[Frameless trigeminal neuralgia radiosurgery with a dedicated linear accelerator: From equipment commissioning to initial clinical results]. / Radiochirurgie des névralgies trigéminales avec accélérateur linéaire dédié sans cadre invasif : de la mise en service de l'appareil aux premiers résultats cliniques.

PURPOSE: Radiosurgery for the treatment of trigeminal neuralgia delivers a very high dose in a single fraction, over a few millimeters, at a single isocenter placed along the nerve. We present here the different steps that have been performed to validate small beams by conical collimators, and report the clinical results of the first patients treated on Novalis Tx®, frameless. MATERIAL AND METHODS: First, the geometric accuracy of 4 and 6mm conical collimators was evaluated using Winston-Lutz tests; then dosimetric data acquisition was performed using high spatial resolution detectors (PTW 60019 microdiamond and a PTW 60017 E-diode). The corrective factors of the TRS 483 report were applied to calculate the collimator aperture factors. These dosimetric data were then compared with the data implemented in the iPlan® treatment planning system. Then end-to-end tests were performed to control the entire treatment process using an anthropomorphic phantom "STEEV". Between 2020 and 2022, 18 patients were treated for refractory trigeminal neuralgia on Novalis Tx®, frameless, with Exactrac® repositioning. A total of 17 patients were evaluated (one was lost to follow-up) using the BNI score for pain assessment and MRI with a median follow-up of 12 months. RESULTS: The quality criteria of geometric and dosimetric accuracy were met for the 6-mm cone but not for the 4-mm cone. All patients were treated with a 6-mm cone with a dose of 90Gy prescribed at the isocenter at the root entry zone. Initial pain control was obtained in 70.5% of our patients, and 53% maintained pain control with a median follow-up of 12 months. All recurrences occurred within 3 to 6 months after radiosurgery. No brainstem toxicity was observed. Six patients had non-disabling facial hypoesthesia, half of whom already had pretreatment hypoesthesia. CONCLUSION: The treatment of trigeminal neuralgia on a dedicated linear accelerator is a highly technical treatment whose accuracy and safety are paramount. The physical measurements allowed the commissioning of the technique with a 6mm cone. Our first clinical results are in accordance with the literature.

Radiosurgical Decompression of Trigeminal Nerve and Its Correlation with Functional Outcome in Tumor-Related Trigeminal Neuralgia.

BACKGROUND: Target selection during Gamma Knife radiosurgery (GKRS) in cases of tumor-related trigeminal neuralgia is always debatable. We analyzed the correlation of regression of tumor size and degree of release of the nerve with long-term pain control. METHODS: Between March 2012 and March 2023, 50 cases of tumor-related trigeminal neuralgia were treated with GKRS (tumor was targeted). Radiological findings after GKRS were categorized into 3 types: 1) tumor volume remained same or decreased, additional segment of nerve not seen; 2) tumor volume decreased, additional segment of trigeminal nerve seen, but tumor still adherent to the nerve; 3) tumor volume decreased, adjacent nerve seen completely separated from tumor. Pain score before and after GKRS (Barrow Neurological Institute I-III: good; Barrow Neurological Institute IV and V: poor) was correlated with these subgroups. RESULTS: At median follow-up of 46.5 months, 18 cases showed type 1 radiological response, 23 showed type 2 response, and 9 showed type 3 response. Good pain control was achieved in 10 (55.5%) patients with type 1, 15 (65.21%) with type 2, and 7 (77.8%) with type 3 responses. The outcome differences among these 3 groups were not statistically significant (P = 0.519). Five patients with type 3 radiological response were off medication, which was statistically better than type 1 and type 2 radiological responses, with 3 patients (P = 0.012) and 2 patients (P = 0.002), respectively, still receiving medication. CONCLUSIONS: Tumor volume reduction after GKRS may be associated with good pain control in tumor-related trigeminal neuralgia. Further, this allows visualization of additional segment of nerve that can be targeted in a second session for treating recurrent or failed cases.

Long-Term Patient-Reported Outcomes of Stereotactic Radiosurgery for Trigeminal Neuralgia.

