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BACKGROUND: Cluster-tic syndrome is a disorder characterized by the coexistence of symptoms related to both cluster headache and trigeminal neuralgia. Etiopathogenesis is not yet well defined. Medical treatment, including drugs for both cluster headache and trigeminal neuralgia, is the first therapeutic choice, whereas more invasive treatments are indicated in the case of pharmacological therapy failure or in the presence of drug side effects. To date, no randomized and/or large cohort trials describing Gamma Knife radiosurgery (GKRS) for cluster-tic syndrome are available, probably due to the syndrome's rarity. OBSERVATIONS: The authors describe the case of a 76-year-old woman with refractory cluster-tic syndrome who underwent GKRS with double target (the retrogasserian portion of the trigeminal nerve and the sphenopalatine ganglion). The Numerical Rating Scale (NRS) of pain and the Barrow Neurological Institute (BNI) pain intensity score before treatment were 7 (up to 10 during paroxysmal pain attacks) and V, respectively. At last follow-up, 24 months after GKRS, the patient had discontinued her pain medications and NRS and BNI pain scores were 1 and I, respectively. No trigeminal sensory disorders were reported. LESSONS: The present case shows that GKRS, in selected cases, could be an effective treatment in patients with refractory cluster-tic syndrome.
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BACKGROUND: While cases of trigeminal neuralgia induced by a brainstem infarct have been reported, the neurosurgical literature lacks clear treatment recommendations in this subpopulation. OBSERVATIONS: The authors present the first case report of infarct-related trigeminal neuralgia treated with pontine descending tractotomy that resulted in durable pain relief after multiple failed surgical interventions, including previous microvascular decompressions and stereotactic radiosurgery. A neuronavigated pontine descending tractotomy of the spinal trigeminal tract was performed and resulted in successful pain relief for a 50-month follow-up period. LESSONS: While many cases of ischemic brainstem lesions are caused by acute stroke, the authors assert that cerebral small vessel disease also plays a role in certain cases and that the relationship between these chronic ischemic brainstem lesions and trigeminal neuralgia is more likely to be overlooked. Furthermore, neurovascular compression may obscure the causative mechanism of infarct-related trigeminal neuralgia, leading to unsuccessful decompressive surgeries in cases in which neurovascular compression may be noncontributory to pain symptomatology. Pontine descending tractotomy may be beneficial in select patients and can be performed either alone or concurrently with microvascular decompression in cases in which the interplay between ischemic lesion and neurovascular compression in the pathophysiology of disease is not clear.
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OBJECTIVE: Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and stereotactic radiosurgery (SRS). The use of MVD in elderly patients has been described but has yet to be prospectively compared to SRS, which is well-tolerated and noninvasive. The authors aimed to directly compare long-term pain control and adverse event rates for first-time surgical treatments for idiopathic TN in the elderly. METHODS: A prospectively collected database was reviewed for TN patients who had undergone treatment between 1997 and 2017 at a single institution. Standardized collection of preoperative demographics, surgical procedure, and postoperative outcomes was performed. Data analysis was limited to patients over the age of 65 years who had undergone a first-time procedure for the treatment of idiopathic TN with at least 1 year of follow-up. RESULTS: One hundred ninety-three patients meeting the study inclusion criteria underwent surgical procedures for TN during the study period (54 MVD, 24 MVD+Rhiz, 115 SRS). In patients in whom an artery was not compressing the trigeminal nerve during MVD, a partial sensory rhizotomy (MVD+Rhiz) was performed. Patients in the SRS cohort were older than those in the MVD and MVD+Rhiz cohorts (mean ± SD, 79.2 ± 7.8 vs 72.9 ± 5.7 and 70.9 ± 4.8 years, respectively; p < 0.0001) and had a higher mean Charlson Comorbidity Index (3.8 ± 1.1 vs 3.0 ± 0.9 and 2.9 ± 1.0, respectively; p < 0.0001). Immediate or short-term postoperative pain-free rates (Barrow Neurological Institute [BNI] pain intensity score I) were 98.1% for MVD, 95.8% for MVD+Rhiz, and 78.3% for SRS (p = 0.0008). At the last follow-up, 72.2% of MVD patients had a favorable outcome (BNI score I-IIIa) compared to 54.2% and 49.6% of MVD+Rhiz and SRS patients, respectively (p = 0.02). In total, 0 (0%) SRS, 5 (9.3%) MVD, and 1 (4.2%) MVD+Rhiz patients developed any adverse event. Multivariate Cox proportional hazards analysis demonstrated that procedure type (p = 0.001) and postprocedure sensory change (p = 0.003) were statistically significantly associated with pain control. CONCLUSIONS: In this study cohort, patients who had undergone MVD had a statistically significantly longer duration of pain freedom than those who had undergone MVD+Rhiz or SRS as their first procedure. Fewer adverse events were seen after SRS, though the MVD-associated complication rate was comparable to published rates in younger patients. Overall, the results suggest that both MVD and SRS are effective options for the elderly, despite their advanced age. Treatment choice can be tailored to a patient's unique condition and wishes.
