Retreatment of trigeminal neuralgia with Gamma Knife radiosurgery: is there an appropriate cumulative dose?

Dvořák, Tomáš; Finn, Arkadiy; Price, Lori Lyn; Mignano, John E.; Fitzek, Markus M.; Wu, Julian K.; Yao, Kevin C.

doi:10.3171/2008.11.jns08770

Cited by 53 publications

(51 citation statements)

References 18 publications

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“…More than 60% of patients undergoing repeat GKRS experience at least 50% improvement in pain. 1,9,13,16,18,19,24,34,36,45 Yet 25% of patients experienced recurrent pain (BNI Score IV or V) at a median of 17 months following a repeat GKRS. 26,34 We hypothesized that there exists a subset of patients who may benefit from a third radiosurgical procedure, predicted by their prior favorable response to GKRS.…”

Section: Discussionmentioning

confidence: 99%

“…There may exist a threshold cumulative dose beyond which the rate of pain relief plateaus or even falls. 1,9,24 It must be noted that despite the median cumulative target dose of 210 Gy, there were no adverse brainstem injuries in our series; it appears that optimal target selection can help to avoid pontine injury. Figure 3 demonstrates the lack of signal changes in the brainstem with the increasing cumulative radiation to the brainstem margin.…”

Section: Maintenancementioning

confidence: 99%

“…29,48 Rates of initial pain relief reported in the literature for single repeat GKRS in TN patients are similar. 1,9,13,16,18,19,24,34,36,45 In a large recent series, Park et al described their experience with repeat GKRS for recurrent TN in 119 patients at a median of 26 months after primary GKRS and noted that 87% of patients achieved initial pain relief (BNI Scores I-IIIb), 88% of whom maintained relief at 1 year, and 70% of whom maintained relief at 3 years after repeat GKRS. 34 Aubuchon et al and…”

Section: Repeat Gkrs For Tnmentioning

confidence: 99%

“…6,15,27,34,38,39,41,46 In 11%-74% of these patients there is worsening of preexisting trigeminal disturbance or new onset of dysfunction following repeat radiosurgery for TN. 1,9,13,16,18,21,24,27,34,43,45 Most patients with TN typically report satisfactory pain relief without bothersome sensory dysfunction following the radiosurgical procedure. Yet several studies have correlated trigeminal sensory loss following GKRS with improved pain control.…”

Section: Trigeminal Sensory Dysfunction After Triple Gkrsmentioning

confidence: 99%

“…15,27,46 Such patients have been found to benefit from repeat GKRS, with success rates of between 62% and 95% at a median 32-month follow-up. 1,9,13,16,18,19,24,34,36,45 In this report, we describe our experience in a small cohort of patients who ultimately underwent 3 GKRS procedures because of the recurrence of medically intractable pain. We analyze the outcomes in such patients, including the extent and duration of pain relief.…”

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confidence: 99%

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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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