J Korean Neurosurg Soc.  2022 Sep;65(5):633-639. 10.3340/jkns.2021.0303.

Gamma Knife Radiosurgery for Trigeminal Neuralgia : Review and Update

• Lee S
• Lee JI

• KMID: 2533026
• DOI: http://doi.org/10.3340/jkns.2021.0303

Abstract

Accurate diagnosis of trigeminal neuralgia (TN) is the starting point for optimal treatment. Gamma knife radiosurgery (GKRS) is currently regarded as one of the first-line treatment options for medically refractory TN. GKRS is a less invasive treatment with a low risk of complications than other surgical procedures that provides a favorable pain control (BNI I–IIIb) rate of >75% at short-term follow-up. Drawbacks of GKRS include the latency period before pain relief and higher recurrence rate compared with microvascular decompression. Therefore, repeat treatment is necessary if the initial GKRS was effective but followed by recurrence. The concept of dose rate and the biologically effective dose of radiation has been actively studied in radiation oncology and is also applied in GKRS for TN to achieve high safety and efficacy by prescribing the optimal dose. Recent progress in functional imaging, such as diffusion tensor imaging, enables us to understand the pathophysiology of TN and predict the clinical outcome after GKRS. Here, we review TN, GKRS, and recent updates, especially in the concepts of radiation dose, diffusion tensor imaging studies, and repeat treatment in GKRS for TN.

Keyword

Radiosurgery; Trigeminal neuralgia; Radiation dosage; Diffusion tensor imaging; Retreatment

Reference

References

1. Alexander AL, Lee JE, Lazar M, Field AS. Diffusion tensor imaging of the brain. Neurotherapeutics. 4:316–329. 2007.

2. Alpert TE, Chung CT, Mitchell LT, Hodge CJ, Montgomery CT, Bogart JA, et al. Gamma knife surgery for trigeminal neuralgia: improved initial response with two isocenters and increasing dose. J Neurosurg. 102 Suppl:185–188. 2005.

3. Arai Y, Kano H, Lunsford LD, Novotny J Jr, Flickinger JC, et al. Does the Gamma Knife dose rate affect outcomes in radiosurgery for trigeminal neuralgia? J Neurosurg. 113 Suppl:168–171. 2010.

4. Aubuchon AC, Chan MD, Lovato JF, Balamucki CJ, Ellis TL, Tatter SB, et al. Repeat gamma knife radiosurgery for trigeminal neuralgia. Int J Radiat Oncol Biol Phys. 81:1059–1065. 2011.

5. Balamucki CJ, Stieber VW, Ellis TL, Tatter SB, Deguzman AF, McMullen KP, et al. Does dose rate affect efficacy? The outcomes of 256 gamma knife surgery procedures for trigeminal neuralgia and other types of facial pain as they relate to the half-life of cobalt. J Neurosurg. 105:730–735. 2006.

6. Barker FG 2nd, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med. 334:1077–1083. 1996.

7. Barzaghi LR, Albano L, Scudieri C, Gigliotti CR, Del Vecchio A, Mortini P. Factors affecting long-lasting pain relief after Gamma knife radiosurgery for trigeminal neuralgia: a single institutional analysis and literature review. Neurosurg Rev. 44:2797–2808. 2021.

8. Baschnagel AM, Cartier JL, Dreyer J, Chen PY, Pieper DR, Olson RE, et al. Trigeminal neuralgia pain relief after gamma knife stereotactic radiosurgery. Clin Neurol Neurosurg. 117:107–111. 2014.

9. Behan B, Chen DQ, Sammartino F, DeSouza DD, Wharton-Shukster E, Hodaie M. Comparison of diffusion-weighted MRI reconstruction methods for visualization of cranial nerves in posterior fossa surgery. Front Neurosci. 11:554. 2017.

10. Brisman R. Repeat gamma knife radiosurgery for trigeminal neuralgia. Stereotact Funct Neurosurg. 81:43–49. 2003.

11. Chen DQ, DeSouza DD, Hayes DJ, Davis KD, O'Connor P, Hodaie M. Diffusivity signatures characterize trigeminal neuralgia associated with multiple sclerosis. Mult Scler. 22:51–63. 2016.

12. Danyluk H, Sankar T, Beaulieu C. High spatial resolution nerve-specific DTI protocol outperforms whole-brain DTI protocol for imaging the trigeminal nerve in healthy individuals. NMR Biomed. 34:e4427. 2021.

13. DeSouza DD, Hodaie M, Davis KD. Abnormal trigeminal nerve microstructure and brain white matter in idiopathic trigeminal neuralgia. Pain. 155:37–44. 2014.