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Cirugía para Descompresión Microvascular , Radiocirugia , Neuralgia del Trigémino , Anciano , Humanos , Dolor Postoperatorio , Estudios Retrospectivos , Resultado del Tratamiento , Neuralgia del Trigémino/cirugíaRESUMEN
OBJECTIVE: Glossopharyngeal neuralgia (GN) is a rare pain condition in which patients experience paroxysmal, lancinating throat pain. Multiple surgical approaches have been used to treat this condition, including microvascular decompression (MVD), and sectioning of cranial nerve (CN) IX and the upper rootlets of CN X, or a combination of the two. The aim of this study was to examine the long-term quality of life and pain-free survival after MVD and sectioning of the CN X/IX complex. METHODS: A combined retrospective chart review and a quality-of-life telephone survey were performed to collect demographic and long-term outcome data. Quality of life was assessed by means of a questionnaire based on a combination of the Barrow Neurological Institute pain intensity scoring criteria and the Brief Pain Inventory-Facial. Kaplan-Meier analysis was performed to determine pain-free survival. RESULTS: Of 18 patients with GN, 17 underwent sectioning of the CN IX/X complex alone or sectioning and MVD depending on the presence of a compressing vessel. Eleven of 17 patients had compression of CN IX/X by the posterior inferior cerebellar artery, 1 had compression by a vertebral artery, and 5 had no compression. One patient (6%) experienced no immediate pain relief. Fifteen (88%) of 17 patients were pain free at the last follow-up (mean 9.33 years, range 5.16-13 years). One patient (6%) experienced throat pain relapse at 3 months. The median pain-free survival was 7.5 years ± 10.6 months. Nine of 18 patients were contacted by telephone. Of the 17 patients who underwent sectioning of the CN IX/X complex, 13 (77%) patients had short-term complaints: dysphagia (n = 4), hoarseness (n = 4), ipsilateral hearing loss (n = 4), ipsilateral taste loss (n = 2), and dizziness (n = 2) at 2 weeks. Nine patients had persistent side effects at latest follow-up. Eight of 9 telephone respondents reported that they would have the surgery over again. CONCLUSIONS: Sectioning of the CN IX/X complex with or without MVD of the glossopharyngeal nerve is a safe and effective surgical therapy for GN with initial pain freedom in 94% of patients and an excellent long-term pain relief (mean 7.5 years).
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Enfermedades del Nervio Glosofaríngeo/cirugía , Nervio Glosofaríngeo/cirugía , Cirugía para Descompresión Microvascular/métodos , Neuralgia/cirugía , Nervio Vago/cirugía , Adulto , Anciano , Trastornos de Deglución/epidemiología , Trastornos de Deglución/etiología , Supervivencia sin Enfermedad , Femenino , Pérdida Auditiva Sensorineural/epidemiología , Pérdida Auditiva Sensorineural/etiología , Pérdida Auditiva Unilateral/epidemiología , Pérdida Auditiva Unilateral/etiología , Ronquera/epidemiología , Ronquera/etiología , Humanos , Masculino , Cirugía para Descompresión Microvascular/efectos adversos , Persona de Mediana Edad , Satisfacción del Paciente , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Calidad de Vida , Recurrencia , Estudios Retrospectivos , Resultado del Tratamiento , Vagotomía/efectos adversos , Vagotomía/métodosRESUMEN
OBJECTIVEAblative procedures are still useful in the treatment of intractable pain despite the proliferation of neuromodulation techniques. In the paper the authors present the results of Gamma Knife thalamotomy (GKT) in various pain syndromes.METHODSBetween 1996 and 2016, unilateral GKT was performed in 30 patients suffering from various severe pain syndromes in whom conservative treatment had failed. There were 20 women and 10 men in the study population, with a median age of 80 years (range 53-89 years). The pain syndromes consisted of 8 patients with classic treatment-resistant trigeminal neuralgia (TN), 6 with postherpetic TN, 5 with TN and constant pain, 1 with TN related to multiple sclerosis, 3 with trigeminal neuropathic pain, 4 with thalamic pain, 1 with phantom pain, 1 with causalgic pain, and 1 with facial pain. The median follow-up period was 24 months (range 12-180 months). Invasive procedures for pain release preceded GKT in 20 patients (microvascular decompression, glycerol rhizotomy, balloon microcompression, Gamma Knife irradiation of the trigeminal root, and radiofrequency thermolesion). The Leksell stereotactic frame, GammaPlan software, and T1- and T2-weighted sequences acquired at 1.5 T were used for localization of the targeted medial thalamus, namely the centromedian (CM) and parafascicularis (Pf) nucleus. The CM/Pf complex was localized 4-6 mm lateral to the wall of the third ventricle, 8 mm posterior to the midpoint, and 2-3 mm superior to the intercommissural line. GKT was performed using the Leksell Gamma Knife with an applied dose ranging from 145 to 150 Gy, with a single shot, 4-mm collimator. Pain relief after radiation treatment was evaluated. Decreased pain intensity to less than 50% of the previous level was considered successful.RESULTSInitial successful results were achieved in 13 (43.3%) of the patients, with complete pain relief in 1 of these patients. Relief was achieved after a median latency of 3 months (range 2-12 months). Pain recurred in 4 (31%) of 13 patients after a median latent interval of 24 months (range 22-30 months). No neurological deficits were observed.CONCLUSIONSThese results suggest that GKT in patients suffering from severe pain syndromes is a relatively successful and safe method that can be used even in severely affected patients. The only risk of GT for the patients in this study was failure of treatment, as no clinical side effects were observed.
