Linac-based stereotactic radiosurgery (SRS) in the treatment of refractory trigeminal neuralgia: Detailed description of SRS procedure and reported clinical outcomes.

Damodar Pokhrel,Timothy Stepp,Paul Camarata,Sumit Sood,Habeeb Saleh,Christopher Mcclinton,Rajeev Badkul,Hongyu Jiang,Fen Wang

doi:10.1002/acm2.12057

Damodar Pokhrel, Timothy Stepp + Show 7 more

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https://doi.org/10.1002/acm2.12057

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Abstract

Purpose/ObjectivesTo present our linac‐based SRS procedural technique for medically and/or surgically refractory trigeminal neuralgia (TN) treatment and simultaneously report our clinical outcomes.Materials and MethodsTwenty‐seven refractory TN patients who were treated with a single fraction of 80 Gy to TN. Treatment delivery was performed with a 4 mm cone size using 7‐arc arrangement with differential‐weighting for Novalis‐TX with six MV‐SRS (1000 MU/min) beam and minimized dose to the brainstem. Before each treatment, Winston–Lutz quality assurance (QA) with submillimeter accuracy was performed. Clinical treatment response was evaluated using Barrow Neurological Institute (BNI) pain intensity score, rated from I to V.ResultsOut of 27 patients, 22 (81%) and 5 (19%) suffered from typical and atypical TN, respectively, and had median follow‐up interval of 12.5 months (ranged: 1–53 months). For 80 Gy prescriptions, delivered total average MU was 19440 ± 611. Average beam‐on‐time was 19.4 ± 0.6 min. Maximum dose and dose to 0.5 cc of brainstem were 13.4 ± 2.1 Gy (ranged: 8.4–15.9 Gy) and 3.6 ± 0.4 Gy (ranged: 3.0–4.9 Gy), respectively. With a median follow‐up of 12.5 months (ranged: 1–45 months) in typical TN patients, the proportion of patients achieving overall pain relief was 82%, of which half achieved a complete pain relief with BNI score of I‐II and half demonstrated partial pain reduction with BNI score of IIIA‐IIIB. Four typical TN patients (18%) had no response to radiosurgery treatment. Of the patients who responded to treatment, actuarial pain recurrence free survival rates were approximately 100%, 75%, and 50% at 12 months, 15 months, and 24 months, respectively. Five atypical TN patients were included, who did not respond to treatment (BNI score: IV–V). However, no radiation‐induced cranial‐toxicity was observed in all patients treated.ConclusionLinac‐based SRS for medically and/or surgically refractory TN is a fast, effective, and safe treatment option for patients with typical TN who had excellent response rates. Patients, who achieve response to treatment, often have durable response rates with moderate actuarial pain recurrence free survival. Longer follow‐up interval is anticipated to confirm our clinical observations.

Highlights

Trigeminal neuralgia (TN) is a neurologic syndrome that presents with spontaneous episodes sever, electric shock-like pain along the trigeminal nerve dermatome(s)
Linac-based stereotactic radiosurgery (SRS) has become an increasingly popular treatment modality for TN due to technological advancements which have allowed for precise radiation delivery in a fast and effective manner.10–13Recently, many researchers have presented linac-based SRS treatment outcomes for TN patients which are comparable with gamma knife data.[14,15,16,17,18,19]
Due to the effectiveness of linac-based SRS for treatment of smaller target such as TN, we sought to present a detailed description of our linac-based SRS technique as well as report our long-term clinical outcomes in patients with medically and/or surgical refractory TN

Summary

Introduction

Trigeminal neuralgia (TN) is a neurologic syndrome that presents with spontaneous episodes sever, electric shock-like pain along the trigeminal nerve dermatome(s). Typical primary treatment strategies consist of medical management with antiseizure medication, surgical intervention such as microvascular decompression, and stereotactic radiosurgery.[1,2,3,4] Historically, gamma knife-based stereotactic radiosurgery (SRS) has been considered an effective and noninvasive alternative treatment modality associated with minimal toxicity — in patients with medically and surgically refractory TN or those who are not ideal surgical candidates.[5,6,7,8,9] For example, in a multi-intuitional review of 503 patients with TN who had been treated with gamma knife-based SRS, 58% of patients achieved complete pain relief and 36% of patients achieved partial pain relief.[8]

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