RESUMEN
Stereotactic radiosurgery is an alternative to conventional surgery for the treatment of trigeminal neuralgia. To better define the safety of radiosurgery and optimal technical choices, we reviewed our patient records and the literature. A total of 334 patients presenting with trigeminal neuralgia were treated between December 1992 and September 2005. A minimum of 1 year of follow-up was available for 262 patients. The mean age was 68 years (range: 30-90); 128 patients were male and 134 female. A neurovascular conflict was clearly visualized on MRI in 167 patients. Twenty-one had a past history of multiple sclerosis and 110 had already received conventional surgical treatment for trigeminal neuralgia. The intervention consisted of gamma knife radiosurgery (GKS) to the retrogasserian cisternal portion of the Vth cranial nerve. The median maximal dose used was 85Gy (range: 70-90). Actuarial curves show a plateau at 5 years for both the risk of hypoesthesia and recurrence. At 5 years, 58% of the patients remain pain-free and 83% have no trigeminal nerve disturbance. The median delay for pain cessation was 15 days. The initial pain-relief rate was 89%. None of the complications reported for the other techniques were observed. Patient selection (typical versus atypical, age, past surgery, multiple sclerosis) and details of operative technique (maximum dose, volume of nerve treated, target location, etc.) had a major influence on the probability of pain relief and toxicity risk. The details of operative technique are turning out to have a major influence on the clinical results. In our experience, high-dose (80-90Gy) retrogasserian (7-8mm from the brainstem) GKS provides the patient with a better chance of long-term pain relief and a lower risk of trigeminal nerve functional disturbance. GKS applied to the cisternal anterior trigeminal nerve using high doses provided safe and effective treatment for trigeminal neuralgia over the long term.
Asunto(s)
Radiocirugia , Neuralgia del Trigémino/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Hipoestesia/etiología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Esclerosis Múltiple/complicaciones , Selección de Paciente , Complicaciones Posoperatorias/epidemiología , Dosis de Radiación , Radiocirugia/métodos , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Neuralgia del Trigémino/clasificación , Neuralgia del Trigémino/etiologíaRESUMEN
BACKGROUND: There is growing interest in the use of radiosurgery in epilepsy. We analyzed our experience in this field in an attempt to define the potential of radiosurgery in epileptology. MATERIAL AND METHODS: [corrected] Our local clinical experience (134 patients), accumulated over the last 15 years, mainly includes treatment of temporal lobe epilepsy without space-occupying lesions (59 patients), including 53 with pure MTLE, 61 cases of hypothalamic hamartoma, two cases of callosotomy, and 12 other types of epilepsy. RESULTS: The analysis of our material, as well as other clinical and experimental data, suggest that the use of radiosurgery is beneficial only to patients in whom a strict preoperative definition of the extent of the epileptogenic zone (or network) has been achieved and strict rules of dose planning have been applied. As soon as these principles are not observed, the risk of treatment failure and/or side effects increases dramatically. Long-term outcome data are now available and published for MTLE but not yet for other types of epilepsy. Long-term safety and efficacy in MTLE are comparable to surgical resection but radiosurgery has the advantage of sparing verbal memory in patients operated by Gamma Knife (GK) on the dominant side. In small hamartomas, the efficacy is comparable to microsurgery but with a dramatic reduction in risk. CONCLUSION: The vast amount of clinical materiel and long-term evaluation now support the use of GK surgery in small hypothalamic hamartomas and MTLE when the patient is at risk of verbal memory loss.
Asunto(s)
Epilepsia del Lóbulo Temporal/cirugía , Procedimientos Neuroquirúrgicos , Radiocirugia , Cognición/fisiología , Cuerpo Calloso/cirugía , Resistencia a Medicamentos , Epilepsia del Lóbulo Temporal/etiología , Epilepsia del Lóbulo Temporal/patología , Hamartoma/complicaciones , Hamartoma/cirugía , Humanos , Enfermedades Hipotalámicas/complicaciones , Enfermedades Hipotalámicas/cirugía , Procedimientos Neuroquirúrgicos/efectos adversos , Procedimientos Neuroquirúrgicos/tendencias , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/psicología , Radiocirugia/efectos adversos , Radiocirugia/tendencias , Riesgo , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
During a surgery of basilar aneurysms via the trans-sylvian approach, we encountered an arterial bleeding caused by rupture of an internal carotid artery aneurysm that had been difficult to diagnose before surgery, as it was a small and brood-neck aneurysm and mimicked arteriosclerosis. In spite of several surgical procedures, the surgical path at the basilar aneurysms became narrow, and we had to abandon the clipping of the aneurysms. Consideration of radiological and intraoperative findings was made for this case, demonstrating a pitfall that neurosurgeons may encounter during surgery.