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Dolor Intratable/radioterapia , Radiocirugia , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Intratable/diagnóstico por imagen , Radiocirugia/métodos , Recurrencia , Tálamo , Resultado del Tratamiento , Neuralgia del Trigémino/diagnóstico por imagen , Neuralgia del Trigémino/radioterapiaRESUMEN
OBJECTIVE: The objective of this study was to assess long-term outcomes of facial pain and numbness after radiosurgery for multiple sclerosis (MS)-related trigeminal neuralgia (MS-TN). METHODS: The authors conducted a retrospective review of their Gamma Knife radiosurgeries (GKRSs) to identify all patients treated for MS-TN (1998-2014) with at least 3 years of follow-up. Treatment and clinical data were obtained via chart review and mailed or telephone surveys. Pain control was defined as a facial pain score of I-IIIb on the Barrow Neurological Institute (BNI) Facial Pain Intensity Scale. Kaplan-Meier analysis was performed to determine the rates of pain control after index and first salvage GKRS procedures. Patients could have had more than 1 salvage procedure. Pain control rates were based on the number of patients at risk during follow-up. RESULTS: Of the 50 living patients who underwent GKRS, 42 responded to surveys (31 women [74%], median age 59 years, range 32-76 years). During the initial GKRS, the trigeminal nerve root entry zone was targeted with a single isocenter, using a 4-mm collimator with the 90% isodose line completely covering the trigeminal nerve and the 50% isodose line abutting the surface of the brainstem. The median maximum radiation dose was 85 Gy (range 50-85 Gy). The median follow-up period was 78 months (range 36-226 months). The rate of pain control after the index GKRS (n = 42) was 62%, 29%, 22%, and 13% at 1, 3, 5, and 7 years, respectively. Twenty-eight patients (67%) underwent salvage treatment, including 25 (60%) whose first salvage treatment was GKRS. The rate of pain control after the first salvage GKRS (n = 25) was 84%, 50%, 44%, and 17% at 1, 3, 5, and 7 years, respectively. The rate of pain control after the index GKRS with or without 1 salvage GKRS (n = 33) was 92%, 72%, 52%, 46%, and 17% at 1, 3, 5, 7, and 10 years, respectively. At last follow-up, 9 (21%) of the 42 patients had BNI grade I facial pain, 35 (83%) had achieved pain control, and 4 (10%) had BNI grade IV facial numbness (very bothersome in daily life). CONCLUSIONS: Index GKRS offers good short-term pain control for MS-TN, but long-term pain control is uncommon. If the index GKRS fails, salvage GKRS appears to offer beneficial pain control with low rates of bothersome facial numbness.
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OBJECTIVE: Microvascular decompression (MVD) and stereotactic radiosurgery (SRS) are common surgical treatments for trigeminal neuralgia (TN). Many patients who receive SRS have pain recurrence; the ideal second intervention is unknown. The authors directly compared pain outcomes after MVD and repeat SRS in a population of patients in whom SRS failed as their first-line procedure for TN, and they identified predictors of pain control. METHODS: The authors reviewed a prospectively collected database of patients undergoing surgery for TN between 1997 and 2014 at the University of California, San Francisco (UCSF). Standardized data collection focused on preoperative clinical characteristics, surgical characteristics, and postoperative outcomes. Patients with typical type 1, idiopathic TN with ≥ 1 year of follow-up were included. RESULTS: In total, 168 patients underwent SRS as their first procedure. Of these patients, 90 had residual or recurrent pain. Thirty of these patients underwent a second procedure at UCSF and had ≥ 1 year of follow-up; 15 underwent first-time MVD and 15 underwent repeat SRS. Patients undergoing MVD were younger than those receiving repeat SRS and were more likely to receive ≥ 80 Gy during the initial SRS. The average follow-up was 44.9 ± 33.6 months for MVD and 48.3 ± 45.3 months for SRS. All patients achieved complete pain freedom without medication at some point during their follow-up. At last follow-up, 80% of MVD-treated patients and 33.3% of SRS-treated patients had a favorable outcome, defined as Barrow Neurological Institute Pain Intensity scores of I-IIIa (p < 0.05). Percentages of patients with favorable outcome at 1 and 5 years were 86% and 75% for the MVD cohort and 73% and 27% for the SRS cohort, respectively (p < 0.05). Multivariate Cox proportional hazards analysis demonstrated that performing MVD was statistically significantly associated with favorable outcome (HR 0.12, 95% CI 0.02-0.60, p < 0.01). There were no statistically significant predictors of favorable outcome in the MVD cohort; however, the presence of sensory changes after repeat SRS was associated with pain relief (p < 0.01). CONCLUSIONS: Patients who received MVD after failed SRS had a longer duration of favorable outcome compared to those who received repeat SRS; however, both modalities are safe and effective. The presence of post-SRS sensory changes was predictive of a favorable pain outcome in the SRS cohort.
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OBJECTIVE: Gamma Knife radiosurgery (GKRS) has emerged as a promising treatment modality for patients with classical trigeminal neuralgia (TN); however, considering that almost half of the patients experience post-GKRS failure or lesion recurrence, a repeat treatment is typically necessary. The existing literature does not offer clear evidence to establish which treatment modality, repeat GKRS or microvascular decompression (MVD), is superior. The present study aimed to compare the overall outcome of patients who have undergone either repeat GKRS or MVD after failure of their primary GKRS; the authors do so by conducting a systematic review and meta-analysis of the literature and analysis of data from their own institution. METHODS: The authors conducted a systematic review and meta-analysis of the PubMed, Cochrane Library, Web of Science, and CINAHL databases to identify studies describing patients who underwent either repeat GKRS or MVD after initial failed GKRS for TN. The primary outcomes were complete pain relief (CPR) and adequate pain relief (APR) at 1 year. The secondary outcomes were rate of postoperative facial numbness and the retreatment rate. The pooled data were analyzed with R software. Bias and heterogeneity were assessed using funnel plots and I2 tests, respectively. A retrospective analysis of a series of patients treated by the authors who underwent repeat GKRS or MVD after post-GKRS failure or relapse is presented. RESULTS: A total of 22 studies met the selection criteria and were included for final data retrieval and meta-analysis. The search did not identify any study that had directly compared outcomes between patients who had undergone repeat GKRS versus those who had undergone MVD. Therefore, the authors' final analysis included two groups: studies describing outcome after repeat GKRS (n = 17) and studies describing outcome after MVD (n = 5). The authors' institutional study was the only study with direct comparison of the two cohorts. The pooled estimates of primary outcomes were APR in 83% of patients who underwent repeat GKRS and 88% of those who underwent MVD (p = 0.49), and CPR in 46% of patients who underwent repeat GKRS and 72% of those who underwent MVD (p = 0.02). The pooled estimates of secondary outcomes were facial numbness in 32% of patients who underwent repeat GKRS and 22% of those who underwent MVD (p = 0.11); the retreatment rate was 19% in patients who underwent repeat GKRS and 13% in those who underwent MVD (p = 0.74). The authors' institutional study included 42 patients (repeat GKRS in 15 and MVD in 27), and the outcomes 1 year after retreatment were APR in 80% of those who underwent repeat GKRS and 81% in those who underwent MVD (p = 1.0); CPR was achieved in 47% of those who underwent repeat GKRS and 44% in those who underwent MVD (p = 1.0). There was no difference in the rate of postoperative facial numbness or retreatment. CONCLUSIONS: The current meta-analysis failed to identify any superiority of one treatment over the other with comparable outcomes in terms of APR, postoperative facial numbness, and retreatment rates. However, MVD was shown to provide a better chance of CPR compared with repeat GKRS.