BACKGROUND: We aimed to evaluate patient-reported outcomes (PROs) of stereotactic radiosurgery (SRS) for TN in terms of treatment efficacy and toxicity. METHODS: We retrospectively analyzed patients who underwent Gamma Knife SRS for idiopathic or classic TN between January 2013 and February 2022. Questionnaires regarding pain relief, treatment toxicity, and post-SRS treatment were sent between late 2022 and early 2023, and the responses received were analyzed. The Faces Pain Scale (FPS, 0: best, 5: worst) was used for quantitative evaluation. RESULTS: Responses were received from 51 patients (76%). The mean pre-SRS FPS score was 4.1 (standard deviation (SD) 1.1). Forty-three patients (83%) reported initial pain relief and the best post-SRS FPS score was 1.1 (SD 1.5) (P < 0.001). At a median follow-up of 50 months, the FPS score was still 1.1 (SD 1.6) (P < 0.001). Analysis of factors contributing to durable pain relief showed neurovascular compression to be associated with FPS score improvement (Odds ratio 5.7, 95% CI 1.1-29.7, P = 0.038). Facial dysesthesia had a mean pre-SRS FPS score of 1.7 (SD 2.0) and a mean score of 1.4 (SD 1.7) at the last follow-up (P = 0.32). Eight patients (15%) received post-SRS interventions and 21 (40%) no longer required pharmacotherapy without post-SRS intervention. Forty-four patients (85%) reported being satisfied with SRS. CONCLUSIONS: We analyzed PROs of SRS for TN using the FPS and showed SRS to be a safe and effective treatment modality achieving long lasting pain relief.

[Stereotactic Radiosurgery for Trigeminal Neuralgia].

Stereotactic radiosurgery(SRS)performed with Gamma Knife or CyberKnife has been reported to be effective in treating trigeminal neuralgia(TN). Microvascular decompression is the first choice of treatment for patients with trigeminal neuralgia who are difficult to treat with drugs because of its high efficacy, with a pain relief rate of 70%-80% after 5 years. The pain relief rate of TN treated with SRS is approximately 50%-60% after 5 years, which is less than that of MVD. SRS is also inferior to surgery, causing more frequent sensory disturbances in the trigeminal nerve area(6%-20%). However, the serious complications, severe morbidity and mortality, associated with SRS are quite rare. SRS is an extremely minimally invasive treatment that does not require general anesthesia and can be used to treat TN with short-term hospitalization or outpatient visits.

Repeat Gamma Knife radiosurgery for recurrent trigeminal neuralgia in patients with multiple sclerosis: a single-center retrospective study.

PURPOSE: Gamma Knife radiosurgery (GKRS) has emerged as an effective treatment option for trigeminal neuralgia (TN) in patients with multiple sclerosis (MS). To date, the outcomes of repeat GKRS for patients with TN and MS with recurrent pain have been investigated in a few patients. This study aims to report the outcomes and predictive factors of pain reduction for MS patients undergoing repeat GKRS for recurrent TN. METHODS: Eighteen patients with MS underwent repeat GKRS for recurrent TN. A retrospective chart review and telephone interviews were conducted to determine background medical history, dosimetric data, and outcomes of the procedure. Facial pain and sensory function were evaluated using the Barrow Neurological Institute (BNI) scales. RESULTS: Fifteen patients achieved a BNI pain score of IIIa or better, indicating pain reduction, within a median period of 21 days after repeat GKRS. The maximum dose for repeat GKRS ranged from 70 to 85 Gy. Pain recurred in 5 patients after a median period of 12 months after GKRS. Percentages of patients with pain reduction at 1, 2, 3, 5, and 7 years were 60%, 60%, 50%, 50%, and 50%, respectively. Older age at repeat GKRS predicted sustained pain reduction (P = 0.01). Seven patients developed facial sensory disturbances, which were bothersome in two patients. CONCLUSIONS: Repeat GKRS may be used as an effective treatment modality for prolonging the duration of pain reduction time in patients with MS and TN. After repeat GKRS, facial sensory disturbances are common; however, they are often not bothersome.

Repeat CyberKnife Radiosurgery for Trigeminal Neuralgia: Outcomes and Complications.

