Preliminary results of 45 patients with trigeminal neuralgia treated with radiosurgery compared to hypofractionated stereotactic radiotherapy, using a dedicated linear accelerator

doi:10.1016/j.jocn.2011.11.036

Journal of Clinical Neuroscience

Volume 19, Issue 10, October 2012, Pages 1401-1403

https://doi.org/10.1016/j.jocn.2011.11.036 Get rights and content

Abstract

Radiosurgery (RS) and hypofractionated stereotactic radiotherapy (HSRT) were performed in 23 and 22 patients respectively for the treatment of trigeminal neuralgia. RS and HSRT were performed with a dedicated linear accelerator (LINAC): an invasive frame (for RS) or a relocatable stereotactic frame fitted with a thermoplastic mask and bite blocks (HSRT) were used for positioning patients. The RS treatment delivered 40 Gy in a single fraction, or for HSRT, the equivalent radiobiological fractionated dose – a total of 72 Gy in six fractions. The target (the retrogasserian cisternal portion of the trigeminal nerve) was identified by fusion of CT scans with 1-mm-thick T2-weighted MRI, and the radiant dose was delivered by a 10-mm-diameter cylindrical collimator. The results were evaluated using the Barrow Neurological Institute pain scale during follow-up (mean 3.9 years). The 95% isodose was applied to the entire target volume. After RS (23 patients), Class 1 results were observed in 10 patients; Class II in nine, Class IIIa in two, Class IIIb in one, and Class V results in one patient. Facial numbness occurred in two (8.7%) patients, and the trigeminal neuralgia recurred in two patients (8.7%). Following HSRT (22 patients), Class I results were achieved in eight patients, Class II in eight, Class IIIa in four, and Class IIIb in two patients; recurrence occurred in six (27.5%), and there were no complications. Thus, both RS and HSRT provided effective and safe therapy for the treatment of trigeminal neuralgia. Patients who underwent RS experienced better pain relief and a lower recurrence rate, whereas those who underwent HRST had no side effects, and in particular, no facial numbness.

Introduction

Radiotherapy has been used in the treatment of trigeminal neuralgia since the discovery of X-rays.¹ Radiosurgery now is performed using the Gamma-Knife (Elekta, Stockholm, Sweden)2, 3, 4, 5 Cyberknife (Accuray, Sunnyvale, CA, USA)6, 7 or dedicated linear accelerator (LINAC)8, 9 delivering high doses in a single fraction to the root entry zone. The reported results have been satisfactory with sensory facial impairment and complications being relatively infrequent.

We aimed to assess whether radiosurgery (RS) at 40 Gy or hypofractionated stereotactic radiotherapy (HSRT) at the radiobiologically equivalent dose, delivered to the retrogasserian cisternal portion of the trigeminal nerve, resulted in effective pain control with a reduced rate of side effects, particularly facial numbness, when compared with the more commonly recommended RS at 70 Gy to 90 Gy. Since 2005, Pollock et al.⁴ have recommended a dose reduction to 76 Gy, particularly for repeat RS, to decrease the morbidity of RS in the treatment of trigeminal neuralgia.

We present our results in a series of 45 patients with idiopathic trigeminal neuralgia treated using RS (40 Gy) or HSRT (radiobiologically equivalent to 40 Gy in single fraction) using a dedicated LINAC.

Section snippets

Methods and materials

All 45 patients had been treated previously for trigeminal neuralgia with medical therapy that was either ineffective or had become so over time. The patients were reviewed over a mean follow-up time of 3.9 years (median 3.1 years; range 2.2–5.2 years). Three patients had been previously treated elsewhere: one with microvascular decompression and subsequent gasserian ganglion glycerolrhizolysis; one with gasserian ganglion balloon compression; and another with microvascular decompression.

The

Results

BNI pain scores (Table 1) were evaluated using a series of clinical examinations (patients were periodically tested for facial sensitivity and questioned regarding pain recurrence, pain improvement, absence of pain, and facial paresthesias) at three, six, and 12 months after treatment, after which, telephone interviews were performed once per year. MRI performed more than one year after treatment did not show any changes in signal intensity of the trigeminal nerve or the surrounding structures.