14. Dhople AA, Adams JR, Maggio WW, Naqvi SA, Regine WF, Kwok Y. Long-term outcomes of Gamma knife radiosurgery for classic trigeminal neuralgia: implications of treatment and critical review of the literature. Clinical article. J Neurosurg. 111:351–358. 2009.

15. Dvorak T, Finn A, Price LL, Mignano JE, Fitzek MM, Wu JK, et al. Retreatment of trigeminal neuralgia with Gamma knife radiosurgery: is there an appropriate cumulative dose? Clinical article. J Neurosurg. 111:359–364. 2009.

16. Erbay SH, Bhadelia RA, Riesenburger R, Gupta P, O'Callaghan M, Yun E, et al. Association between neurovascular contact on MRI and response to Gamma knife radiosurgery in trigeminal neuralgia. Neuroradiology. 48:26–30. 2006.

17. Flickinger JC, Pollock BE, Kondziolka D, Phuong LK, Foote RL, Stafford SL, et al. Does increased nerve length within the treatment volume improve trigeminal neuralgia radiosurgery? A prospective double-blind, randomized study. Int J Radiat Oncol Biol Phys. 51:449–454. 2001.

18. Fountas KN, Lee GP, Smith JR. Outcome of patients undergoing gamma knife stereotactic radiosurgery for medically refractory idiopathic trigeminal neuralgia: Medical College of Georgia's experience. Stereotact Funct Neurosurg. 84:88–96. 2006.

19. Gellner V, Kurschel S, Kreil W, Holl EM, Ofner-Kopeinig P, Unger F. Recurrent trigeminal neuralgia: long term outcome of repeat Gamma knife radiosurgery. J Neurol Neurosurg Psychiatry. 79:1405–1407. 2008.

20. Hasegawa T, Kondziolka D, Spiro R, Flickinger JC, Lunsford LD. Repeat radiosurgery for refractory trigeminal neuralgia. Neurosurgery. 50:494–500. discussion 500-502. 2002.

21. Helis CA, Hughes RT, Munley MT, Bourland JD, Jacobson T, Lucas JT, et al. Results of a third Gamma knife radiosurgery for trigeminal neuralgia. J Neurosurg. 134:1237–1243. 2020.

22. Helis CA, Lucas JT Jr, Bourland JD, Chan MD, Tatter SB, Laxton AW. Repeat radiosurgery for trigeminal neuralgia. Neurosurgery. 77:755–761. discussion 761. 2015.

23. Herman JM, Petit JH, Amin P, Kwok Y, Dutta PR, Chin LS. Repeat gamma knife radiosurgery for refractory or recurrent trigeminal neuralgia: treatment outcomes and quality-of-life assessment. Int J Radiat Oncol Biol Phys. 59:112–116. 2004.

24. Herweh C, Kress B, Rasche D, Tronnier V, Tröger J, Sartor K, et al. Loss of anisotropy in trigeminal neuralgia revealed by diffusion tensor imaging. Neurology. 68:776–778. 2007.

25. Hodaie M, Chen DQ, Quan J, Laperriere N. Tractography delineates microstructural changes in the trigeminal nerve after focal radiosurgery for trigeminal neuralgia. PLoS One. 7:e32745. 2012.

26. Huang CF, Chuang JC, Tu HT, Chou MC. Microsurgical outcomes after failed repeated Gamma Knife surgery for refractory trigeminal neuralgia. J Neurosurg. 105 Suppl:117–119. 2006.

27. Hung PS, Chen DQ, Davis KD, Zhong J, Hodaie M. Predicting pain relief: use of pre-surgical trigeminal nerve diffusion metrics in trigeminal neuralgia. Neuroimage Clin. 15:710–718. 2017.

28. Hung PS, Tohyama S, Zhang JY, Hodaie M. Temporal disconnection between pain relief and trigeminal nerve microstructural changes after Gamma knife radiosurgery for trigeminal neuralgia. J Neurosurg. 133:727–735. 2019.

29. Kim YH, Kim DG, Kim JW, Kim YH, Han JH, Chung HT, et al. Is it effective to raise the irradiation dose from 80 to 85 Gy in Gamma knife radiosurgery for trigeminal neuralgia? Stereotact Funct Neurosurg. 88:169–176. 2010.

30. Kimball BY, Sorenson JM, Cunningham D. Repeat Gamma knife surgery for trigeminal neuralgia: long-term results. J Neurosurg. 113 Suppl:178–183. 2010.

