Radiosurgical Treatment Of Trigeminal Neuralgia Research Articles

Radiosurgical treatment of trigeminal neuralgia using the CyberKnife system

Trigeminal neuralgia (TN) is the most common neuralgia, among others. In the Medical Center of Yuriy Spizhenko LLC from 2013 to 2020, 24 patients with TN were treated using the CyberKnife unified robotic system for radiosurgical treatment. This system is the maximum accuracy of <1 mm of receiving a therapeutic dose in a pathological tissue with minimal exposure to surrounding tissues due to a sharp drop in the dose gradient. A positive effect of the treatment was observed in 19 patients. 4 patients did not notice any improvement in their condition, an additional rhizotomy was performed, and 3 patients underwent drug blockade and continued taking carbamazepine. The CyberKnife robotic system for radiosurgical treatment is a safe, effective alternative to invasive surgical intervention, without the need for additional rehabilitation period and improves the patient's quality of life

Radiosurgical treatment of trigeminal neuralgia: experience of the Radiosurgery Center of the N.V. Sklifosovsky Research Institute for Emergency Medicine

The study objective is to evaluate early results of radiosurgical treatment (RST) of drug-resistant trigeminal neuralgia (TN) of various etiology.Materials and methods. Between 01.01.2016 and 01.07.2018 at the Radiosurgery Center of the N.V. Sklifosovsky Research Institute for Emergency Medicine, 14 patients with drug-resistant TN underwent RST. Per magnetic resonance imaging, prior to treatment 7 patients had neurovascular conflict, 2 had demyelination of the root of the trigeminal nerve due to multiple sclerosis, and 5 patients showed no pathologies of the brain. Irradiation of the cisternal portion of the trigeminal nerve at the distance of 7.5 mm from the entry into the brainstem with prescribed dose of 90 Gy was performed. Follow-up period was 8–20 months. The difference in fractional anisotropy (FA) at the affected and healthy sides was evaluated in patients with TN prior to RST to divide them into 2 groups: with significant FA decrease and with moderate FA decrease.Results. All patients who underwent RST with PD >80 Gy (85.7 %) noted decreased level of pain or its full disappearance. In 11 (78.5 %) patients, anesthetic effect manifested itself 3–6 weeks after RST, in 1–3 months after RST. Full analgesic effect was achieved in a patient with idiopathic type II TN (PD 84 Gy) 3 months after RST, in a patient with neurovascular conflict and type I TN (PD 86 Gy) 6 weeks after RST, in a patient with multiple sclerosis and type I TN (PD 81 Gy) 3 weeks after RST. In the last-mentioned patient, pain returned 12 months after RST but with lower intensity. In 2 (14.3 %) patients (PD 80 Gy), no positive effect was observed in 6 months of follow up. Hypesthesia of a face area (RST complication) was diagnosed in only 1 (7.2 %) patient 8 months after RST, and it persisted for 6 weeks gradually regressing. There was no statistically significant correlation between FA decrease and RST outcome, but it was observed that outcome was more favorable in patients with moderately decreased FA.Conclusion. RST of drug-resistant forms of TN with PD >80 Gy significantly reduces pain syndrome 3–6 weeks after treatment and is characterized by low risk of complications.

Gamma Knife Radiosurgery for Trigeminal Neuralgia: A Comparison of Dose Protocols.

Purpose: A variety of treatment plans including an array of prescription doses have been used in radiosurgery treatment of trigeminal neuralgia (TN). However, despite a considerable experience in the radiosurgical treatment of TN, an ideal prescription dose that balances facial dysesthesia risk with pain relief durability has not been determined. Methods and Materials: This retrospective study of patients treated with radiosurgery for typical TN evaluates two treatment doses in relation to outcomes of pain freedom, bothersome facial numbness, and patient satisfaction with treatment. All patients were treated with radiosurgery for intractable and disabling TN. A treatment dose protocol change from 80 to 85 Gy provided an opportunity to compare two prescription doses. The variables evaluated were pain relief, treatment side-effect profile, and patient satisfaction. Results: Typical TN was treated with 80 Gy in 26 patients, and 85 Gy in 37 patients. A new face sensory disturbance was reported after 80 Gy in 16% and after 85 Gy in 27% (p = 0.4). Thirteen failed an 80 Gy dose whereas seven failed an 85 Gy dose. Kaplan–Meier analysis found that at 29 months 50% failed an 80 Gy treatment compared with 79% who had durable pain relief after 85 Gy treatment (p = 0.04). Conclusion: The 85 Gy dose for TN provided a more durable pain relief compared to the 80 Gy one without a significantly elevated occurrence of facial sensory disturbance.