Discussion

Many therapies have been proposed for the treatment of medically refractory trigeminal neuralgia: anatomically destructive methods, including retrogasserian rootlet thermocoagulation14, 15, 16, and percutaneous balloon compression;¹⁷ and anatomically non-destructive methods, including gasserian ganglion glycerolrhizolysis,18, 19 and microvascular decompression.²⁰ Non-invasive procedures are also performed, including various types of RS. We agree with Onofrio¹⁶ that: “each procedure has its

Conclusions

RS at 40 Gy and HSTR at 72 Gy was an effective treatment for idiopathic trigeminal neuralgia. RS resulted more effective pain control than HSRT, with a minor rate of recurrence, and with rare facial numbness, which did not occur after HSRT. Further experience is required to choose between RS at 40 Gy or HSRT for individual patients. We agree with the hypothesis that both methods have a neuromodulatory effect rather than causing damage to the trigeminal nerve.²²

Conflict of interest/disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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Cited by (15)

High-Dose Frameless Stereotactic Radiosurgery for Trigeminal Neuralgia: A Single-Institution Experience and Systematic Review
2022, World Neurosurgery
Stereotactic radiosurgery is an effective treatment option for trigeminal neuralgia (TN), with frameless stereotactic radiosurgery (fSRS) allowing for a less invasive experience. A single-institutional series and systematic review of the literature were performed for cases of TN treated with fSRS.
Patients at our institution with TN that were treated with fSRS from the years 2012–2021 were included. Similarly, multiple databases were searched for studies regarding TN treated with fSRS where patient-level data was included from 2004–2020. Pain levels, via the Barrow Neurological Institute (BNI) scale, before and after treatment were analyzed. Pooled analysis was performed to compare treatment outcomes between studies using CyberKnife and LINAC modalities.
Twenty-three patients at our institution were treated with LINAC fSRS (median treatment dose: 85 Gy). Most patients had TN refractory to previous procedural treatments. Eight (35%) patients had an excellent posttreatment response (BNI I-II), while 11 (48%) patients had a good result (BNI IIIa/b). Eight patients had recurrence of pain. A total of 30 articles were included in the systematic review, encompassing 1705 patients. At last follow-up, 63.1% (774/1227) of patients endorsed an excellent response, while 16.1% (197/1227) had a good response, and 22.5% (215/957) of patients had recurrence. Pain response, facial numbness rates, and pain recurrence rates were not significantly different between CyberKnife and LINAC modalities.
Frameless SRS for TN appears to be an efficacious noninvasive option for patients with substantial comorbidities, who have failed other treatment methods, although it can be limited by higher recurrence rates.
Trigeminal neuralgia and persistent idiopathic facial pain (atypical facial pain)
2022, Disease-a-Month
Citation Excerpt :
It is felt that the fractionation may be a good strategy to limit radiation doses to the brainstem. More anterior targeting of the trigeminbal nerve has also been proposed.89,90 If there is no evidence of trigeminal neurovascular contact or there are significant comorbidities, ablative procedures can be considered- the least invasive is the previously noted stereotactic radiosurgery (SRS).
Radiotherapy of non-tumoral refractory neurological pathologies
2020, Cancer/Radiotherapie
Citation Excerpt :
Facial numbness occurred in 20% of patients and led to clinical disturbance in 6% of the cohort at 36 months. A retrospective series of 45 patients compared SRS to hypofractionated intracranial SBRT delivered using a linear accelerator [75]. The prescribed doses to the isocenter were 40 Gy in a single session and 72 Gy in six fractions, with an α/β ratio at 2.5 Gy.
Intracranial radiotherapy has been improved, primarily because of the development of stereotactic approaches. While intracranial stereotactic body radiotherapy is mainly indicated for treatment of benign or malignant tumors, this procedure is also effective in the management of other neurological pathologies; it is delivered using GammaKnife® and linear accelerators. Thus, brain arteriovenous malformations in patients who are likely to experience permanent neurological sequelae can be managed by single session intracranial stereotactic body radiotherapy, or radiosurgery, in specific situations, with an advantageous benefit/risk ratio. Radiosurgery can be recommended for patients with disabling symptoms, which are poorly controlled by medication, such as trigeminal neuralgia, and tremors, whether they are essential or secondary to Parkinson's disease. This literature review aims at defining the place of intracranial stereotactic body radiotherapy in the management of patients suffering from non-tumoral refractory neurological pathologies. It is clear that the multidisciplinary collaboration of experienced teams from Neurosurgery, Neurology, Neuroradiology, Radiation Oncology and Medical Physics is needed for the procedures using high precision radiotherapy techniques, which deliver high doses to locations near functional brain areas.
La radiothérapie intracrânienne a accompli de nombreux progrès techniques, notamment par l’émergence des approches en conditions stéréotaxiques. Si les indications de radiothérapie stéréotaxique intracrânienne concernent essentiellement des tumeurs bénignes ou malignes, cette technique s’avère également efficace dans la prise en charge d’autres maladies neurologiques; elle peut être administrée au moyen du GammaKnife® et d’accélérateurs linéaires. Ainsi, les malformations artérioveineuses intracérébrales chez des patients susceptibles d’être exposés à des séquelles neurologiques définitives, peuvent être prises en charge par radiothérapie stéréotaxique intracrânienne en séance unique, ou radiochirurgie, dans des situations spécifiques, avec un rapport bénéfice/risque favorable. Une radiochirurgie peut également être recommandée chez des patients présentant des symptômes invalidants et très modérément contrôlés sous traitement médicamenteux, tels une névralgie faciale, un tremblement, qu’il soit essentiel ou secondaire à une maladie de Parkinson. Cette revue de la littérature vise à définir la place de la radiothérapie stéréotaxique intracrânienne dans la prise en charge des patients atteints de ces maladies neurologiques réfractaires non tumorales. Il est certain que la collaboration multidisciplinaire d’équipes expérimentées de Neurochirurgie, de Neurologie, de Neuro-Radiologie, d’Oncologie-Radiothérapie et de Physique Médicale est nécessaire dans la mise en oeuvre de ces prises en charge basées sur des techniques de radiothérapie de haute précision délivrant des doses élevées près de zones cérébrales fonctionnelles.
Treatment Outcomes in Trigeminal Neuralgia–A Systematic Review of Domains, Dimensions and Measures