31. Kondziolka D, Flickinger JC, Lunsford LD, Habeck M. Trigeminal neuralgia radiosurgery: the University of Pittsburgh experience. Stereotact Funct Neurosurg 66 Suppl. 1:343–348. 1996.

32. Kondziolka D, Lunsford LD, Flickinger JC, Young RF, Vermeulen S, Duma CM, et al. Stereotactic radiosurgery for trigeminal neuralgia: a multiinstitutional study using the gamma unit. J Neurosurg. 84:940–945. 1996.

33. Kondziolka D, Zorro O, Lobato-Polo J, Kano H, Flannery TJ, Flickinger JC, et al. Gamma knife stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg. 112:758–765. 2010.

34. Leal PRL, Roch JA, Hermier M, Souza MAN, Cristino-Filho G, Sindou M. Structural abnormalities of the trigeminal root revealed by diffusion tensor imaging in patients with trigeminal neuralgia caused by neurovascular compression: a prospective, double-blind, controlled study. Pain. 152:2357–2364. 2011.

35. Lee JY, Sandhu S, Miller D, Solberg T, Dorsey JF, Alonso-Basanta M. Higher dose rate Gamma knife radiosurgery may provide earlier and longer-lasting pain relief for patients with trigeminal neuralgia. J Neurosurg. 123:961–968. 2015.

36. Leksell L. The stereotaxic method and radiosurgery of the brain. Acta Chir Scand. 102:316–319. 1951.

37. Lindquist C, Kihlström L, Hellstrand E. Functional neurosurgery--a future for the Gamma knife? Stereotact Funct Neurosurg. 57:72–81. 1991.

38. Linskey ME, Ratanatharathorn V, Peñagaricano J. A prospective cohort study of microvascular decompression and Gamma knife surgery in patients with trigeminal neuralgia. J Neurosurg. 109 Suppl:160–172. 2008.

39. Longhi M, Rizzo P, Nicolato A, Foroni R, Reggio M, Gerosa M. Gamma knife radiosurgery for trigeminal neuralgia: results and potentially predictive parameters--part I: idiopathic trigeminal neuralgia. Neurosurgery. 61:1254–1260. discussion 1260-1261. 2007.

40. Lucas JT Jr, Nida AM, Isom S, Marshall K, Bourland JD, Laxton AW, et al. Predictive nomogram for the durability of pain relief from Gamma knife radiation surgery in the treatment of trigeminal neuralgia. Int J Radiat Oncol Biol Phys. 89:120–126. 2014.

41. Marshall K, Chan MD, McCoy TP, Aubuchon AC, Bourland JD, McMullen KP, et al. Predictive variables for the successful treatment of trigeminal neuralgia with gamma knife radiosurgery. Neurosurgery. 70:566–572. discussion 572-573. 2012.

42. Matsuda S, Serizawa T, Nagano O, Ono J. Comparison of the results of 2 targeting methods in Gamma Knife surgery for trigeminal neuralgia. J Neurosurg. 109 Suppl:185–189. 2008.

43. Mendelson ZS, Velagala JR, Kohli G, Heir GM, Mammis A, Liu JK. Painfree outcomes and durability of surgical intervention for trigeminal neuralgia: a comparison of gamma knife and microvascular decompression. World Neurosurg. 112:e732–e746. 2018.

44. O'Donnell LJ, Westin CF. An introduction to diffusion tensor image analysis. Neurosurg Clin N Am. 22:185–196. viii. 2011.

45. Omar NB, Amburgy JW, Self DM, Christen AM, Larios EA, Ditty BJ, et al. Repeat gamma knife stereotactic radiosurgery in the treatment of trigeminal neuralgia: a single-center experience and focused review of the literature. J Clin Neurosci. 70:102–107. 2019.

46. Park KJ, Kondziolka D, Berkowitz O, Kano H, Novotny J Jr, Niranjan A, et al. Repeat gamma knife radiosurgery for trigeminal neuralgia. Neurosurgery. 70:295–305. discussion 305. 2012.

47. Park SH, Hwang SK, Kang DH, Park J, Hwang JH, Sung JK. The retrogasserian zone versus dorsal root entry zone: comparison of two targeting techniques of Gamma knife radiosurgery for trigeminal neuralgia. Acta Neurochir (Wien). 152:1165–1170. 2010.

48. Pollock BE, Foote RL, Link MJ, Stafford SL, Brown PD, Schomberg PJ. Repeat radiosurgery for idiopathic trigeminal neuralgia. Int J Radiat Oncol Biol Phys. 61:192–195. 2005.

