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

Clinical article

Restricted access


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.


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.


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.


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.

Abbreviations used in this paper: CN = cranial nerve; GKS = Gamma Knife surgery; MU = monitor unit; SAD = source-to-axis distance; SRS = stereotactic radiosurgery.

Article Information

Address correspondence to: Martina Descovich, Ph.D., Department of Radiation Oncology, University of California, San Francisco, 1600 Divisadero Street, Suite H1031, Box 1708, San Francisco, California 94143-1708. email: mdescovich@radonc.ucsf.edu.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Example of high-dose coverage for a Gamma Knife (GK) and a nonisocentric CyberKnife (CK) plan. The 60- and 70-Gy isodose lines are presented for the Gamma Knife (thin segmented line) and for the CyberKnife (thick curved line) with the same color scheme.

  • View in gallery

    “Easy” case. Dose distribution (thin lines) in the axial (upper) and sagittal (lower) planes for an isocentric (left) and nonisocentric (right) CyberKnife plan. For comparison, the Gamma Knife dose distribution is displayed as color wash.

  • View in gallery

    “Difficult” case. Dose distribution (thin lines) in the axial (upper) and sagittal (lower) plane for an isocentric (left) and nonisocentric (right) CyberKnife plan. For comparison, the Gamma Knife dose distribution is displayed as color wash.

  • View in gallery

    Dose volume histogram on semilogarithmic scale for the whole tissue. Comparison between Gamma Knife (diamonds), nonisocentric CyberKnife (squares), and isocentric CyberKnife (triangles).

  • View in gallery

    Dose to 0.01 cm3 of brainstem (left) and the volume of the brainstem receiving a dose of 8 Gy (right) in the 5 cases.

  • View in gallery

    Dose to 0.1 cm3 of temporal lobe (left) and the volume of the temporal lobe receiving a dose of 8 Gy (right) in the 5 cases.

  • View in gallery

    Dose to 1 mm3 of CNs VII (left) and VIII (right) in the 5 cases.


  • 1

    Adler JR JrBower RGupta GLim MEfron AGibbs IC: Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia. Neurosurgery 64:2 SupplA84A902009

  • 2

    Adler JR JrChang SDMurphy MJDoty JGeis PHancock SL: The Cyberknife: a frameless robotic system for radiosurgery. Stereotact Funct Neurosurg 69:1241281997

  • 3

    Chavez GDDe Salles AASolberg TDPedroso AEspinoza DVillablanca P: Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia. Neurosurgery 56:E6282005

  • 4

    Dhople AAAdams JRMaggio WWNaqvi SARegine WFKwok Y: Long-term outcomes of Gamma Knife radiosurgery for classic trigeminal neuralgia: implications of treatment and critical review of the literature. Clinical article. J Neurosurg 111:3513582009

  • 5

    Fariselli LMarras CDe Santis MMarchetti MMilanesi IBroggi G: CyberKnife radiosurgery as a first treatment for idiopathic trigeminal neuralgia. Neurosurgery 64:2 SupplA96A1012009

  • 6

    Han JHKim DGChung HTPaek SHKim YHKim CY: Long-term outcome of gamma knife radiosurgery for treatment of typical trigeminal neuralgia. Int J Radiat Oncol Biol Phys 75:8228272009

  • 7

    Kondziolka DLunsford LDFlickinger JCYoung RFVermeulen SDuma CM: Stereotactic radiosurgery for trigeminal neuralgia: a multiinstitutional study using the gamma unit. J Neurosurg 84:9409451996

  • 8

    Kondziolka DZorro OLobato-Polo JKano HFlannery TJFlickinger JC: Gamma Knife stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg 112:7587652010

  • 9

    Leksell L: The stereotaxic method and radiosurgery of the brain. Acta Chir Scand 102:3163191951

  • 10

    Leksell L: Sterotaxic radiosurgery in trigeminal neuralgia. Acta Chir Scand 137:3113141971

  • 11

    Leksell L: [Trigeminal neuralgia. Some neurophysiologic aspects and a new method of therapy.]. Lakartidningen 68:514551481971. (Swedish)

  • 12

    Li KMa L: Selective source blocking for Gamma Knife radiosurgery of trigeminal neuralgia based on analytical dose modelling. Phys Med Biol 49:345534632004

  • 13

    Lim MVillavicencio ATBurneikiene SChang SDRomanelli PMcNeely L: CyberKnife radiosurgery for idiopathic trigeminal neuralgia. Neurosurg Focus 18:5E92005

  • 14

    Little ASShetter AGShetter MEBay CRogers CL: Long-term pain response and quality of life in patients with typical trigeminal neuralgia treated with gamma knife stereotactic radiosurgery. Neurosurgery 63:9159242008

  • 15

    Massager NLorenzoni JDevriendt DDesmedt FBrotchi JLevivier M: Gamma knife surgery for idiopathic trigeminal neuralgia performed using a far-anterior cisternal target and a high dose of radiation. J Neurosurg 100:5976052004

  • 16

    Massager NMurata NTamura MDevriendt DLevivier MRégis J: Influence of nerve radiation dose in the incidence of trigeminal dysfunction after trigeminal neuralgia radiosurgery. Neurosurgery 60:6816882007

  • 17

    Massager NNissim OMurata NDevriendt DDesmedt FVanderlinden B: Effect of beam channel plugging on the outcome of gamma knife radiosurgery for trigeminal neuralgia. Int J Radiat Oncol Biol Phys 65:120012052006

  • 18

    Pollock BEPhuong LKFoote RLStafford SLGorman DA: High-dose trigeminal neuralgia radiosurgery associated with increased risk of trigeminal nerve dysfunction. Neurosurgery 49:58642001

  • 19

    Régis JMetellus PDufour HRoche PHMuracciole XPellet W: Long-term outcome after gamma knife surgery for secondary trigeminal neuralgia. J Neurosurg 95:1992052001

  • 20

    Régis JMetellus PHayashi MRoussel PDonnet ABille-Turc F: Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia. J Neurosurg 104:9139242006

  • 21

    Régis JTamura MGuillot CYomo SMuraciolle XNagaje M: Radiosurgery with the world's first fully robotized Leksell Gamma Knife PerfeXion in clinical use: a 200-patient prospective, randomized, controlled comparison with the Gamma Knife 4C. Neurosurgery 64:3463562009

  • 22

    Sanchez-Mejia ROLimbo MCheng JSCamara JWard MMBarbaro NM: Recurrent or refractory trigeminal neuralgia after microvascular decompression, radiofrequency ablation, or radiosurgery. Neurosurg Focus 18:5e122005

  • 23

    Villavicencio ATLim MBurneikiene SRomanelli PAdler JRMcNeely L: Cyberknife radiosurgery for trigeminal neuralgia treatment: a preliminary multicenter experience. Neurosurgery 62:6476552008




All Time Past Year Past 30 Days
Abstract Views 130 130 18
Full Text Views 147 147 4
PDF Downloads 149 149 2
EPUB Downloads 0 0 0


Google Scholar