205 Optimizing Outcomes with Permissive Brainstem Dosing and Anatomic Considerations in the Radiosurgical Treatment of Trigeminal Neuralgia

Abstract INTRODUCTION CyberKnife stereotactic radiosurgery (SRS) for trigeminal neuralgia (TGN) administers non-isometric, conformational high-dose radiation to the root entry zone, with possible post-procedural numbness from excessive brainstem exposure. We evaluated outcomes from two treatment plans differing in their maximum brainstem dose. METHODS A retrospective, single-institution review of 91 TGN patients treated with CyberKnife from January 2005-May 2007 (Plan A, N = 47) and January 2009-August 2013 (Plan B, N = 44) was conducted. Plan A (vs B) aimed for a maximum brainstem dose of 40 vs 25 Gy, respectively, both in one fraction with 75 Gy to the 100% isodose line. Primary outcome was self-reported pain control. Secondary outcomes included change in Barrow Neurologic Institute (BNI) pain and numbness scores. Pre-pontine nerve length, maximum brainstem dose, and treatment history were additionally recorded for their predictive contribution by matched-cohort regression. RESULTS >Patients were followed for a mean of 23 months, and 62% were naiuml;ve to treatment. Plans A and B exhibited treatment failure, durable improvement, and pain recurrence in 6.4% vs 18.0% (P = 0.084), 68.1% vs 36.4% (P = 0.002), and 25.5% vs 45.5% (P = 0.047), respectively. Mean BNI pain scores improved for 74.5% vs 61.3% (P = 0.18), while BNI numbness scores increased for 45.2% and 72.7% (P = 0.042). Cohorts differed in baseline nerve length at 10.1 mm vs 7.5 mm (P < 0.001). Regression analysis on cohorts matched by length demonstrated that treatment plans allowing higher brainstem maximum dosing was associated with pain improvement (P = 0.05), and univariate analyses showing longer nerve length predicted decreased numbness (P = 0.03). Furthermore, under Plan A, improvement was predicted by age, prior decompression and prior SRS (AUC = 0.82). CONCLUSION These outcomes show a higher maximum brainstem dose constraint may result in better pain control without worsening rates of facial numbness. Future application of CyberKnife SRS may consider higher doses in patients with longer nerves and no prior treatment history.

Meta-Analysis on Safety and Efficacy of Microsurgical and Radiosurgical Treatment of Trigeminal Neuralgia.

Classic trigeminal neuralgia is often treated pharmacologically first. However, microvascular decompression (MVD) or radiosurgical treatment (RS) can render medication unnecessary. Objective appraisals of the 2 treatment modalities are scarce. To compare the evidence regarding safety and efficiency of MVD and RS. We searched PubMed for studies describing pain control, complications, and recurrences after MVD or RS between 2005 and 2015. Because randomized studies are lacking, we focused the statistical analysis on cohort clinical trials. Differences in outcome after treatment with either MVD or RS were analyzed using t tests and weighted averages. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Fifty-three studies (13,805 patients, in 11 prospective and 42 retrospective studies) were analyzed. Initial success rates were 71.1% for RS and 86.9% for MVD (P < 0.0001). At last follow-up (>5 years after intervention), success rates decreased to 63.8% for RS versus 84% for MVD (P= 0.036). Thirty-six months after the intervention, median percentage of recurrence was 11% for MVD and 25% for RS (P= 0.0015). The length of recurrence-free intervals was similar for MVD and RS (30.45 vs. 30.55 months; P= 0.987). There was no significant difference between the incidence of hearing loss after MVD and RS (1.51% vs. 0.74%; P= 0.21). Facial dysesthesia was reported more frequently after radiosurgery (2.3% vs. 28.8%; P= 0.02). MVD is a valid first-line treatment option for young patients free of comorbidities. First-line RS can be advised in patients with a higher surgical risk.

