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Dušan Urgošík, Josef Vymazal, Vilibald Vladyka and Roman Liščák

Object. Postherpetic neuralgia is a syndrome characterized by intractable pain. Treatment of this pain has not yet been successful. Patients with postherpetic neuralgia will therefore benefit from any progress in the treatment strategy. The authors performed gamma knife radiosurgery (GKS) as a noninvasive treatment for postherpetic trigeminal neuralgia (TN) and evaluated the success rate for pain relief.

Methods. Between 1995 and February 1999, six men and 10 women were treated for postherpetic TN; conservative treatment failed in all of them. The median follow up was 33 months (range 8–34 months). The radiation was focused on the root of the trigeminal nerve in the vicinity of the brainstem (maximal dose 70–80 Gy in one fraction, 4-mm collimator). The patients were divided into five groups according to degree of pain relief after treatment.

A successful result (excellent, very good, and good) was reached in seven (44%) patients and radiosurgery failed in nine (56%). Pain relief occurred after a median interval of 1 month (range 10 days–6 months). No radiation-related side effects have been observed in these patients.

Conclusions. These results suggest that GKS for postherpetic TN is a relatively successful and safe method that can be used in patients even if they are in poor condition. In case this method fails, other treatment options including other neurosurgical procedures are not excluded.

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Veronika Paštyková, Josef Novotný Jr., Tomáš Veselský, Dušan Urgošík, Roman Liščák and Josef Vymazal


The aim of this study was to compare 3 different methods to assess the geometrical distortion of two 1.5-T and one 3-T magnetic resonance (MR) scanners and to evaluate co-registration accuracy. The overall uncertainty of each particular method was also evaluated.


Three different MR phantoms were used: 2 commercial CIRS skull phantoms and PTGR known target phantom and 1 custom cylindrical Perspex phantom made in-house. All phantoms were fixed in the Leksell stereotactic frame and examined by a Siemens Somatom CT unit, two 1.5-T Siemens (Avanto and Symphony) MRI systems, and one 3-T Siemens (Skyra) MRI system. The images were evaluated using Leksell GammaPlan software, and geometrical deviation of the selected points from the reference values were determined. The deviations were further investigated for both definitions including fiducial-based and co-registration–based in the case of the CIRS phantom images. The same co-registration accuracy assessment was also performed for a clinical case. Patient stereotactic imaging was done on 3-T Skyra, 1.5-T Avanto, and CT scanners.


The accuracy of the CT scanner was determined as 0.10, 0.30, and 0.30 mm for X, Y, and Z coordinates, respectively. The total estimated uncertainty in distortion measurement in one coordinate was determined to be 0.32 mm and 0.14 mm, respectively, for methods using and not using CT as reference imaging. Slightly more significant distortions were observed when using the 3-T than either 1.5-T MR units. However, all scanners were comparable within the estimated measurement error. Observed deviation/distortion for individual X, Y, and Z stereotactic coordinates was typically within 0.50 mm for all 3 scanners and all 3 measurement methods employed. The total radial deviation/distortion was typically within 1.00 mm. Maximum total radial distortion was observed when the CIRS phantom was used; 1.08 ± 0.49 mm, 1.15 ± 0.48 mm, and 1.35 ± 0.49 mm for Symphony, Avanto, and Skyra, respectively. The co-registration process improved image stereotactic definition in a clinical case in which fiducial-based stereotactic definition was not accurate; this was demonstrated for 3-T stereotactic imaging in this study. The best results were shown for 3-T MR image co-registration with CT images improving image stereotactic definition by about 0.50 mm. The results obtained with patient data provided a similar trend of improvement in stereotactic definition by co-registration.


All 3 methods/phantoms used were evaluated as satisfactory for the image distortion measurement. The method using the PTGR phantom had the lowest uncertainty as no reference CT imaging was needed. Image co-registration can improve stereotactic image definition when fiducial-based definition is not accurate.

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Roman Liscák, Vilibald Vladyka, Gabriela Simonová, Josef Vymazal and Josef Novotny Jr.

Object. The authors conducted a study to record more detailed information about the natural course and factors predictive of outcome following gamma knife surgery (GKS) for cavernous hemangiomas.

Methods. One hundred twelve patients with brain cavernous hemangiomas underwent GKS between 1993 and 2000. The median prescription dose was 16 Gy. One hundred seven patients were followed for a median of 48 months (range 6–114 months). The rebleeding rate was 1.6%, which is not significantly different with that prior to radiosurgery (2%). An increase in volume was observed in 1.8% of cases and a decrease in 45%. Perilesional edema was detected in 27% of patients, which, together with the rebleeding, caused a transient morbidity rate of 20.5% and permanent morbidity rate of 4.5%. Before radiosurgery 39% of patients suffered from epilepsy and this improved in 45% of them. Two patients with brainstem cavernous hemangiomas died due to rebleeding. Rebleeding was more frequent in female middle-aged patients with a history of bleeding, a larger lesion volume, and a prescription dose below 13 Gy. Edema after GKS occurred more frequently in patients who had surgery, a larger lesion volume, and in those in whom the prescription dose was more than 13 Gy.

Conclusions. Gamma knife surgery of cavernous hemangiomas can produce an acceptable rate of morbidity, which can be reduced by using a lower margin dose. Lesion regression was observed in many patients. Radiosurgery seems to remain a suitable treatment modality in carefully selected patients.