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OBJECTIVE: Nervus intermedius neuralgia (NIN) or geniculate neuralgia is a rare facial pain condition consisting of sharp, lancinating pain deep in the ear and can occur alongside trigeminal neuralgia (TN). Studies on the clinical presentation, intraoperative findings, and ultimately postoperative outcomes are extremely limited. The aim of this study was to examine the clinical presentation and surgical findings, and determine pain-free survival after sectioning of the nervus intermedius (NI). METHODS: The authors conducted a retrospective chart review and survey of patients who were diagnosed with NIN at one institution and who underwent neurosurgical interventions. Pain-free survival was determined through chart review and phone interviews using a modified facial pain and quality of life questionnaire and represented as Kaplan-Meier curves. RESULTS: The authors found 15 patients with NIN who underwent microsurgical intervention performed by two surgeons from 2002 to 2016 at a single institution. Fourteen of these patients underwent sectioning of the NI, and 8 of 14 had concomitant TN. Five patients had visible neurovascular compression (NVC) of the NI by the anterior inferior cerebellar artery in most cases where NVC was found. The most common postoperative complaints were dizziness and vertigo, diplopia, ear fullness, tinnitus, and temporary facial nerve palsy. Thirteen of the 14 patients reportedly experienced pain relief immediately after surgery. The mean length of follow-up was 6.41 years (range 8 months to 14.5 years). Overall recurrence of any pain was 42% (6 of 14), and 4 patients (isolated NIN that received NI sectioning alone) reported their pain was the same or worse than before surgery at longest follow-up. The median pain-free survival was 4.82 years ± 14.85 months. The median pain-controlled survival was 6.22 years ± 15.78 months. CONCLUSIONS: In this retrospective review, sectioning of the NI produced no major complications, such as permanent facial weakness or deafness, and was effective for patients when performed in addition to other procedures. After sectioning of the NI, patients experienced 4.8 years pain free and experienced 6.2 years of less pain than before surgery. Alone, sectioning of the NI was not effective. The pathophysiology of NIN is not entirely understood. It appears that neurovascular compression plays only a minor role in the syndrome and there is a high degree of overlap with TN.
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Nervio Facial/cirugía , Microcirugia/métodos , Neuralgia/cirugía , Adolescente , Adulto , Anciano , Nervio Facial/patología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neuralgia/diagnóstico , Estudios Retrospectivos , Encuestas y Cuestionarios , Adulto JovenRESUMEN
OBJECTIVE: Gamma Knife radiosurgery (GKRS) is an important treatment modality for trigeminal neuralgia (TN). Current longitudinal assessment after GKRS relies primarily on clinical diagnostic measures, which are highly limited in the prediction of long-term clinical benefit. An objective, noninvasive, predictive tool would be of great utility to advance the clinical management of patients. Using diffusion tensor imaging (DTI), the authors' aim was to determine whether early (6 months post-GKRS) target diffusivity metrics can be used to prognosticate long-term pain relief in patients with TN. METHODS: Thirty-seven patients with TN treated with GKRS underwent 3T MRI scans at 6 months posttreatment. Diffusivity metrics of fractional anisotropy, axial diffusivity, radial diffusivity, and mean diffusivity were extracted bilaterally from the radiosurgical target of the affected trigeminal nerve and its contralateral, unaffected nerve. Early (6 months post-GKRS) diffusivity metrics were compared with long-term clinical outcome. Patients were identified as long-term responders if they achieved at least 75% reduction in preoperative pain for 12 months or longer following GKRS. RESULTS: Trigeminal nerve diffusivity at 6 months post-GKRS was predictive of long-term clinical effectiveness, where long-term responders (n = 19) showed significantly lower fractional anisotropy at the radiosurgical target of their affected nerve compared to their contralateral, unaffected nerve and to nonresponders. Radial diffusivity and mean diffusivity, correlates of myelin alterations and inflammation, were also significantly higher in the affected nerve of long-term responders compared to their unaffected nerve. Nonresponders (n = 18) did not exhibit any characteristic diffusivity changes after GKRS. CONCLUSIONS: The authors demonstrate that early postsurgical target diffusivity metrics have a translational, clinical value and permit prediction of long-term pain relief in patients with TN treated with GKRS. Importantly, an association was found between the footprint of radiation and clinical effectiveness, where a sufficient level of microstructural change at the radiosurgical target is necessary for long-lasting pain relief. DTI can provide prognostic information that supplements clinical measures, and thus may better guide the postoperative assessment and clinical decision-making for patients with TN.
