Outcome Predictors After Gamma Knife Radiosurgery for Recurrent Trigeminal Neuralgia

Kano, Hideyuki; Kondziolka, Douglas; Yang, Huai‐Che; Zorro, Óscar; Lobato-Polo, Javier; Flannery, Thomas; Flickinger, John C.; Lunsford, L. Dade

doi:10.1227/neu.0b013e3181fa098a

Cited by 50 publications

(27 citation statements)

References 38 publications

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“…Future prospective studies may also aid in identifying predictors or outcome variables which will help clinicians to decide on the optimal treatment modality. Though such predictors have been studied in some recent series [26,27], they are lacking high quality evidence.…”

Section: Future Directionsmentioning

confidence: 99%

Long term efficacy and patient satisfaction of microvascular decompression and gamma knife radiosurgery for trigeminal neuralgia

Nanda

Javalkar

Zhang

et al. 2015

Journal of Clinical Neuroscience

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Section: Future Directionsmentioning

confidence: 99%

Long term efficacy and patient satisfaction of microvascular decompression and gamma knife radiosurgery for trigeminal neuralgia

Nanda

Javalkar

Zhang

et al. 2015

Journal of Clinical Neuroscience

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“…1,2,[16][17][18][19] The dose range for the first treatment of TN with GKS is most commonly 70-90 Gy. This study provides information about long-term pain relief, adverse effects, changes in medication(s), and effects on quality of life and patient satisfaction using 90 Gy, which is in the upper range of commonly used doses.…”

mentioning

confidence: 99%

Long-term outcome of high-dose Gamma Knife surgery in treatment of trigeminal neuralgia

Young¹,

Shivazad

Kryscio

et al. 2013

JNS

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Object Despite the widespread use of Gamma Knife surgery (GKS) for trigeminal neuralgia (TN), controversy remains regarding the optimal treatment dose and target site. Among the published studies, only a few have focused on long-term outcomes (beyond 2 years) using 90 Gy, which is in the higher range of treatment doses used (70–90 Gy). Methods The authors followed up on 315 consecutive patients treated with the Leksell Gamma Knife unit using a 4-mm isocenter without blocks. The isocenter was placed on the trigeminal nerve with the 20% isodose line tangential to the pontine surface (18 Gy). At follow-up, 33 patients were deceased; 282 were mailed an extensive questionnaire regarding their outcomes, but 32 could not be reached. The authors report their analysis of the remaining 250 cases. The patients' mean age at the time of survey response and the mean duration of follow-up were 70.8 ± 13.1 years and 68.9 ± 41.8 months, respectively. Results One hundred eighty-five patients (85.6%) had decreased pain intensity after GKS. Modified Marseille Scale (MMS) pain classifications after GKS at follow-up were: Class I (pain free without medication[s]) in 104 (43.7%), Class II (pain free with medication[s]) in 66 (27.7%), Class III (> 90% decrease in pain intensity) in 23 (9.7%), Class IV (50%–90% decrease in pain intensity) in 20 (8.4%), Class V (< 50% decrease in pain intensity) in 11 (4.6%), and Class VI (pain becoming worse) in 14 (5.9%). Therefore, 170 patients (71.4%) were pain free (Classes I and II) and 213 (89.5%) had at least 50% pain relief. All patients had pain that was refractory to medical management prior to GKS, but only 111 (44.4%) were being treated with medication at follow-up (p < 0.0001). Eighty patients (32.9%) developed numbness after GKS, and 74.5% of patients with numbness had complete pain relief. Quality of life and patient satisfaction on a 10-point scale were reported at mean values (± SD) of 7.8 ± 3.1 and 7.7 ± 3.4, respectively. Most of the patients (87.7%) would recommend GKS to another patient. Patients with prior surgical treatments had increased latency to pain relief and were more likely to continue medicines (p < 0.05). Moreover, presence of altered facial sensations prior to radiosurgery was associated with higher pain intensity, longer pain episodes, more frequent pain attacks, worse MMS pain classification, and more medication use after GKS (p < 0.05). Conversely, increase in numbness intensity after GKS was associated with a decrease in pain intensity and pain length (p < 0.05). Conclusions Gamma Knife surgery using a maximum dose of 90 Gy to the trigeminal nerve provides satisfactory long-term pain control, reduces the use of medication, and improves quality of life. Physicians must be aware that higher doses may be associated with an increase in bothersome sensory complications. The benefits and risks of higher dose selection must be carefully discussed with patients, since facial numbness, even if bothersome, may be an acceptable trade-off for patients with severe pain.