BACKGROUND: CyberKnife radiosurgery (RS), as an initial first treatment, is recognized as an efficient and safe modality for trigeminal neuralgia (TN). However, knowledge on repeat CyberKnife RS in refractory cases is limited. The objective was to evaluate the clinical outcomes of repeat CyberKnife RS for TN. METHODS: A retrospective review of 33 patients with refractory TN treated a second time with CyberKnife RS from 2009 to 2021. The median follow-up period after the second RS was 26.0 months (range 0.3-115.8). The median dose for the repeat RS was 60 Gy (range 60.0-70.0). Pain relief after the intervention was assessed using the Barrow Neurological Institute scale for pain (I-V). Scores I to IIIb were classified as an adequate pain relief and scores IV-V were classified as a treatment failure. RESULTS: After the second RS, initial adequate pain relief was achieved in 87.9% of cases. The actuarial probabilities of maintaining an adequate pain relief at 6, 12, 24, and 36 months were 92.1%, 74.0%, 58.2%, and 58.2%, respectively. Regarding sustained pain relief, there was no significant difference between the first and the second RS. Sensory toxicity after the first RS was predictive of a better outcome following the second RS. The onset of hypesthesia rate was the same after the first or the second RS (21%). CONCLUSION: Repeat RS is an effective and safe method for the treatment of refractory TN.

Alexithymia and depression may predict treatment failure in patients undergoing Gamma Knife radiosurgery for trigeminal neuralgia: the potential contribution of colored pain drawings.

OBJECTIVE: Gamma Knife radiosurgery (GKRS) effectively achieves high rates of pain control in trigeminal neuralgia (TN); however, psychological factors can also impact how individuals perceive pain and respond to treatment. The authors aimed to measure the effects of alexithymia and depression on GKRS outcomes, as well as the potential role of colored pain drawings (CPDs) in identifying patients who require additional psychological support. METHODS: Seventy-three medically intractable, typical patients with TN were included. Participants completed a visual analog scale (VAS), the Toronto Alexithymia Scale (TAS-20), and the Turkish version of the Beck Depression Inventory-II (BDI-II). Participants used colored pens to draw their pain patterns on standardized face charts and CPDs were categorized as expected or unexpected. Based on the Barrow Neurological Institute pain scale, patients were categorized as responders or nonresponders. RESULTS: Most patients (63%) were female, and the median age was 60 (range 27-88) years. Of 73 patients, 56 (76.7%) were responders and 17 (23.3%) were nonresponders. Forty-nine patients (67.1%) had expected CPDs, whereas 24 (32.9%) had unexpected CPDs. Responder and nonresponder groups had similar ages, genders, education, comorbidities, and initial VAS scores. Both groups preferred the colors red and black to describe intense pain (79.2% vs 67.3%, p = 0.411). Significantly better pain relief was observed in patients with expected CPDs than in those with unexpected CPDs (87.8% vs 54.2%, p = 0.003). The unexpected CPD group had significantly more alexithymia (58.3% vs 32.7%, p = 0.045). The mean BDI-II score of the cohort was 26 (range 15-37) and was significantly higher in the unexpected group (28.3 vs 24.8, p = 0.028). Unexpected CPD (OR 12.540) and higher TAS-20 score (OR 3.22) increased treatment failure risk. CONCLUSIONS: The outcomes of TN treatment can be influenced by psychological factors, and patients with TN with higher total TAS-20 and BDI-II scores, along with unexpected CPDs, had an increased likelihood of treatment failure. CPDs can be accessed quickly and may allow the physician to screen out most patients with unfavorable psychometrics and proceed with the necessary treatment with appropriate psychological support.

Impact of Multiple Sclerosis Subtypes on Pain Management in Patients With Trigeminal Neuralgia After Stereotactic Radiosurgery: An International Multicenter Analysis.