Cyberknife radiosurgery in treating trigeminal neuralgia

PurposeTo assess the short term efficacy of Cyberknife stereotactic radiosurgical treatment of trigeminal neuralgia (TN).Methods17 consecutive patients with medically or surgically refractory unilateral TN were treated with Cyberknife radiosurgery. Using...

Radiosurgical treatment of trigeminal neuralgia: A follow-up experience over three years

To assess the safety and efficacy of radiosurgical treatment for trigeminal neuralgia (TN), we reviewed a total of 32 patients with refractory TN treated with gamma knife radiosurgery (GKRS) and followed-up for over 3 years. A median maximum dose of 80 Gy was delivered to the involved trigeminal nerve root entry zone. Treatment outcomes were assessed based on patients’ self-reports. A univariate analysis was used to determine the predictors for treatment outcomes. In a median follow-up of 41 months, an improved response to GKRS was observed in 27 patients (84%). Actuarial analysis showed that the 12, 24, 36, and 58month percentages of improved response were 72, 67, 56 and 47% respectively. Pain relief occurred in a median time of 3.5 months, and was maintained for a median of 21 months. Twelve patients (44%) complained with recurrence of the pain after a median of 10 months. Actuarial analysis revealed that the 12, 24, 36 and 58 month recurrence rates were 7, 15, 15 and 11% respectively. Facial numbness, the only complication, was observed in 3 patients (9.4%). Univariate analysis revealed that a higher maximum dose and a shorter distance between the pontine edge and target center were associated with improved response; that a lower maximum dose and prior surgical treatment experience were associated with increased risk of recurrence of pretreatment pain; and that higher maximum dose and two isocenters were associated with the occurrence of complications. In conclusion, GKRS can effectively relieves the pain with low morbidity, but the long-term benefits that patients derive from it are still limited. Patient outcome is mainly determined by radiation dose and site, and prior surgical treatment experience. Key words: Gamma knife, trigeminal neuralgia, radiosurgery, outcomes.

A dosimetric comparison between Gamma Knife and CyberKnife treatment plans for trigeminal neuralgia

Object The Leksell Gamma Knife and the Accuray CyberKnife systems have been used in the radiosurgical treatment of trigeminal neuralgia. The 2 techniques use different delivery methods and different treatment parameters. In the past, CyberKnife treatments have been associated with an increased incidence of treatment-related complications, such as facial numbness. The goal of this study was to develop a method for planning a CyberKnife treatment for trigeminal neuralgia that would reproduce the dosimetric characteristics of a Gamma Knife plan. A comparison between Gamma Knife and CyberKnife treatment plans obtained with this method is presented. Methods Five patients treated using the Gamma Knife Perfexion Unit were selected for this study. All patients underwent CT cisternography to accurately identify the position of the trigeminal nerve. The Gamma Knife plans used either one 4-mm-diameter collimator or two coincident 4-mm collimators (one open and one with sector blocking) placed at identical isocenter coordinates. A maximum local dose of 80 Gy was prescribed. Critical structures and representative isodose lines were outlined in GammaPlan and exported to the CyberKnife treatment planning platform. CyberKnife treatments were developed using the 5-mm-diameter cone and the trigeminal node set, which provides an effective collimation diameter of 4 mm at the isocenter. The 60-Gy isodose volume imported from GammaPlan was used as the target in the CyberKnife plans. The CyberKnife treatments were optimized to achieve target dose and critical structure sparing similar to the Gamma Knife plans. Isocentric and nonisocentric delivery techniques were investigated. Treatment plans were compared in terms of dosimetric characteristics, delivery, and planning efficiency. Results CyberKnife treatments using the 5-mm cone and the trigeminal node set can closely reproduce the dose distribution of Gamma Knife plans. CyberKnife isocentric and nonisocentric plans provide comparable results. The average length of the trigeminal nerve receiving a dose of 60 Gy was 4.5, 4.5, and 4.4 mm for Gamma Knife, nonisocentric CyberKnife, and isocentric CyberKnife, respectively. However, minimizing the dose to the critical structures was more difficult with the CyberKnife and required the use of tuning structures. In addition, the dose falloff away from the target was steeper in Gamma Knife plans, probably due to the larger number of beams (192 beams for Perfexion vs ~ 100 beams for CyberKnife). While the treatment time with the CyberKnife is generally shorter, the planning time is significantly longer. Conclusions CyberKnife radiosurgical parameters can be optimized to mimic the dose distribution of Gamma Knife plans. However, Gamma Knife plans result in superior sparing of critical structures (brainstem, temporal lobe, and cranial nerves VII and VIII) and in steeper dose falloff away from the target. The clinical significance of these effects is unknown.