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“…As has been mentioned, higher doses at individual treatments can yield better pain relief but with more sensory disturbance. 6,22,27,29,34,47,48 However, it may be that cumulative doses need to be much higher than reported here to produce dramatically higher rates of sensory disturbance.…”

Section: Trigeminal Sensory Dysfunction After Triple Gkrsmentioning

confidence: 66%

“…6,50 As the total maximal dose increases, a higher number of patients note postprocedural trigeminal nerve dysfunction ranging from mild facial numbness or paresthesias to annoying deafferentation sequelae such as dysesthesias. 6,22,47 Regardless of the dose delivered, the benefit of radiosurgery may decline over time and may lead to symptom recurrence. Among management options for recurrent medically refractory trigeminal neuralgia (TN), GKRS is often appealing in patients with advanced age or medical comorbidities, especially for those patients on a long-term regimen of anticoagulation or antiplatelet therapy.…”

mentioning

confidence: 99%

The results of a third Gamma Knife procedure for recurrent trigeminal neuralgia

Tempel

Chivukula

Monaco

et al. 2015

JNS

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OBJECT Gamma Knife radiosurgery (GKRS) is the least invasive treatment option for medically refractory, intractable trigeminal neuralgia (TN) and is especially valuable for treating elderly, infirm patients or those on anticoagulation therapy. The authors reviewed pain outcomes and complications in TN patients who required 3 radiosurgical procedures for recurrent or persistent pain. METHODS A retrospective review of all patients who underwent 3 GKRS procedures for TN at 4 participating centers of the North American Gamma Knife Consortium from 1995 to 2012 was performed. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes. RESULTS Seventeen patients were identified; 7 were male and 10 were female. The mean age at the time of last GKRS was 79.6 years (range 51.2–95.6 years). The TN was Type I in 16 patients and Type II in 1 patient. No patient suffered from multiple sclerosis. Eight patients (47.1%) reported initial complete pain relief (BNI Score I) following their third GKRS and 8 others (47.1%) experienced at least partial relief (BNI Scores II–IIIb). The average time to initial response was 2.9 months following the third GKRS. Although 3 patients (17.6%) developed new facial sensory dysfunction following primary GKRS and 2 patients (11.8%) experienced new or worsening sensory disturbance following the second GKRS, no patient sustained additional sensory disturbances after the third procedure. At a mean follow-up of 22.9 months following the third GKRS, 6 patients (35.3%) reported continued Score I complete pain relief, while 7 others (41.2%) reported pain improvement (BNI Scores II–IIIb). Four patients (23.5%) suffered recurrent TN following the third procedure at a mean interval of 19.1 months. CONCLUSIONS A third GKRS resulted in pain reduction with a low risk of additional complications in most patients with medically refractory and recurrent, intractable TN. In patients unsuitable for other microsurgical or percutaneous strategies, especially those receiving long-term oral anticoagulation or antiplatelet agents, GKRS repeated for a third time was a satisfactory, low risk option.

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Outcome Predictors After Gamma Knife Radiosurgery for Recurrent Trigeminal Neuralgia

Cited by 50 publications

References 38 publications

Long term efficacy and patient satisfaction of microvascular decompression and gamma knife radiosurgery for trigeminal neuralgia

Long term efficacy and patient satisfaction of microvascular decompression and gamma knife radiosurgery for trigeminal neuralgia

Long-term outcome of high-dose Gamma Knife surgery in treatment of trigeminal neuralgia

The results of a third Gamma Knife procedure for recurrent trigeminal neuralgia

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