BACKGROUND AND OBJECTIVES: Trigeminal neuralgia affects approximately 2% of patients with multiple sclerosis (MS) and often shows higher rates of pain recurrence after treatment. Previous studies on the effectiveness of stereotactic radiosurgery (SRS) for trigeminal neuralgia did not consider the different MS subtypes, including remitting relapsing (RRMS), primary progressive (PPMS), and secondary progressive (SPMS). Our objective was to investigate how MS subtypes are related to pain control (PC) rates after SRS. METHODS: We conducted a retrospective multicenter analysis of prospectively collected databases. Pain status was assessed using the Barrow National Institute Pain Intensity Scales. Time to recurrence was estimated through the Kaplan-Meier method and compared groups using log-rank tests. Logistic regression was used to calculate the odds ratio (OR). RESULTS: Two hundred and fifty-eight patients, 135 (52.4%) RRMS, 30 (11.6%) PPMS, and 93 (36%) SPMS, were included from 14 institutions. In total, 84.6% of patients achieved initial pain relief, with a median time of 1 month; 78.7% had some degree of pain recurrence with a median time of 10.2 months for RRMS, 8 months for PPMS, 8.1 months for SPMS ( P = .424). Achieving Barrow National Institute-I after SRS was a predictor for longer periods without recurrence ( P = .028). Analyzing PC at the last available follow-up and comparing with RRMS, PPMS was less likely to have PC (OR = 0.389; 95% CI 0.153-0.986; P = .047) and SPMS was more likely (OR = 2.0; 95% CI 0.967-4.136; P = .062). A subgroup of 149 patients did not have other procedures apart from SRS. The median times to recurrence in this group were 11.1, 9.8, and 19.6 months for RRMS, PPMS, and SPMS, respectively (log-rank, P = .045). CONCLUSION: This study is the first to investigate the relationship between MS subtypes and PC after SRS, and our results provide preliminary evidence that subtypes may influence pain outcomes, with PPMS posing the greatest challenge to pain management.

TN-RS: a novel scoring system predicts Gamma Knife Radiosurgery outcome for trigeminal neuralgia patients.

BACKGROUND: Gamma Knife Radiosurgery (GKRS) is an effective treatment option for medically refractory trigeminal neuralgia (TN). This study examines GKRS outcome in a large cohort of TN patients and highlights pretreatment factors associated with pain relief. METHODS: This is a single-center retrospective analysis of patients treated with GKRS for TN between 2011 and 2019. Pain relief was assessed at 1 year, and 2-3 years following GKRS. Multivariable analysis identified several factors that predicted pain relief. These predicting factors were applied to establish a pain relief scoring system. RESULTS: A total of 162 patients met inclusion criteria. At 1 year post-GKRS, the breakdown of Barrow Neurological Institute (BNI) score for pain relief was as follows: 77 (48%) score of I, 13 (8%) score of II, 37 (23%) score of III, 22 (14%) score of IV, and 13 (8%) score of V. Factors that were significantly associated with pain-free outcome at 1 year were: Typical form of TN (OR = 2.2 [1.1, 4.9], p = 0.049), No previous microvascular decompression (OR = 4.4 [1.6, 12.5], p = 0.005), Response to medical therapy (OR = 2.7 [1.1, 6.1], p = 0.018), and Seniority > 60 years (OR = 2.8 [1.4, 5.5], p = 0.003). The term "Trigeminal Neuralgia-RadioSurgery" was used to create the TN-RS acronym representing the significant factors. A stepwise increase in the median predicted probability of pain-free outcome at 1 year from 3% for patients with a score of 0 to 69% for patients with a maximum score of 4. CONCLUSION: The TN-RS scoring system can assist clinicians in identifying patients that may benefit from GNRS for TN by predicting 1-year pain-free outcomes.

Stereotactic Radiosurgery for Medically Refractory Trigeminal Neuralgia Secondary to Stroke: A Systematic Review and Clinical Case Presentation.

BACKGROUND: Trigeminal neuralgia (TN) is a paroxysmal, unilateral, brief, shock-like pain in ≥1 divisions of the trigeminal nerve. It can result from multiple causes; however, TN secondary to stroke is very rare. METHODS: We present the case of TN secondary to pontine infarction treated with incremental doses of neuropathic pain medication for >5 years before conservative management failed. He was then treated with stereotactic radiosurgery (SRS). Additionally, we conducted a systematic review using standard PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for all the cases of TN with brainstem stroke from 1976 to 2022. RESULTS: Our patient was an 82-year-old man. Magnetic resonance imaging demonstrated a pontine lesion consistent with stroke. The Barrow Neurological Institute (BNI) score at presentation was 5. He received a marginal dose of 60 Gy to the 80% isodose line in a single fraction to a volume of 0.05 cm3. The immediate post-treatment BNI score was 0 and remained at 0 for 3 months, when he experienced recurrence. The recurrence was treated with oxcarbazepine. His pain remained well controlled with a lower dose of oxcarbazepine, and he had no adverse effects at 1 year of follow-up with a BNI score of 3. The systemic review identified 21 case reports with a combined cohort of 25 patients with TN secondary to stroke. Only 3 patients were treated with SRS, 2 of whom reported symptom improvement at 6 months and 8 months of follow-up with no adverse events. CONCLUSIONS: Our case and literature review demonstrate durable and effective treatment with SRS, which can be considered a safe and effective treatment option for patients with stroke-associated TN.

