Gamma knife surgery for idiopathic trigeminal neuralgia performed using a far-anterior cisternal target and a high dose of radiation

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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.

Article Information

Address reprint requests to: Nicolas Massager, M.D., Gamma Knife Center, University Hospital Erasme, Route de Lennik 808, B-1070 Brussels, Belgium. email: nmassage@ulb.ac.be.

© AANS, except where prohibited by US copyright law.

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Figures

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    Example of radiosurgical planning in which a combination of axial CT scans and T2-weighted and Gd-enhanced T1-weighted MR images are used for the gamma knife treatment of a right-sided TN. The cisternal portion of the trigeminal nerve is contoured on the T1-weighted (pink line) and T2-weighted (blue line) axial MR sequences. The plexus triangularis is indicated by a red arrow. The 90% isodose line (yellow line) is positioned on the cisternal portion of the nerve by using a very anterior target that is located immediately posterior to the gasserian ganglion. The right side of the brainstem, which previously was contoured (red line) to provide a dose—volume histogram, does not come into contact with the 15-Gy isodose line (green line).

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    Graph of Kaplan—Meier actuarial curves demonstrating the pain relief rate in our population.

  • View in gallery

    Bar graphs demonstrating the pain control rate for different distances between the target and the brainstem (upper left), for different radiation doses received by the first 1 mm3 (upper right) and the first 10 mm3 (lower left) of the brainstem, and for patients with and without induced facial numbness (lower right). The darker portions of the bars represent the unsatisfactory pain reduction group (fair and poor pain control) and the lighter portions represent the satisfactory pain reduction group (excellent and good pain control).

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