Top 25 Cited Gamma Knife® Surgery Articles - Trigeminal Neuralgia

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Dusan Urgosik, Roman Liscak, Josef Novotny Jr., Josef Vymazal, and Vilibald Vladyka

Object. The authors present the long-term follow-up results (minimum 5 years) of patients with essential trigeminal neuralgia (TN) who were treated with gamma knife surgery (GKS).

Methods. One hundred seven patients (61 females and 46 males) underwent GKS. The median follow up was time was 60 months (range 12–96 months). The target was the trigeminal root, and the maximum dose was 70 to 80 Gy. Repeated GKS was performed in 19 patients for recurrent pain, and the same dose was used.

Initial successful results were achieved in 96% of patients, with complete pain relief in 80.4%. Relief was achieved after a median latency of 3 months (range 1 day–13 months). Gamma knife surgery failed in 4% of patients. Pain recurred in 25% of patients after a median latent interval of 36 months (6–94 months). The initial success rate after a second GKS was 89% and 58% of patients were pain free. Pain relapse occurred in only one patient in this group. Hypesthesia was observed in 20% of patients after the first GKS and in 32% after the second GKS. The median interval to hypaesthesia was 35 months (range 3–94 months) after one treatment and 21 months (range 1–72 months) after a second treatment.

Conclusions. The initial success rate of pain relief was high and comparable to that reported in other studies. A higher than usual incidence of sensory impairment after GKS could be the long duration of follow-up study and due to the detailed neurological examination.

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Timothy D. Solberg, Steven J. Goetsch, Michael T. Selch, William Melega, Goran Lacan, and Antonio A. F. DeSalles

Object. The purpose of this work was to investigate the targeting and dosimetric characteristics of a linear accelerator (LINAC) system dedicated for stereotactic radiosurgery compared with those of a commercial gamma knife (GK) unit.

Methods. A phantom was rigidly affixed within a Leksell stereotactic frame and axial computerized tomography scans were obtained using an appropriate stereotactic localization device. Treatment plans were performed, film was inserted into a recessed area, and the phantom was positioned and treated according to each treatment plan. In the case of the LINAC system, four 140° arcs, spanning ± 60° of couch rotation, were used. In the case of the GK unit, all 201 sources were left unplugged. Radiation was delivered using 3- and 8-mm LINAC collimators and 4- and 8-mm collimators of the GK unit. Targeting ability was investigated independently on the dedicated LINAC by using a primate model.

Measured 50% spot widths for multisource, single-shot radiation exceeded nominal values in all cases by 38 to 70% for the GK unit and 11 to 33% for the LINAC system. Measured offsets were indicative of submillimeter targeting precision on both devices. In primate studies, the appearance of an magnetic resonance imaging—enhancing lesion coincided with the intended target.

Conclusions. Radiosurgery performed using the 3-mm collimator of the dedicated LINAC exhibited characteristics that compared favorably with those of a dedicated GK unit. Overall targeting accuracy in the submillimeter range can be achieved, and dose distributions with sharp falloff can be expected for both devices.

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Ronald Brisman

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.

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Nicolas Massager, José Lorenzoni, Daniel Devriendt, Françoise Desmedt, Jacques Brotchi, and Marc Levivier

Object. Gamma knife surgery (GKS) has emerged as a suitable treatment of pharmacologically resistant idiopathic trigeminal neuralgia. The optimal radiation dose and target for this therapy, however, remain to be defined. The authors analyzed the results of GKS in which a high dose of radiation and a distal target was used, to determine the best parameters for this treatment.

Methods. The authors evaluated results in 47 patients who were treated with this approach. All patients underwent clinical and magnetic resonance imaging examinations at 6 weeks, 6 months, and 1 year post-GKS. Fifteen potential prognostic factors associated with favorable pain control were studied.

The mean follow-up period was 16 months (range 6–42 months). The initial pain relief was excellent (100% pain control) in 32 patients, good (90–99% pain control) in seven patients, fair (50–89% pain control) in three patients, and poor (< 50% pain control) in five patients. The actuarial curve of pain relief displayed a 59% rate of excellent pain control and a 71% excellent or good pain control at 42 months after radiosurgery. Radiosurgery-induced facial numbness was bothersome for two patients and mild for 18 patients. Three prognostic factors were found to be statistically significant factors for successful pain relief: a shorter distance between the target and the brainstem, a higher radiation dose delivered to the brainstem, and the development of a facial sensory disturbance after radiosurgery.