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Imagen de Difusión Tensora/tendencias , Manejo del Dolor/tendencias , Cuidados Posoperatorios/tendencias , Radiocirugia/tendencias , Neuralgia del Trigémino/diagnóstico por imagen , Neuralgia del Trigémino/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Anisotropía , Imagen de Difusión Tensora/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Cuidados Posoperatorios/métodos , Pronóstico , Radiocirugia/métodos , Estudios Retrospectivos , Factores de TiempoRESUMEN
OBJECTIVE In microvascular decompression surgery for trigeminal neuralgia and hemifacial spasm, the bridging veins are dissected to provide the surgical corridors, and the veins of the brainstem may be mobilized in cases of venous compression. Strategy and technique in dissecting these veins may affect the surgical outcome. The authors investigated solutions for minimizing venous complications and reviewed the outcome for venous decompression. METHODS The authors retrospectively reviewed their surgical series of microvascular decompression for trigeminal neuralgia and hemifacial spasm in patients treated between 2005 and 2017. Surgical strategies included preservation of the superior petrosal vein and its tributaries, thorough dissection of the arachnoid sleeve that enveloped these veins, cutting of the inferior petrosal vein over the lower cranial nerves, and mobilization or cutting of the veins of the brainstem that compressed the nerve roots. The authors summarized the patient characteristics, operative findings, and postoperative outcomes according to the vascular compression types as follows: artery alone, artery and vein, and vein alone. They analyzed the data using chi-square and 1-way ANOVA tests. RESULTS The cohort was composed of 121 patients with trigeminal neuralgia and 205 patients with hemifacial spasm. The superior petrosal vein and its tributaries were preserved with no serious complications in all patients with trigeminal neuralgia. Venous compression alone and arterial and venous compressions were observed in 4% and 22%, respectively, of the patients with trigeminal neuralgia, and in 1% and 2%, respectively, of those with hemifacial spasm (p < 0.0001). In patients with trigeminal neuralgia, 35% of those with artery and venous compressions and 80% of those with venous compression alone had atypical neuralgia (p = 0.015). The surgical cure and recurrence rates of trigeminal neuralgias with venous compression were 60% and 20%, respectively, and with arterial and venous compressions the rates were 92% and 12%, respectively (p < 0.0001, p = 0.04). In patients with hemifacial spasm who had arterial and venous compressions, their recurrence rate was 60%, and that was significantly higher compared to other compression types (p = 0.0008). CONCLUSIONS Dissection of the arachnoid sleeve that envelops the superior petrosal vein may help to reduce venous complications in surgery for trigeminal neuralgia. Venous compression may correlate with worse prognosis even with thorough decompression, in both trigeminal neuralgia and hemifacial spasm.
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Tronco Encefálico/irrigación sanguínea , Tronco Encefálico/cirugía , Espasmo Hemifacial/cirugía , Cirugía para Descompresión Microvascular/métodos , Microvasos/cirugía , Neuralgia del Trigémino/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Espasmo Hemifacial/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Neuralgia del Trigémino/diagnósticoRESUMEN
OBJECTIVEPatients with multiple sclerosis (MS)-associated trigeminal neuralgia (TN) have higher recurrence and retreatment rates than non-MS patients. The optimal management strategy and role for microsurgical rhizotomy (MSR) for MS-TN remains to be determined. The aim of this study was to report time to treatment failure (TTF) and pain scores following MSR compared to percutaneous and Gamma Knife procedures.METHODSTime to treatment failure was analyzed after MSR (n = 14) versus prior procedures (n = 53) among MS-TN patients. Kaplan-Meier curves and log-rank test were utilized to compare TTF after MSR versus prior procedures using the same cohort of patients as their own control group. Subsequent analysis compared TTF after MSR to TTF after 93 other procedures among a second cohort of 18 MS-TN patients not undergoing MSR. BNI pain scores were compared between MSR and other procedures among the MS-TN cohort using a chi-square test.RESULTSTTF was significantly longer after MSR than after other procedures in the MSR cohort (median TTF 79 vs 10 months, respectively, p < 0.0001). Similarly, TTF was longer after MSR than after prior procedures in the non-MSR cohort (median TTF 79 vs 13 months, respectively, p < 0.001). MSR resulted in a higher proportion of excellent pain scores when compared to other procedures in the non-MSR cohort (77% vs 29%, p < 0.001). Probability of treatment survival was higher after MSR than after other procedures at all time points (3, 6, 12, 24, 36, and 48 months). There were no deaths or major complications after MSR.CONCLUSIONSTTF was significantly longer following MSR compared to prior procedures in MS-TN patients. Additionally, a higher proportion of patients achieved excellent BNI pain scores after MSR.
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OBJECTIVES: The aims of this systematic review are to provide an objective summary of the published literature specific to the treatment of classical trigeminal neuralgia with stereotactic radiosurgery (RS) and to develop consensus guideline recommendations for the use of RS, as endorsed by the International Society of Stereotactic Radiosurgery (ISRS). METHODS: The authors performed a systematic review of the English-language literature from 1951 up to December 2015 using the Embase, PubMed, and MEDLINE databases. The following MeSH terms were used in a title and abstract screening: "radiosurgery" AND "trigeminal." Of the 585 initial results obtained, the authors performed a full text screening of 185 studies and ultimately found 65 eligible studies. Guideline recommendations were based on level of evidence and level of consensus, the latter predefined as at least 85% agreement among the ISRS guideline committee members. RESULTS: The results for 65 studies (6461 patients) are reported: 45 Gamma Knife RS (GKS) studies (5687 patients [88%]), 11 linear accelerator (LINAC) RS studies (511 patients [8%]), and 9 CyberKnife RS (CKR) studies (263 patients [4%]). With the exception of one prospective study, all studies were retrospective.The mean maximal doses were 71.1-90.1 Gy (prescribed at the 100% isodose line) for GKS, 83.3 Gy for LINAC, and 64.3-80.5 Gy for CKR (the latter two prescribed at the 80% or 90% isodose lines, respectively). The ranges of maximal doses were as follows: 60-97 Gy for GKS, 50-90 Gy for LINAC, and 66-90 Gy for CKR.Actuarial initial freedom from pain (FFP) without medication ranged from 28.6% to 100% (mean 53.1%, median 52.1%) for GKS, from 17.3% to 76% (mean 49.3%, median 43.2%) for LINAC, and from 40% to 72% (mean 56.3%, median 58%) for CKR. Specific to hypesthesia, the crude rates (all Barrow Neurological Institute Pain Intensity Scale scores included) ranged from 0% to 68.8% (mean 21.7%, median 19%) for GKS, from 11.4% to 49.7% (mean 27.6%, median 28.5%) for LINAC, and from 11.8% to 51.2% (mean 29.1%, median 18.7%) for CKR. Other complications included dysesthesias, paresthesias, dry eye, deafferentation pain, and keratitis. Hypesthesia and paresthesia occurred as complications only when the anterior retrogasserian portion of the trigeminal nerve was targeted, whereas the other listed complications occurred when the root entry zone was targeted. Recurrence rates ranged from 0% to 52.2% (mean 24.6%, median 23%) for GKS, from 19% to 63% (mean 32.2%, median 29%) for LINAC, and from 15.8% to 33% (mean 25.8%, median 27.2%) for CKR. Two GKS series reported 30% and 45.3% of patients who were pain free without medication at 10 years. CONCLUSIONS: The literature is limited in its level of evidence, with only one comparative randomized trial (1 vs 2 isocenters) reported to date. At present, one can conclude that RS is a safe and effective therapy for drug-resistant trigeminal neuralgia. A number of consensus statements have been made and endorsed by the ISRS.
