleation. The severe side effect of neovascular glaucoma developed in 21 (35%) patients in a high-dose group with larger tumors and in proximity to the ciliary body. A reduction in the prescription dose to 40 Gy or less and excluding treatment to tumors near the ciliary body decreased the rate of glaucoma without affecting the rate of tumor control. Conclusions. Gamma knife radiosurgery at a prescription dose of 45 Gy or more can achieve tumor regression in 85% of the uveal melanomas treated. Neovascular glaucoma can develop in patients when using this dose in tumors near the ciliary body. It is advised that such tumors be avoided and that the prescription dose be reduced to 40 Gy.

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.

Analysis of the causes of treatment failure in gamma knife radiosurgery for intracranial arteriovenous malformations

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 104-106 ◽  
Author(s):  
Yang Kwon ◽  
Sang Ryong Jeon ◽  
Jeong Hoon Kim ◽  
Jung Kyo Lee ◽  
Dong Sook Ra ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Treatment Failure ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Intracranial Arteriovenous Malformations ◽  
Content Type ◽  
The Mean ◽  
Fine Print

Object. The authors sought to analyze causes for treatment failure following gamma knife radiosurgery (GKS) for intracranial arteriovenous malformations (AVMs), in cases in which the nidus could still be observed on angiography 3 years postsurgery. Methods. Four hundred fifteen patients with AVMs were treated with GKS between April 1990 and March 2000. The mean margin dose was 23.6 Gy (range 10–25 Gy), and the mean nidus volume was 5.3 cm3 (range 0.4–41.7 cm3). The KULA treatment planning system and conventional subtraction angiography were used in treatment planning. One hundred twenty-three of these 415 patients underwent follow-up angiography after GKS. After 3 years the nidus was totally obliterated in 98 patients (80%) and partial obliteration was noted in the remaining 25. There were several reasons why complete obliteration was not achieved in all cases: inadequate nidus definition in four patients, changes in the size and location of the nidus in five patients due to recanalization after embolization or reexpansion after hematoma reabsorption, a large AVM volume in five patients, a suboptimal radiation dose to the thalamic and basal ganglia in eight patients, and radioresistance in three patients with an intranidal fistula. Conclusions. The causes of failed GKS for treatment of AVMs seen on 3-year follow-up angiograms include inadequate nidus definition, large nidus volume, suboptimal radiation dose, recanalization/reexpansion, and radioresistance associated with an intranidal fistula.

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