Conclusions. To optimize pain control and minimize complications of this therapy, we recommend that the nerve be targeted at a distance of 5 to 8 mm from the brainstem.

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Andrew G. Shetter, C. Leland Rogers, Francisco Ponce, Jeffrey A. Fiedler, Kris Smith, and Burton L. Speiser

Object. Pain may fail to respond or may recur after initial gamma knife radiosurgery (GKS) for trigeminal neuralgia (TN). The authors examined their experience with performing a second GKS procedure in these patients.

Methods. Twenty-nine patients underwent repeated GKS for TN at our institution between March 1997 and March 2002. Questionnaires were mailed to patients to assess the degree of their pain relief and the extent of facial numbness. Nineteen patients responded. All patients underwent repeated GKS involving a single 4-mm isocenter directed at the trigeminal nerve as it exited the brainstem (mean maximum dose 23.2 Gy). At a mean follow up of 13.5 months after the second procedure, 10 patients (53%) were pain free and medication free. Four patients (21%) were pain free but elected to continue medication in reduced dose, and two patients (11%) had incomplete but satisfactory pain control and were still taking medication. There was new-onset facial numbness in eight patients (42%), rated as tolerable in all instances.

Conclusions. Patients with facial numbness had a greater likelihood of being pain free than those with no sensory loss. The authors observed no cases of corneal anesthesia, keratitis, or deafferentation pain.

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C. Leland Rogers, Andrew G. Shetter, Francisco A. Ponce, Jeffrey A. Fiedler, Kris A. Smith, and Burton L. Speiser

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.

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Shinji Matsuda, Toru Serizawa, Makato Sato, and Junichi Ono

Object. The purpose of this paper is to report a unique complication of gamma knife radiosurgery (GKS) for trigeminal neuralgia (TN). The nature of this complication and its related factors are discussed.

Methods. Forty-one medically refractory patients with TN were treated with GKS. All patients received 80 Gy to the proximal trigeminal nerve root, using a 4-mm collimator and a single isocenter. Follow up consisted of three monthly outpatient sessions after GKS. Improvement, recurrence, complications, and changes in magnetic resonance imaging were recorded. To evaluate the factors behind the complications, a subgroup of 33 patients was assessed in whom the follow-up duration was more than 9 months.

The follow-up duration was 3 to 36 months (mean 13 months). The results were excellent in 20 patients, good in 11, and fair in seven. No patient had a poor result. Three patients suffered recurrences. Seven patients suffered complications 9 to 24 months after GKS. All seven patients complained of facial numbness and hypesthesia was recorded. Three of them also complained of “dry eye” with diminution or absence of corneal reflex but no other abnormalities of the cornea and conjunctiva were found on ophthalmological examination. In these three patients, hypesthesia of the first division of the trigeminal nerve area had been found before their “dry eye” symptoms appeared. The irradiated volume on the brainstem was significantly related to this complication.

Conclusions. The dry eye symptom seems to be a special form of sensory disturbance. An overdose of radiation to the brainstem may play an important role in the manifestation of this complication.

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Bruce E. Pollock, Loi K. Phuong, Deborah A. Gorman, Robert L. Foote, and Scott L. Stafford

Object. Each year a greater number of patients with trigeminal neuralgia (TN) undergo radiosurgery, including a large number of patients who are candidates for microvascular decompression (MVD).

Methods. The case characteristics and outcomes of 117 consecutive patients who underwent radiosurgery were retrieved from a prospectively maintained database. The mean patient age was 67.8 years; and the majority (58%) of patients had undergone surgery previously. The dependent variable for all analyses of facial pain was complete pain relief without medication (excellent outcome). Median follow-up duration was 26 months (range 1–48 months). The actuarial rate of achieving and maintaining an excellent outcome was 57% and 55% at 1 and 3 years, respectively, after radiosurgery. A greater percentage of patients who had not previously undergone surgery achieved and maintained excellent outcomes (67% at 1 and 3 years) than that of patients who had undergone prior surgery (51% and 47% at 1 and 3 years, respectively; relative risk [RR] = 1.77, 95% confidence interval [CI] 1.01–3.13, p = 0.04). New persistent trigeminal dysfunction was noted in 43 patients (37%). Tolerable numbness or paresthesias occurred in 29 patients (25%), whereas bothersome dysesthesias developed in 14 patients (12%). Only a radiation dose of 90 Gy correlated with new trigeminal deficits or dysesthesias (RR = 3.10, 95% CI 1.64–5.81, p < 0.001). Excellent outcomes in patients with new trigeminal dysfunction were achieved and maintained at rates of 76% and 74% at 1 and 3 years, respectively, after radiosurgery, compared with respective rates of 46% and 42% in patients who did not experience postradiosurgery trigeminal dysfunction (RR = 4.53, 95% CI 2.03–9.95, p < 0.01).