Treatment of trigeminal neuralgia with linear accelerator radiosurgery: initial results

Object. Radiosurgery has emerged as an important treatment of trigeminal neuralgia. Substantial advantages have been demonstrated in safety and comfort over other modalities. Radiosurgical treatment of trigeminal neuralgia has been well investigated with gamma knife devices involving fixed cobalt sources. Few reports exist concerning trigeminal neuralgia treated using linear accelerator (LINAC)—based devices. In recent years these devices have reached the level of mechanical precision that is required for such functional treatments. The authors describe their initial experience with radiosurgical treatment of trigeminal neuralgia when using a BrainLAB Novalis LINAC device equipped with the commercially available 4-mm collimator. Methods. A total of 32 patients were treated in a 12-month period between November 2002 and November 2003. The median patient age was 67 years (range 38–84 years). Facial pain was graded using the Barrow Neurological Institute (BNI) scoring system. All patients' pain was BNI Grade IV or V prior to treatment. Of these patients, 22 were undergoing initial treatment, and 10 were undergoing retreatment for recurrent pain following various treatments including percutaneous procedures, gamma knife surgery (GKS), or microvascular decompression. Two patients had multiple sclerosis. In patients undergoing initial radiosurgery, the most proximal segment of the cisternal portion of the trigeminal nerve received 85 to 90 Gy administered in a 5— or 7—noncoplanar arc single-isocenter plan with a 4-mm circular collimator. In patients undergoing repeated radiosurgery, the target received 60 Gy. Overall good and excellent results (BNI Grade I, II, or III) were achieved in 25 (78%) of 32 patients. The median time to pain relief was 6 weeks. Fair results (improvement in pain with BNI Grade IV) were achieved in three patients (9%), and poor results (no improvement in pain and BNI Grade IV or V) were seen in four (13%). Two patients demonstrated new trigeminal dysfunction following treatment. No other complications occurred. Conclusions. High-precision imaging and LINAC instrumentation have allowed for treatment of trigeminal neuralgia with results and safety comparable to those achieved using GKS. Linear accelerator—based radiosurgery with the Novalis device is a safe and effective method of managing trigeminal neuralgia and may become the preferred means at centers where the technology is available.

Treatment of trigeminal neuralgia with linear accelerator radiosurgery: initial results.