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Radiocirugia/métodos , Neuralgia del Trigémino/cirugía , Humanos , Radiocirugia/estadística & datos numéricos , Resultado del TratamientoRESUMEN
OBJECTIVE: The objective of this study was to assess outcomes after Gamma Knife radiosurgery (GKRS) re-irradiation for palliation of patients with trigeminal pain secondary to recurrent malignant skull base tumors. METHODS: From 2009 to 2016, 26 patients who had previously undergone radiation treatment to the head and neck received GKRS for palliation of trigeminal neuropathic pain secondary to recurrence of malignant skull base tumors. Twenty-two patients received single-fraction GKRS to a median dose of 17 Gy (range 15-20 Gy) prescribed to the 50% isodose line (range 43%-55%). Four patients received fractionated Gamma Knife Extend therapy to a median dose of 24 Gy in 3 fractions (range 21-27 Gy) prescribed to the 50% isodose line (range 45%-50%). Those with at least a 3-month follow-up were assessed for symptom palliation. Self-reported pain was evaluated by the numeric rating scale (NRS) and MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) pain score. Frequency of as-needed (PRN) analgesic use and opioid requirement were also assessed. Baseline opioid dose was reported as a fentanyl-equivalent dose (FED) and PRN for breakthrough pain use as oral morphine-equivalent dose (OMED). The chi-square and Student t-tests were used to determine differences before and after GKRS. RESULTS: Seven patients (29%) were excluded due to local disease progression. Two experienced progression at the first follow-up, and 5 had local recurrence from disease outside the GKRS volume. Nineteen patients were assessed for symptom palliation with a median follow-up duration of 10.4 months (range 3.0-34.4 months). At 3 months after GKRS, the NRS scores (n = 19) decreased from 4.65 ± 3.45 to 1.47 ± 2.11 (p < 0.001); MDASI-HN pain scores (n = 13) decreased from 5.02 ± 1.68 to 2.02 ± 1.54 (p < 0.01); scheduled FED (n = 19) decreased from 62.4 ± 102.1 to 27.9 ± 45.5 mcg/hr (p < 0.01); PRN OMED (n = 19) decreased from 43.9 ± 77.5 to 10.9 ± 20.8 mg/day (p = 0.02); and frequency of any PRN analgesic use (n = 19) decreased from 0.49 ± 0.55 to 1.33 ± 0.90 per day (p = 0.08). At 6 months after GKRS, 9 (56%) of 16 patients reported being pain free (NRS score 0), with 6 (67%) of the 9 being both pain free and not requiring analgesic medications. One patient treated early in our experience developed a temporary increase in trigeminal pain 3-4 days after GKRS requiring hospitalization. All subsequently treated patients were given a single dose of intravenous steroids immediately after GKRS followed by a 2-3-week oral steroid taper. No further cases of increased or new pain after treatment were observed after this intervention. CONCLUSIONS: GKRS for palliation of trigeminal pain secondary to recurrent malignant skull base tumors demonstrated a significant decrease in patient-reported pain and opioid requirement. Additional patients and a longer follow-up duration are needed to assess durability of symptom relief and local control.
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Radiocirugia/métodos , Neoplasias de la Base del Cráneo/complicaciones , Neuralgia del Trigémino/etiología , Neuralgia del Trigémino/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/uso terapéutico , Dolor Irruptivo/tratamiento farmacológico , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Dolor de Cuello/etiología , Dolor de Cuello/cirugía , Recurrencia Local de Neoplasia , Dimensión del Dolor , Cuidados Paliativos , Dosis de Radiación , Esteroides/uso terapéutico , Resultado del Tratamiento , Neuralgia del Trigémino/tratamiento farmacológicoRESUMEN
OBJECTIVEThe aim of this study was to create prediction models for outcome parameters by decision tree analysis based on clinical and laboratory data in patients with aneurysmal subarachnoid hemorrhage (aSAH).METHODSThe database consisted of clinical and laboratory parameters of 548 patients with aSAH who were admitted to the Neurocritical Care Unit, University Hospital Zurich. To examine the model performance, the cohort was randomly divided into a derivation cohort (60% [n = 329]; training data set) and a validation cohort (40% [n = 219]; test data set). The classification and regression tree prediction algorithm was applied to predict death, functional outcome, and ventriculoperitoneal (VP) shunt dependency. Chi-square automatic interaction detection was applied to predict delayed cerebral infarction on days 1, 3, and 7.RESULTSThe overall mortality was 18.4%. The accuracy of the decision tree models was good for survival on day 1 and favorable functional outcome at all time points, with a difference between the training and test data sets of < 5%. Prediction accuracy for survival on day 1 was 75.2%. The most important differentiating factor was the interleukin-6 (IL-6) level on day 1. Favorable functional outcome, defined as Glasgow Outcome Scale scores of 4 and 5, was observed in 68.6% of patients. Favorable functional outcome at all time points had a prediction accuracy of 71.1% in the training data set, with procalcitonin on day 1 being the most important differentiating factor at all time points. A total of 148 patients (27%) developed VP shunt dependency. The most important differentiating factor was hyperglycemia on admission.CONCLUSIONSThe multiple variable analysis capability of decision trees enables exploration of dependent variables in the context of multiple changing influences over the course of an illness. The decision tree currently generated increases awareness of the early systemic stress response, which is seemingly pertinent for prognostication.