49. Pollock BE, Foote RL, Stafford SL, Link MJ, Gorman DA, Schomberg PJ. Results of repeated gamma knife radiosurgery for medically unresponsive trigeminal neuralgia. J Neurosurg 93 Suppl. 3:162–164. 2000.

50. Pollock BE, Phuong LK, Gorman DA, Foote RL, Stafford SL. Stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg. 97:347–353. 2002.

51. Rand RW, Jacques DB, Melbye RW, Copcutt BG, Levenick MN, Fisher MR. Leksell Gamma knife treatment of tic douloureux. Stereotact Funct Neurosurg 61 Suppl. 1:93–102. 1993.

52. Régis J, Tuleasca C, Resseguier N, Carron R, Donnet A, Gaudart J, et al. Long-term safety and efficacy of Gamma knife surgery in classical trigeminal neuralgia: a 497-patient historical cohort study. J Neurosurg. 124:1079–1087. 2016.

53. Régis J, Tuleasca C, Resseguier N, Carron R, Donnet A, Yomo S, et al. The very long-term outcome of radiosurgery for classical trigeminal neuralgia. Stereotact Funct Neurosurg. 94:24–32. 2016.

54. Shaya M, Jawahar A, Caldito G, Sin A, Willis BK, Nanda A. Gamma knife radiosurgery for trigeminal neuralgia: a study of predictors of success, efficacy, safety, and outcome at LSUHSC. Surg Neurol. 61:529–534. discussion 534-535. 2004.

55. Sheehan J, Pan HC, Stroila M, Steiner L. Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors. J Neurosurg. 102:434–441. 2005.

56. Shetter AG, Rogers CL, Ponce F, Fiedler JA, Smith K, Speiser BL. Gamma knife radiosurgery for recurrent trigeminal neuralgia. J Neurosurg. 97(5 Suppl):536–538. 2002.

57. Smith DR, Saadatmand HJ, Wu CC, Black PJ, Wuu YR, Lesser J, et al. Treatment outcomes and dose rate effects following Gamma knife stereotactic radiosurgery for vestibular schwannomas. Neurosurgery. 85:E1084–E1094. 2019.

58. Song SK, Sun SW, Ju WK, Lin SJ, Cross AH, Neufeld AH. Diffusion tensor imaging detects and differentiates axon and myelin degeneration in mouse optic nerve after retinal ischemia. Neuroimage. 20:1714–1722. 2003.

59. Song SK, Sun SW, Ramsbottom MJ, Chang C, Russell J, Cross AH. Dysmyelination revealed through MRI as increased radial (but unchanged axial) diffusion of water. Neuroimage. 17:1429–1436. 2002.

60. Song SK, Yoshino J, Le TQ, Lin SJ, Sun SW, Cross AH, et al. Demyelination increases radial diffusivity in corpus callosum of mouse brain. Neuroimage. 26:132–140. 2005.

61. Tempel ZJ, Chivukula S, Monaco EA 3rd, Bowden G, Kano H, Niranjan A, et al. The results of a third Gamma knife procedure for recurrent trigeminal neuralgia. J Neurosurg. 122:169–179. 2015.

62. Tohyama S, Walker MR, Zhang JY, Cheng JC, Hodaie M. Brainstem trigeminal fiber microstructural abnormalities are associated with treatment response across subtypes of trigeminal neuralgia. Pain. 162:1790–1799. 2021.

63. Tuleasca C, Paddick I, Hopewell JW, Jones B, Millar WT, Hamdi H, et al. Establishment of a therapeutic ratio for Gamma knife radiosurgery of trigeminal neuralgia: the critical importance of biologically effective dose versus physical dose. World Neurosurg. 134:e204–e213. 2020.

64. Tuleasca C, Régis J, Sahgal A, De Salles A, Hayashi M, Ma L, et al. Stereotactic radiosurgery for trigeminal neuralgia: a systematic review. J Neurosurg. 130:733–757. 2018.

65. Wang DD, Raygor KP, Cage TA, Ward MM, Westcott S, Barbaro NM, et al. Prospective comparison of long-term pain relief rates after first-time microvascular decompression and stereotactic radiosurgery for trigeminal neuralgia. J Neurosurg. 128:68–77. 2018.

66. Wang JY, Bender MT, Bettegowda C. Percutaneous procedures for the treatment of trigeminal neuralgia. Neurosurg Clin N Am. 27:277–295. 2016.

67. Xu Z, Schlesinger D, Moldovan K, Przybylowski C, Sun X, Lee CC, et al. Impact of target location on the response of trigeminal neuralgia to stereotactic radiosurgery. J Neurosurg. 120:716–724. 2014.

68. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 38:p. 1–211. 2018.