Radiosurgery has emerged as an important treatment of trigeminal neuralgia. Substantial advantages have been demonstrated in safety and comfort over other modalities. Radiosurgical treatment of trigeminal neuralgia has been well investigated with gamma knife devices involving fixed cobalt sources. Few reports exist concerning trigeminal neuralgia treated using linear accelerator (LINAC)-based devices. In recent years these devices have reached the level of mechanical precision that is required for such functional treatments. The authors describe their initial experience with radiosurgical treatment of trigeminal neuralgia when using a BrainLAB Novalis LINAC device equipped with the commercially available 4-mm collimator. A total of 32 patients were treated in a 12-month period between November 2002 and November 2003. The median patient age was 67 years (range 38-84 years). Facial pain was graded using the Barrow Neurological Institute (BNI) scoring system. All patients' pain was BNI Grade IV or V prior to treatment. Of these patients, 22 were undergoing initial treatment, and 10 were undergoing retreatment for recurrent pain following various treatments including percutaneous procedures, gamma knife surgery (GKS), or microvascular decompression. Two patients had multiple sclerosis. In patients undergoing initial radiosurgery, the most proximal segment of the cisternal portion of the trigeminal nerve received 85 to 90 Gy administered in a 5- or 7-noncoplanar arc single-isocenter plan with a 4-mm circular collimator. In patients undergoing repeated radiosurgery, the target received 60 Gy. Overall good and excellent results (BNI Grade I, II, or III) were achieved in 25 (78%) of 32 patients. The median time to pain relief was 6 weeks. Fair results (improvement in pain with BNI Grade IV) were achieved in three patients (9%), and poor results (no improvement in pain and BNI Grade IV or V) were seen in four (13%). Two patients demonstrated new trigeminal dysfunction following treatment. No other complications occurred. High-precision imaging and LINAC instrumentation have allowed for treatment of trigeminal neuralgia with results and safety comparable to those achieved using GKS. Linear accelerator-based radiosurgery with the Novalis device is a safe and effective method of managing trigeminal neuralgia and may become the preferred means at centers where the technology is available.

Treatment of trigeminal neuralgia with linear accelerator radiosurgery: initial results

Object. Radiosurgery has emerged as an important treatment of trigeminal neuralgia. Substantial advantages have been demonstrated in safety and comfort over other modalities. Radiosurgical treatment of trigeminal neuralgia has been well investigated with gamma knife devices involving fixed cobalt sources. Few reports exist concerning trigeminal neuralgia treated using linear accelerator (LINAC)—based devices. In recent years these devices have reached the level of mechanical precision that is required for such functional treatments. The authors describe their initial experience with radiosurgical treatment of trigeminal neuralgia when using a BrainLAB Novalis LINAC device equipped with the commercially available 4-mm collimator. Methods. A total of 32 patients were treated in a 12-month period between November 2002 and November 2003. The median patient age was 67 years (range 38–84 years). Facial pain was graded using the Barrow Neurological Institute (BNI) scoring system. All patients' pain was BNI Grade IV or V prior to treatment. Of these patients, 22 were undergoing initial treatment, and 10 were undergoing retreatment for recurrent pain following various treatments including percutaneous procedures, gamma knife surgery (GKS), or microvascular decompression. Two patients had multiple sclerosis. In patients undergoing initial radiosurgery, the most proximal segment of the cisternal portion of the trigeminal nerve received 85 to 90 Gy administered in a 5— or 7—noncoplanar arc single-isocenter plan with a 4-mm circular collimator. In patients undergoing repeated radiosurgery, the target received 60 Gy. Overall good and excellent results (BNI Grade I, II, or III) were achieved in 25 (78%) of 32 patients. The median time to pain relief was 6 weeks. Fair results (improvement in pain with BNI Grade IV) were achieved in three patients (9%), and poor results (no improvement in pain and BNI Grade IV or V) were seen in four (13%). Two patients demonstrated new trigeminal dysfunction following treatment. No other complications occurred. Conclusions. High-precision imaging and LINAC instrumentation have allowed for treatment of trigeminal neuralgia with results and safety comparable to those achieved using GKS. Linear accelerator—based radiosurgery with the Novalis device is a safe and effective method of managing trigeminal neuralgia and may become the preferred means at centers where the technology is available.