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Hemorragia Subaracnoidea/terapia , Adulto , Anciano , Algoritmos , Árboles de Decisión , Femenino , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Sistema de Registros , Hemorragia Subaracnoidea/mortalidad , Análisis de Supervivencia , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVEPetroclival meningiomas (PCMs) can cause devastating clinical symptoms due to mass effect on cranial nerves (CNs); thus, patients harboring these tumors need treatment. Many neurosurgeons advocate for microsurgery because removal of the tumor can provide relief or result in symptom disappearance. Gamma Knife radiosurgery (GKRS) is often an alternative for surgery because it can cause tumor shrinkage with improvement of symptoms. This study evaluates qualitative volumetric changes of PCM after primary GKRS and its impact on clinical symptoms.METHODSThe authors performed a retrospective study of patients with PCM who underwent primary GKRS between 2003 and 2015 at the Gamma Knife Center of the Elisabeth-Tweesteden Hospital in Tilburg, the Netherlands. This study yields 53 patients. In this study the authors concentrate on qualitative volumetric tumor changes, local tumor control rate, and the effect of the treatment on trigeminal neuralgia (TN).RESULTSLocal tumor control was 98% at 5 years and 93% at 7 years (Kaplan-Meier estimates). More than 90% of the tumors showed regression in volume during the first 5 years. The mean volumetric tumor decrease was 21.2%, 27.1%, and 31% at 1, 3, and 6 years of follow-up, respectively. Improvement in TN was achieved in 61%, 67%, and 70% of the cases at 1, 2, and 3 years of follow-up, respectively. This was associated with a mean volumetric tumor decrease of 25% at the 1-year follow-up to 32% at the 3-year follow-up.CONCLUSIONSGKRS for PCMs yields a high tumor control rate with a low incidence of neurological deficits. Many patients with TN due to PCM experienced improvement in TN after radiosurgery. GKRS achieves significant volumetric tumor decrease in the first years of follow-up and thereafter.
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Neoplasias Meníngeas/radioterapia , Meningioma/radioterapia , Radiocirugia/instrumentación , Neoplasias de la Base del Cráneo/radioterapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Neoplasias Meníngeas/patología , Meningioma/patología , Microcirugia , Persona de Mediana Edad , Países Bajos , Neoplasias de la Base del Cráneo/patología , Resultado del Tratamiento , Carga TumoralRESUMEN
OBJECTIVE Glossopharyngeal neuralgia (GPN) is a rare and disabling condition. Just as for trigeminal neuralgia, Gamma Knife radiosurgery (GKRS) is increasingly proposed as a therapeutic option for GPN. The purpose of this study was to assess long-term safety and efficacy of GKRS for this indication. METHODS From 2007 to 2015, 9 patients (4 male and 5 female) underwent a total of 10 GKRS procedures. All of the patients presented with GPN that was refractory to all medical treatment, and all had a long history of pain. One patient had previously undergone surgical microvascular decompression. In 5 cases, a neurovascular conflict had been identified on MRI. For the GKRS procedure, the glossopharyngeal nerve was localized on MRI and CT under stereotactic conditions. The target was located at the glossopharyngeal meatus of the jugular foramen. The dose administered to the nerve was 80 Gy in 3 procedures and 90 Gy in the others. Follow-up was planned for 3, 6, and 12 months after the procedure and annually thereafter. RESULTS Eight patients experienced an improvement in their pain. The median length of time from GKRS to symptom improvement in this group was 7 weeks (range 2-12 months). At the first follow-up, 6 patients were pain-free (pain intensity scores of I-III, based on an adaptation of the Barrow Neurological Institute scoring system for trigeminal neuralgia), including 4 patients who were also medication-free (I). One patient had partial improvement (IV) and 2 patients had no change. The mean duration of follow-up was 46 months (range 10-90 months). At the last follow-up 6 patients remained pain-free (pain scores of I-III), including 4 patients who were pain free with no medication (I). No side effect was observed. CONCLUSIONS Because of its safety and efficacy, GKRS appears to be a useful tool for treatment of GPN, including first-line treatment.
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Neoplasias de los Nervios Craneales/radioterapia , Enfermedades del Nervio Glosofaríngeo/radioterapia , Radiocirugia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Radiocirugia/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD), stereotactic radiosurgery (SRS), and radiofrequency ablation (RFA). Although the efficacy of each procedure has been described, few studies have directly compared these treatment modalities on pain control for TN. Using a large prospective longitudinal database, the authors aimed to 1) directly compare long-term pain control rates for first-time surgical treatments for idiopathic TN, and 2) identify predictors of pain control. METHODS The authors reviewed a prospectively collected database for all patients who underwent treatment for TN between 1997 and 2014 at the University of California, San Francisco. Standardized collection of data on preoperative clinical characteristics, surgical procedure, and postoperative outcomes was performed. Data analyses were limited to those patients who received a first-time procedure for treatment of idiopathic TN with > 1 year of follow-up. RESULTS Of 764 surgical procedures performed at the University of California, San Francisco, for TN (364 SRS, 316 MVD, and 84 RFA), 340 patients underwent first-time treatment for idiopathic TN (164 MVD, 168 SRS, and 8 RFA) and had > 1 year of follow-up. The analysis was restricted to patients who underwent MVD or SRS. Patients who received MVD were younger than those who underwent SRS (median age 63 vs 72 years, respectively; p < 0.001). The mean follow-up was 59 ± 35 months for MVD and 59 ± 45 months for SRS. Approximately 38% of patients who underwent MVD or SRS had > 5 years of follow-up (60 of 164 and 64 of 168 patients, respectively). Immediate or short-term (< 3 months) postoperative pain-free rates (Barrow Neurological Institute Pain Intensity score of I) were 96% for MVD and 75% for SRS. Percentages of patients with Barrow Neurological Institute Pain Intensity score of I at 1, 5, and 10 years after MVD were 83%, 61%, and 44%, and the corresponding percentages after SRS were 71%, 47%, and 27%, respectively. The median time to pain recurrence was 94 months (25th-75th quartiles: 57-131 months) for MVD and 53 months (25th-75th quartiles: 37-69 months) for SRS (p = 0.006). A subset of patients who had MVD also underwent partial sensory rhizotomy, usually in the setting of insignificant vascular compression. Compared with MVD alone, those who underwent MVD plus partial sensory rhizotomy had shorter pain-free intervals (median 45 months vs no median reached; p = 0.022). Multivariable regression demonstrated that shorter preoperative symptom duration (HR 1.005, 95% CI 1.001-1.008; p = 0.006) was associated with favorable outcome for MVD and that post-SRS sensory changes (HR 0.392, 95% CI 0.213-0.723; p = 0.003) were associated with favorable outcome for SRS. CONCLUSIONS In this longitudinal study, patients who received MVD had longer pain-free intervals compared with those who underwent SRS. For patients who received SRS, postoperative sensory change was predictive of favorable outcome. However, surgical decision making depends upon many factors. This information can help physicians counsel patients with idiopathic TN on treatment selection.