A Case Series of Stereotactic Radiosurgery First for Trigeminal Neuralgia: A History of Stereotactic Radiosurgery Does Not Complicate Microvascular Decompression.

BACKGROUND AND OBJECTIVES: The influence of prior stereotactic radiosurgery (SRS) on outcomes of subsequent microvascular decompression (MVD) for patients with trigeminal neuralgia (TN) is not well understood. To directly compare pain outcomes in patients undergoing primary MVD vs those undergoing MVD with a history of 1 prior SRS procedure. METHODS: We retrospectively reviewed all patients undergoing MVD at our institution from 2007 to 2020. Patients were included if they underwent primary MVD or had a history of SRS alone before MVD. Barrow Neurological Institute (BNI) pain scores were assigned at preoperative and immediate postoperative time points and at every follow-up appointment. Evidence of pain recurrence was recorded and compared via Kaplan-Meier analysis. Multivariate Cox proportional hazards regression was used to identify factors associated with worse pain outcomes. RESULTS: Of patients reviewed, 833 met our inclusion criteria. Thirty-seven patients were in the SRS alone before MVD group, and 796 patients were in the primary MVD group. Both groups demonstrated similar preoperative and immediate postoperative BNI pain scores. There were no significant differences between average BNI at final follow-up between the groups. Multiple sclerosis (hazard ratio (HR) = 1.95), age (HR = 0.99), and female sex (HR = 1.43) independently predicted increased likelihood of pain recurrence on Cox proportional hazards analysis. SRS alone before MVD did not predict increased likelihood of pain recurrence. Furthermore, Kaplan-Meier survival analysis demonstrated no relationship between a history of SRS alone and pain recurrence after MVD ( P = .58). CONCLUSION: SRS is an effective intervention for TN that may not worsen outcomes for subsequent MVD in patients with TN.

The Use of Stereotactic Radiosurgery to Treat Functional Disorders: A Topic Discussion.

Stereotactic radiosurgery (SRS) is a well-known modality for the treatment of malignant brain tumors. SRS, however, can also be used to treat non-malignant functional disorders such as epilepsy, tremor, trigeminal neuralgia (TN), obsessive compulsive disorder (OCD), and intractable pain among others. Given the limited prospective data guiding treatment of these benign disorders, this article serves as a consolidated discussion of the application of SRS for functional ailments, hopefully serving as a reference for those considering application of this technique in clinical practice.

Effect of Non-Ablative Non-Thermal CO2 Laser on Drug-Resistant Trigeminal Neuralgia: A Pilot Study.

Background: Trigeminal neuralgia is one of the most severe pain conditions that humans experience. Drug resistance is a challenging event during treatment that results in using higher doses of drugs or referring for neurosurgical treatment. Laser therapy is also an effective method for pain control. Objective: The aim of this study was to evaluate the effect of non-ablative non-thermal CO2 laser (NANTCL) on reducing pain in patients with drug-resistant trigeminal neuralgia (DRTN) for the very first time. Materials and methods: Twenty-four patients with DRTN were randomly divided into laser and placebo groups. Patients in the laser group received NANTCL (10,600 nm, 1.1 W, 100 HZ, 20 sec) on trigger points that were covered with lubricant gel 3 days in a week for 2 weeks. The placebo group received sham laser. The patients were requested to grade their pain on a visual analog scale (VAS) immediately, 1 week, 1 month, and 3 months after treatment. Results: In the laser group, the results revealed a significant decrease between the initial pain and the pain in all follow-up sessions. Only in three patients, 3 months after completion of laser therapy, pain returned to the initial level. In the control group, a significant difference was seen only between the pain of baseline and final session of laser irradiation. In laser group, the mean of pain (VAS) was lower than the placebo group in all follow-up sessions; however, it was only significant for 1 week after laser therapy. Conclusions: This study revealed that short-period application of NANTCL is effective for pain relief in patients with DRTN, especially those with extraoral trigger points. Clinical trial registration number: IRCT2013052113406N1.