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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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Josef Novotný Jr., Josef Novotný, Václav Spĕvác˘ek, Pavel Dvor˘ák, Tomás˘ Cechák, Roman Lis˘c˘ák, Gustav Broz˘ek, Jaroslav Tintĕra and Josef Vymazal

Object. The purpose of this study was to investigate the use of a polymer gel—based dosimeter for the evaluation of geometric and dosimetric inaccuracies during gamma knife radiosurgery and during the irradiation of an experimental animal.

Methods. A polymer gel dosimeter, based on acrylic monomers, was used for experiments conducted in this study. The accuracy of the dosimeter was evaluated on a Siemens EXPERT 1-tesla scanner in the transmitter/receiver head coil with the use of a multiecho sequence with 16 echoes, TE 22.5 to 360 msec, TR 2000 msec, slice thickness 2 mm, field of view 255 mm, and a pixel size of 0.5 × 0.5 mm2. Two experiments were conducted. First, the head phantom containing the polymer gel dosimeter was irradiated using 4-, 8-, 14-, and 18-mm isocenters. Second, a specially designed rat phantom was irradiated by four 4-mm isocenters. The dose profiles in the x, y, and z axes were calculated in the treatment planning system and measured with the polymer gel dosimeter and the results were compared.

There was good agreement between the measured and calculated dose profiles. The maximum deviation in the spatial position of the center of measured and calculated dose profiles was 0.5 mm in the head phantom and 1 mm in the rat phantom. The maximum deviation in the width of the selected reference isodose of measured profiles was 1.2 mm in the head phantom and 1.1 mm in the rat phantom.

Conclusions. The use of the polymer gel—based dosimeter for the verification of stereotactic procedures has advantages compared with other dosimetric systems. The dosimeter itself is tissue equivalent. Three-dimensional dose distributions can be measured and the dosimeter allows simulation of the therapeutic procedures.

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Josef Novotny Jr., Josef Vymazal, Josef Novotny, Daniela Tlachacova, Michal Schmitt, Pavel Chuda, Dusan Urgosik and Roman Liscak

Object. The authors sought to compare the accuracy of stereotactic target imaging using the Siemens 1T EXPERT and 1.5T SYMPHONY magnetic resonance (MR) units.

Methods. A water-filled cylindrical Perspex phantom with axial and coronal inserts containing grids of glass rods was fixed in the Leksell stereotactic frame and subjected to MR imaging in Siemens 1T EXPERT and Siemens 1.5T SYMPHONY units. Identical sequences were used for each unit. The images were transferred to the GammaPlan treatment planning system. Deviations between stereotactic coordinates based on MR images and estimated real geometrical positions given by the construction of the phantom insert were evaluated for each study. The deviations were further investigated as a function of the MR unit used, MR sequence, the image orientation, and the spatial position of measured points in the investigated volume.

Conclusions. Larger distortions were observed when using the SYMPHONY 1.5T unit than those with the EXPERT 1T unit. Typical average distortion in EXPERT 1T was not more than 0.6 mm and 0.9 mm for axial and coronal images, respectively. Typical mean distortion for SYMPHONY 1.5T was not more than 1 mm and 1.3 mm for axial and coronal images, respectively. The image sequence affected the distortions in both units. Coronal T2-weighted spin-echo images performed in subthalamic imaging produced the largest distortions of 2.6 mm and 3 mm in the EXPERT 1T and SYMPHONY 1.5T, respectively. Larger distortions were observed in coronal slices than in axial slices in both units, and this effect was more pronounced in SYMPHONY 1.5T. Noncentrally located slice positions in the investigated volume of the phantom were associated with larger distortions.

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Roman Liscak, Dusan Urgosik, Tomas Chytka, Gabriela Simonova, Josef Novotny Jr., Josef Vymazal, Khumar Guseynova and Vilibald Vladyka


Glomus tumors usually display indolent behavior, and the effectiveness of radiation in stopping their growth can be assessed after long-term follow-up. Currently only midterm results of radiosurgery are available, so the authors included patients treated by Gamma Knife at least 10 years ago in this study to obtain a perspective of long-term results.


During the period from 1992 to 2003, the Gamma Knife was used to treat 46 patients with glomus tumors. The age of the patients ranged from 21 to 79 years (median 56 years). Gamma Knife radiosurgery was the primary treatment in 17 patients (37%). Open surgery preceded radiosurgery in 46% of cases, embolization in 17%, and fractionated radiotherapy in 4%. The volume of the tumor ranged from 0.2 to 24.3 cm3 (median 3.6 cm3). The minimal dose to the tumor margin ranged between 10 and 30 Gy (median 20 Gy).


One patient was lost for follow-up after radiosurgery. Clinical follow-up was available in 45 patients and 44 patients were followed with MRI in a follow-up period that ranged from 12 to 217 months (median 118 months). Neurological deficits improved in 19 (42%) of 45 patients and deteriorated in 2 patients (4%). Tumor size decreased in 34 (77%) of 44 patients with imaging follow-up, while an increase in volume was observed in 1 patient (2%) 182 months after radiosurgery and Gamma Knife treatment was repeated. One patient underwent another Gamma Knife treatment for secondary induced meningioma close to the glomus tumor 98 months after initial radiosurgical treatment. Seven patients died 22–96 months after radiosurgery (median 48 months), all for unrelated reasons.


Radiosurgery has proved to be a safe treatment with a low morbidity rate and a reliable long-term antiproliferative effect.