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Cirugía para Descompresión Microvascular , Radiocirugia , Neuralgia del Trigémino/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Dimensión del Dolor , Complicaciones Posoperatorias , Pronóstico , Estudios Prospectivos , Recurrencia , Adulto JovenRESUMEN
OBJECTIVE Although CT-guided selective percutaneous radiofrequency thermocoagulation (PRFT) via the foramen rotundum (FR) has been used in the clinic as a novel successful treatment for isolated, second division (maxillary nerve [V2]), idiopathic trigeminal neuralgia (ITN), there is only very limited related literature published to date. This report aims to provide more detail for physicians about this technique. METHODS Between March 2013 and April 2014, 20 patients with isolated V2 ITN refractory to or intolerant of drug treatment were treated by CT-guided selective PRFT via the FR at the First Affiliated Hospital of Nanchang University. The outcome of pain relief was assessed using the Barrow Neurological Institute (BNI) pain score, and grouped as good (BNI Class I or II, no medication required) and bad (BNI Class III-V, medication required or failed). Recurrence was defined as a relapse to a previous lower level after attainment of any higher level of pain relief. Adverse effects and complications were also monitored and recorded. RESULTS All patients (100%) obtained good pain relief including BNI Class I in 17 patients (85%) and BNI Class II in 3 patients (15%) immediately postoperatively. None of the patients were lost to follow-up. During the mean follow-up period of 24.3 months (range 18-30 months), 2 patients (10%) experienced recurring pain and the mean time until recurrence was 10.5 months (range 8-13 months). No adverse effects or complications occurred except for transient numbness restricted to the V2 dermatome in all patients (100%) and facial hematoma in 3 patients (15%). CONCLUSIONS In the current study, CT-guided selective PRFT via the FR not only achieved absolute selective lesioning to V2, but also helped patients attain successful pain relief with few adverse effects. These limited data suggest that CT-guided selective PRFT via the FR appears to be a feasible, safe, effective, and even relatively ideal treatment for isolated V2 ITN, but these findings need confirmation from further studies.
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Electrocoagulación , Ablación por Radiofrecuencia , Tomografía Computarizada por Rayos X , Neuralgia del Trigémino/diagnóstico por imagen , Neuralgia del Trigémino/terapia , Anciano , Electrocoagulación/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Nervio Maxilar , Persona de Mediana Edad , Manejo del Dolor/métodos , Dimensión del Dolor , Ablación por Radiofrecuencia/métodos , Recurrencia , Resultado del TratamientoRESUMEN
OBJECTIVE Feasible clinical scores for predicting shunt-dependent hydrocephalus (SDHC) after aneurysmal subarachnoid hemorrhage (aSAH) are scarce. The chronic hydrocephalus ensuing from SAH score (CHESS) was introduced in 2015 and has a high predictive value for SDHC. Although this score is easy to calculate, several early clinical and radiological factors are required. The authors designed the retrospective analysis described here for external CHESS validation and determination of predictive values for the radiographic Barrow Neurological Institute (BNI) scoring system and a new simplified combined scoring system. METHODS Consecutive data of 314 patients with aSAH were retrospectively analyzed with respect to CHESS parameters and BNI score. A new score, the shunt dependency in aSAH (SDASH) score, was calculated from independent risk factors identified with multivariate analysis. RESULTS Two hundred twenty-five patients survived the initial phase after the hemorrhage, and 27.1% of these patients developed SDHC. The SDASH score was developed from results of multivariate analysis, which revealed acute hydrocephalus (aHP), a BNI score of ≥ 3, and a Hunt and Hess (HH) grade of ≥ 4 to be independent risk factors for SDHC (ORs 5.709 [aHP], 6.804 [BNI], and 4.122 [HH]; p < 0.001). All 3 SDHC scores tested (CHESS, BNI, and SDASH) reliably predicted chronic hydrocephalus (ORs 1.533 [CHESS], 2.021 [BNI], and 2.496 [SDASH]; p ≤ 0.001). Areas under the receiver operating curve (AUROC) for CHESS and SDASH were comparable (0.769 vs 0.785, respectively; p = 0.447), but the CHESS and SDASH scores were superior to the BNI grading system for predicting SDHC (BNI AUROC 0.649; p = 0.014 and 0.001, respectively). In contrast to CHESS and BNI scores, an increase in the SDASH score coincided with a monotonous increase in the risk of developing SDHC. CONCLUSIONS The newly developed SDASH score is a reliable tool for predicting SDHC. It contains fewer factors and is more intuitive than existing scores that were shown to predict SDHC. A prospective score evaluation is needed.