Radiosurgery for classical trigeminal neuralgia: impact of the shot size on clinical outcome.

BACKGROUND: This study compares the outcome of patients suffering from medically refractory classical trigeminal neuralgia (TN) after treatment with radiosurgery using two different shot sizes (5- and 6-mm). METHODS: All patients included in this open, prospective, non-controlled study were treated in a single institution for TN (95 cases in 93 patients) with LINear ACcelerators (LINAC) single-dose radiosurgery using a 5-mm shot (43 cases) or 6-mm shot (52 cases). The target was positioned on the intracisternal part of the trigeminal nerve. RESULTS: The mean Dmax (D0.035) to the brainstem was higher in the 6-mm group: 12.6 vs 21.3 Gy (p < 0.001). Pain relief was significantly better in the 6-mm group: at 12 and 24 months in the 6-mm group the rate of pain-free patients was 90.2 and 87.8%, respectively vs. 73.6 and 73.6% in the 5-mm group (p = 0.045). At 12 and 24 months post-radiosurgical hypoesthesia was more frequent in the 6-mm group: 47.0 and 58% vs.11.3 and 30.8% in the 5-mm group (p = 0.002). To investigate the effect of cone diameter and the dose to the brainstem on outcomes, patients were stratified into three groups: group 1 = 5-mm shot, (all Dmax < 25 Gy, 43 cases), group 2 = 6-mm shot, Dmax < 25 Gy (32 cases), group 3 = 6-mm shot Dmax > 25 Gy (20 cases). At 12 months the rates of hypoesthesia were 11.3, 33.5 and 76.0%, respectively in groups 1, 2 and 3 (p < 0.001) and the rates of recurrence of pain were 26.4, 16.5 and 5%, respectively, (p = 0.11). CONCLUSION: LINAC treatment with a 6-mm shot provided excellent control of pain, but increased the rate of trigeminal nerve dysfunction, especially when the maximum dose to the brainstem was higher than 25 Gy.

Long-Term Efficacy of Gamma Knife Radiosurgery on Pain Control in Trigeminal Neuralgia.

AIM: To investigate the efficacy of Gamma Knife radiosurgery (GKRS) in patients with Burchiel type 1 and 2 trigeminal neuralgia (TN). MATERIAL AND METHODS: A retrospective analysis of prospectively collected data of 163 patients who underwent GKRS between December 2006 and December 2021 was performed. The median follow-up was 37 (range, 6-168) months. The target was the cisternal portion of the trigeminal nerve, and the median prescribed dose was 85 (range, 75-90) Gy. Pain severity was evaluated using the Barrow Neurological Institute (BNI) pain intensity score. All patients had BNI IV or V before GKRS. BNI IIIb or better was defined as adequate pain relief. Logistic regression analysis was conducted to determine the prognostic significance of different pretreatment and treatment variables. RESULTS: The initial pain relief rate was 85%, with a median period of 25 (range, 1-90) days. At the final follow-up, 62.5% of patients had adequate pain relief. BNI I was achieved in 8% of patients within the first 24 h after GKRS; this rate was 22% at the final follow-up. The pain-free interval was significantly shorter in the 75 Gy group than in the 90 Gy group (p=0.04). The predicted adequate pain relief rates at the 3rd and 6th month and 1st, 3rd, 5th, and 7th year were 84%, 79%, 76%, 67%, 59%, and 55%, respectively. The complication rate was 8%, with disturbing facial sensorial dysfunction in four patients, decreased corneal reflex in three patients, and masseter dysfunction in six patients. Univariate and multivariate logistic regression analyses revealed Burchiel type 1 TN (p=0.001) and male gender (p=0.037) as predictors of increased initial pain relief rate and shorter time to initial pain relief day, respectively. CONCLUSION: Appropriate patient selection is the key to successful TN treatment. GKRS can be recommended, especially for patients with Burchiel type 1 TN, with low complication rates and effective long-term pain relief.