2020, World Neurosurgery: X
Citation Excerpt :
The IMMPACT Outcome Domains are as follows: 1) Pain; 2) Physical functioning; 3) Emotional functioning; 4) Participant ratings of global improvement/satisfaction; 5) Symptoms and adverse events; and 6) Participant disposition. With the exception of 8 papers, all studies used pain as an outcome domain (Figure 2 and Table 1).13-459 Symptoms and adverse events also were described in a high number of papers (n = 386); however, the impact of treatment on physical and emotional functioning was significantly less evaluated, in 46 and 17 studies, respectively (Tables 2 and 3).460-464
Trigeminal neuralgia (TN) is a painful disorder characterized by sudden electric shock–like pain. It is a rare condition for which multiple treatments are available, including medical and surgical. The best treatment option is yet to be defined, and this is related to the lack of definition in the treatment outcomes and outcome measures. The aim of this systematic review was to summarize all the outcomes and outcomes measures that have been published to date and highlight variability in their use.
We have conducted a literature search using a wide range of databases (1946–2019 for medical and 2008–2019 for surgical treatment), for all intervention studies in TN. Four hundred and sixty-seven studies were selected for data extraction on TN classification, data collection method, intervention, and treatment outcomes mapped to the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT guidelines).
Most studies collected data on pain (n = 459) and side effects (n = 386) domains; however, very few collected data on the impact of treatment on physical (n = 46) and emotional functioning (n = 17) and on patient satisfaction (n = 35). There was high variability on outcome measures used for pain relief (n = 10), pain intensity (n = 9), and frequency of pain episodes (n = 3).
A clear definition of what are the important outcomes for patients with TN is essential. The choice of standardized outcome measures allowing for consistent reporting in TN treatment will allow for comparison of studies and facilitate treatment choice for patients and clinicians thus, improving health outcomes and reducing health care cost.
Meta-Analysis on Safety and Efficacy of Microsurgical and Radiosurgical Treatment of Trigeminal Neuralgia
2017, World Neurosurgery
Classic trigeminal neuralgia is often treated pharmacologically first. However, microvascular decompression (MVD) or radiosurgical treatment (RS) can render medication unnecessary. Objective appraisals of the 2 treatment modalities are scarce.
To compare the evidence regarding safety and efficiency of MVD and RS.
We searched PubMed for studies describing pain control, complications, and recurrences after MVD or RS between 2005 and 2015. Because randomized studies are lacking, we focused the statistical analysis on cohort clinical trials. Differences in outcome after treatment with either MVD or RS were analyzed using t tests and weighted averages. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed.
Fifty-three studies (13,805 patients, in 11 prospective and 42 retrospective studies) were analyzed. Initial success rates were 71.1% for RS and 86.9% for MVD (P < 0.0001). At last follow-up (>5 years after intervention), success rates decreased to 63.8% for RS versus 84% for MVD (P = 0.036). Thirty-six months after the intervention, median percentage of recurrence was 11% for MVD and 25% for RS (P = 0.0015). The length of recurrence-free intervals was similar for MVD and RS (30.45 vs. 30.55 months; P = 0.987).
There was no significant difference between the incidence of hearing loss after MVD and RS (1.51% vs. 0.74%; P = 0.21). Facial dysesthesia was reported more frequently after radiosurgery (2.3% vs. 28.8%; P = 0.02).
MVD is a valid first-line treatment option for young patients free of comorbidities. First-line RS can be advised in patients with a higher surgical risk.
Outcome of radiosurgery treatment with a linear accelerator in patients with trigeminal neuralgia
2017, Neurologia
Comprobación de la efectividad de la radiocirugía en pacientes diagnosticados de neuralgia del v par y análisis de posibles factores predictores.
Se analizaron todos los pacientes entre 2004 y 2011 tratados mediante radiocirugía con acelerador lineal. Se administraron dosis de 60 Gy a 1-2 mm de la entrada del nervio con isodosis de 20% máxima sobre el tronco. Se analizaron los resultados clínicos de control del dolor y efectos secundarios a los 12 y 36 meses (escala BNI).
Se incluyó a 71 pacientes en el estudio (seguimiento medio 50,50 m). La mejoría del dolor a los 12 meses fue del 68,11% (28,98% BNI score i-ii; 39,12% BNI score iii y a los 36 meses del 58,21% (23,88% BNI score i-ii; 34,32% BNI score III). El tiempo medio de mejoría fue de 3,69 meses y la tasa de reincidencia tras mejoría del 44,68%. Se aprecian diferencias estadísticas en la mejoría para pacientes con dolores típicos a los 12 y 36 meses (p < 0,047 y p < 0,002). Se analiza el inicio de la mejoría mediante gráficas de Kaplan-Meyer. En el análisis en función de variables se obtuvo diferencia estadísticamente significativa entre dolores típicos y atípicos a los 36 meses (p < 0,012). En 15 pacientes se registraron efectos secundarios (20,89%), 9 de ellos por adormecimiento facial (13,43%) y solo 2 con relevancia clínica (2,98%).
De acuerdo con nuestra experiencia, la radiocirugía es un tratamiento eficaz de la neuralgia del trigémino, con escasos efectos secundarios. El dolor típico parece un factor de buen pronóstico para la mejoría del dolor.
An overview of the effectiveness of radiosurgery in patients diagnosed with trigeminal neuralgia with an analysis of potential predictors of good outcome.
All patients treated with linear accelerator radiosurgery between 2004 and 2011 were analysed. A dose of 60 Gy dose was administered 1 to 2 mm from the root entry zone with a maximum isodose of 20% delivered to the brainstem. Clinical results for pain control and any side effects were analysed at 12 and 36 months (BNI score).
The study included 71 patients (mean follow-up 50.5 months). Pain improvement at 12 months was observed in 68.11% of the total (28.98% with BNI score i-ii; 39.12% with BNI score iii) and at 36 months in 58.21% (23.88% BNI score i-ii; 34.32% BNI score iii). Average recovery time was 3.69 months and the relapse rate was 44.68%. Patients with typical pain displayed statistically significant differences in improvement rates at 12 and at 36 months (P<047 and P<.002). Onset of improvement was analysed using Kaplan-Meyer plots. Statistically significant differences were observed between patients with typical and atypical pain at 36 months (P<.012) in Kaplan-Meyer plots. Side effects were recorded in 15 patients (20.89%), including 9 cases of facial numbness (13.43%); only 2 cases were clinically relevant (2.98%).
According to our results, radiosurgery is an effective treatment for trigeminal neuralgia, with few side effects. Typical pain seems to be a good predictor of pain relief.