Conclusions. Radiosurgical treatment provides complete pain relief for the majority of patients with idiopathic TN. There is a strong correlation between the development of new facial sensory loss and achievement and maintenance of pain relief after this procedure. Because the long-term results of radiosurgery still remain unknown, MVD should continue to be the primary operation for medically fit patients with TN.

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Jean Régis, Philippe Metellus, Henry Dufour, Pierre-Hughes Roche, Xavier Muracciole, William Pellet, Francois Grisoli, and Jean-Claude Peragut

Object. This study was directed to evaluate the potential role of gamma knife surgery (GKS) in the treatment of secondary trigeminal neuralgia (TN). The authors have identified three anatomicoclinical types of secondary TN requiring different radiosurgical approaches.

Methods. Pain control was retrospectively analyzed in a population of patients harboring tumors of the middle or posterior fossa that involved the trigeminal nerve pathway. This series included 53 patients (39 women and 14 men) treated using GKS between July 1992 and June 1997. The median follow-up period was 55 months. Treatment strategies differed according to lesion type, topography, and size, as well as visibility of the fifth cranial nerve in the prepontine cistern. Three different treatment groups were established. When the primary goal was treatment of the lesion (Group IV, 46 patients) we obtained pain cessation in 79.5% of cases. In some patients in whom GKS was not indicated for treatment of the lesion, TN was treated by targeting the fifth nerve directly in the prepontine cistern if visible (Group II, three patients) or in the part of the lesion including this nerve if the nerve root could not be identified (Group III, four patients). No deaths and no radiosurgically induced adverse effects were observed, but in two cases there was slight hypesthesia (Group IV). The neuropathic component of the facial pain appeared to be poorly sensitive to radiosurgery. At the last follow-up examination, six patients (13.3%) exhibited recurrent pain, which was complete in four cases (8.8%) and partial in two (4.4%).

Conclusions. The results of GKS regarding facial pain control are very similar to those achieved by microsurgery according to series published in the literature. Nevertheless, the low rate of morbidity and the greater comfort afforded the patient render GKS safer and thus more attractive.

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Satoshi Maesawa, Camille Salame, John C. Flickinger, Stephen Pirris, Douglas Kondziolka, and L. Dade Lunsford

Object. Stereotactic radiosurgery is an increasingly used and the least invasive surgical option for patients with trigeminal neuralgia. In this study, the authors investigate the clinical outcomes in patients treated with this procedure.

Methods. Independently acquired data from 220 patients with idiopathic trigeminal neuralgia who underwent gamma knife radiosurgery were reviewed. The median age was 70 years (range 26–92 years). Most patients had typical features of trigeminal neuralgia, although 16 (7.3%) described additional atypical features. One hundred thirty-five patients (61.4%) had previously undergone surgery and 80 (36.4%) had some degree of sensory disturbance related to the earlier surgery.

Patients were followed for a maximum of 6.5 years (median 2 years). Complete or partial relief was achieved in 85.6% of patients at 1 year. Complete pain relief was achieved in 64.9% of patients at 6 months, 70.3% at 1 year, and 75.4% at 33 months. Patients with an atypical pain component had a lower rate of pain relief (p = 0.025). Because of recurrences, only 55.8% of patients had complete or partial pain relief at 5 years. The absence of preoperative sensory disturbance (p = 0.02) or previous surgery (p = 0.01) correlated with an increased proportion of patients who experienced complete or partial pain relief over time. Thirty patients (13.6%) reported pain recurrence 2 to 58 months after initial relief (median 15.4 months). Only 17 patients (10.2% at 2 years) developed new or increased subjective facial paresthesia or numbness, including one who developed deafferentation pain.

Conclusions. Radiosurgery for idiopathic trigeminal neuralgia was safe and effective, and it provided benefit to a patient population with a high frequency of prior surgical intervention.