Stereotactic radiosurgery for trigeminal neuralgia: a multiinstitutional study using the gamma unit

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✓ A multiinstitutional study was conducted to evaluate the technique, dose-selection parameters, and results of gamma knife stereotactic radiosurgery in the management of trigeminal neuralgia. Fifty patients at five centers underwent radiosurgery performed with a single 4-mm isocenter targeted at the nerve root entry zone. Thirty-two patients had undergone prior surgery, and the mean number of procedures that had been performed was 2.8 (range 1–7). The target dose of the radiosurgery used in the current study varied from 60 to 90 Gy. The median follow-up period after radiosurgery was 18 months (range 11–36 months). Twenty-nine patients (58%) responded with excellent control (pain free), 18 (36%) obtained good control (50%–90% relief), and three (6%) experienced treatment failure. The median time to pain relief was 1 month (range 1 day–6.7 months). Responses remained consistent for up to 3 years postradiosurgery in all cases except three (6%) in which the patients had pain recurrence at 5, 7, and 10 months. At 2 years, 54% of patients were pain free and 88% had 50% to 100% relief.

A maximum radiosurgical dose of 70 Gy or greater was associated with a significantly greater chance of complete pain relief (72% vs. 9%, p = 0.0003). Three patients (6%) developed increased facial paresthesia after radiosurgery, which resolved totally in one case and improved in another. No patient developed other deficits or deafferentation pain. The proximal trigeminal nerve and root entry zone, which is well defined on magnetic resonance imaging, is an appropriate anatomical target for radiosurgery. Radiosurgery using the gamma unit is an additional effective surgical approach for the management of medically or surgically refractory trigeminal neuralgia. A longer-term follow-up review is warranted.

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Address reprint requests to: Douglas Kondziolka, M.D., M.Sc., F.R.C.S.(C), Suite B-400 Presbyterian University Hospital, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213–2582.

© AANS, except where prohibited by US copyright law.

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Figures

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    Volume acquisition contrast-enhanced magnetic resonance images (short TR) obtained at 1-mm slice intervals showing the left trigeminal nerve in an 83-year-old man who underwent two prior glycerol rhizotomies. a: Axial and coronal views. b: Images showing targeting of the nerve. A single 4-mm isocenter was used to irradiate the trigeminal nerve; on the axial image the inner circle shows the 50% isodose and the outer circle, the 10% isodose. A maximum dose of 70 Gy was administered. The patient has been pain free for the past 19 months.

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    Graphs displaying Kaplan—Meier plots. Upper: Percent of patients with pain relief versus time postradiosurgery. The number of patients at each interval is noted in parentheses. Center: Percent of patients with 50% to 100% pain relief versus time postradiosurgery, stratified by dose. Lower: Percent of patients with complete pain relief versus time postradiosurgery, stratified by dose. A dose of at least 70 Gy was associated with better outcomes.

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    Axial magnetic resonance images obtained during radiosurgery and 6 months postradiosurgery. a: Image obtained during the procedure showing the isodose plan for trigeminal neuralgia radiosurgery. A maximum dose of 70 Gy was delivered using a single 4-mm isocenter to the left trigeminal nerve. The 10%, 20%, and 50% isodose lines are shown. b: Six months after radiosurgery, a 4-mm diameter region of contrast enhancement is identified in the trigeminal nerve, within the radiosurgical volume (arrowhead).

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