Radiosurgical treatment of trigeminal neuralgia: evaluating quality of life and treatment outcomes

Purpose To assess the safety, efficacy, and quality of life (QOL) associated with radiosurgical treatment for trigeminal neuralgia (TN). Methods and materials Between June 1996 and June 2001, 112 patients with TN refractory to medical or surgical management were treated with gamma knife radiosurgery (GKRS) at the University of Maryland Medical Center. A median prescription dose of 75 Gy (range: 70–80 Gy) was delivered to the involved trigeminal nerve root entry zone. Treatment outcomes were assessed through patient self-reports of pain control and medication usage during follow-up visits. In addition, patients responded to a standard questionnaire containing the Barrow Neurologic Institute Pain Scale (BNI) and selected sections of the McGill Pain Scale. Treatment outcomes and objective quality of life measures were also addressed. Results Ninety-six patients (86%) completed questionnaires for a median follow-up of 30 months (range: 8–66 months). Seventy-four patients (77%) reported pain relief occurring after a median of 3 weeks (range: 0–24 weeks) after GKRS. A decrease in medication usage was noted in 66% of patients. Actuarial analysis demonstrated 1-year, 2-year, and 3-year recurrence rates of 23%, 33%, and 39%, respectively. Response to treatment was associated with lack of prior surgical treatment ( p = 0.03) and less than 50 months’ pain duration before GKRS ( p = 0.04). Patients who described their TN pain as more severe than their worst non-TN headache pain (McGill Pain Scale IV–V vs. I–III) were also more likely to respond to treatment ( p < 0.001). Seven (7.3%) patients reported new or increased trigeminal dysfunction; however, only 3.1% reported these symptoms as bothersome (BNI III–IV). Patients with sustained pain relief reported an average of 100% improvement in their QOL as a direct result of pain relief after GKRS, and 100% believed that the procedure was successful. Furthermore, among those patients with temporary pain relief and subsequent recurrence, 65% felt their treatment was a success with an average of 80% improvement in their QOL. Conclusions GKRS provides significant pain relief and improves QOL in the majority of patients treated for TN, with few bothersome side effects. Patients with both temporary and sustained responses to treatment realized significant improvements in QOL after GKRS, and considered their treatment successful. Longer follow-up of these patients may reveal additional recurrences highlighting the importance of studies evaluating repeat GKRS and optimization of current treatment techniques and patient selection.

Radiosurgical Treatment of Trigeminal Neuralgia

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841 Gamma Knife Radiosurgical Treatment of Trigeminal Neuralgia Associated with Multiple Sclerosis

841 Gamma Knife Radiosurgical Treatment of Trigeminal Neuralgia Associated with Multiple Sclerosis

841 Gamma Knife Radiosurgical Treatment of Trigeminal Neuralgia Associated with Multiple Sclerosis

841 Gamma Knife Radiosurgical Treatment of Trigeminal Neuralgia Associated with Multiple Sclerosis

Gamma Knife Radiosurgery for the Treatment of Trigeminal Neuralgia

One hundred and ten patients with trigeminal neuralgia were treated with the Gamma Knife using a single isocenter, the 4 mm secondary collimator helmet and a radiosurgical dose maximum of 70 or 80-Gy. The isocenter was placed at the trigeminal sensory root adjacent to the pons as identified on stereotactic MRI scans. Follow-up periods range from 4–49 months (mean 19.8 months). Initial pain relief was achieved in 95.5% of patients with typical trigeminal neuralgia symptoms, who had not had prior surgical intervention, and only 3.3% of these patients experienced recurrent pain during the follow-up period. Patients with atypical features to their pains or who had prior unsuccessful surgical attempts to relieve their pains achieved initial and long-term pain relief in 88 and 69%, respectively. Three patients (2.7%) developed delayed loss of facial sensation following treatment, but no other complications of any kind were noted. We believe that Gamma Knife radiosurgery is the safest and most effective form of treatment which is currently available for trigeminal neuralgia. We recommend early radiosurgical treatment of trigeminal neuralgia once the diagnosis is clearly established.

Radiosurgical Treatment of Trigeminal Neuralgia with the Leksell Gamma Knife: Promising Early Results

Radiosurgical Treatment of Trigeminal Neuralgia with the Leksell Gamma Knife: Promising Early Results