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Clinical StudyPreliminary results of 45 patients with trigeminal neuralgia treated with radiosurgery compared to hypofractionated stereotactic radiotherapy, using a dedicated linear accelerator

Abstract

Introduction

Section snippets

Methods and materials

Results

Discussion

Conclusions

Conflict of interest/disclosures

Int J Oncol Bio Phys

Surg Neurol

1897-celebrating of the centennial-Hermann Moritz Gocht and radiation therapy in the treatment of Trigeminal neuralgia

Acta Neurochir (Wien)

Gamma knife surgery for trigeminal neuralgia: outcome, imaging, and brainstem correlates

Int J Radiat Oncol Biol Phys

Long-term pain response and quality of life in patients with typical trigeminal neuralgia treated with gamma knife stereotactic radiosurgery

Neurosurgery

Prospective controlled trial of gamma knife surgery for essential trigeminal neuralgia

J Neurosurg

CyberKnife radiosurgery for idiopathic trigeminal neuralgia

Neurosurg Focus

Cyberknife radiosurgery for trigeminal neuralgia

Stereotact Funct Neurosurg

Treatment of trigeminal neuralgia with linear accelerator radiosurgery: initial results

J Neurosurg

Dedicated linear accelerator radiosurgery for the treatment of trigeminal neuralgia

J Neurosurg

The application of the linear-quadratic dose-effect equation to fractionated and protracted radiotherapy

Br J Radiol

Clinical Study
Preliminary results of 45 patients with trigeminal neuralgia treated with radiosurgery compared to hypofractionated stereotactic radiotherapy, using a dedicated linear accelerator