Gamma Knife Radiosurgery Targeting the Trigeminal Nerve for Tumor-Related Trigeminal Neuralgia: A Case Series.

BACKGROUND: Tumor-related trigeminal neuralgia (TN) is a challenging condition to manage that is commonly treated by surgical resection of the tumor. Stereotactic radiosurgery targeting the tumor is used to control pain and tumor growth in patients unsuitable for surgery. Stereotactic radiosurgery targeting the trigeminal nerve has been explored as a viable treatment for patients with tumor-related TN who are unsuitable for surgical removal of the tumor or whose pain is refractory to radiation therapy targeting the tumor. Information regarding the efficacy of this procedure is limited to only a few studies. We report the outcomes of Leskell Gamma Knife radiosurgery (GKRS) targeting the trigeminal nerve for tumor-related TN from a case series. METHODS: A retrospective review of our GKRS database identified 6 patients with unilateral tumor-related TN treated with GKRS targeting the trigeminal nerve between 2014 and 2020. Five patients had undergone previous radiation therapy targeting the tumor. Facial pain and sensory function were evaluated using the Barrow Neurological Institute scales. RESULTS: Three patients achieved a Barrow Neurological Institute score of IIIb or better, indicating pain reduction, within a mean period of 4.3 months after GKRS. The maximum dose for GKRS ranged from 80 to 88 Gy. Pain recurred in 1 patient at 64 months after GKRS. No patient developed permanent facial sensory disturbances. No adverse event was recorded. CONCLUSIONS: GKRS targeting the trigeminal nerve could be a safe and effective treatment for a subset of patients with tumor-related TN who are unsuitable for surgical removal of the tumor or whose pain is refractory to radiation therapy targeting the tumor.

Safety and Efficacy of Gamma Knife Radiosurgery for the Management of Trigeminal Neuralgia: A Retrospective and Cross-Sectional Study.

Background: Medical management is the first line of care for patients with trigeminal neuralgia (TN), and carbamazepine is the drug of choice used alone or in combination with other drugs. Gamma knife radiosurgery (GKRS) has been an established option in the management of refractory TN based on its noninvasiveness and robust safety profile. Our study aims to confirm the safety and assess the efficacy of GKRS in the management of TN. Material and Methods: A retrospective review of the patients with refractory TN treated with GKRS from 1997 to March 2019 by the senior author was carried out. Out of 194 eligible patients, detailed clinical information was not available in 41 patients. The remaining 153 patients' case files (post-GKRS cohort) were reviewed, and data obtained were collated, computed, and analyzed. An additional cross-sectional analysis was carried out telephonically in the post-GKRS cohort in January 2021 using Barrow Neurological Institute (BNI) pain scoring, to obtain the long-term efficacy of GKRS in TN. Results: The majority of the patients (96.1%) received a radiation dose of 80 Gy. At 6 months, 94.8% of patients had satisfactory response to GKRS. Follow-up ranged between 1 and 7.5 years. The recurrence rate was 9.2% and the complication rate was 4.6%. Facial numbness was the commonest complication. No mortality was reported. The cross-sectional arm of the study had a response rate of 39.2% (60 patients). Adequate pain relief (BNI I/II/IIIa/IIIb) was reported in 85% of patients. Conclusion: GKRS is a safe and effective modality of treatment for TN without any major complications. Both short-term and long-term efficacies are excellent.

Effect of electromagnetic therapy versus low-level laser therapy on diabetic patients with trigeminal neuralgia: a randomized control trial.

BACKGROUND: Trigeminal neuralgia (TN) is defined as intense, abrupt, often unilateral, stabbing, short, repeated episodes of pain in one or more distributional branches of the trigeminal nerve. AIM: To see how electromagnetic therapy (EMT) compared to low-level laser therapy (LLLT) affect TN in diabetes patients. DESIGN: This is a randomized controlled trial. SETTING: Physical therapy and Neurology Outpatients Clinics at Faculty of Physical Therapy. POPULATION: One hundred and forty diabetic patients with TN were evaluated for eligibility. As a result, 126 diabetic patients with TN were included in this trial. They were randomly divided into three equal-sized groups using random allocation software. Due to travel to another country, two patients did not complete the treatment protocol, and four opted out of the post-therapy evaluation. So, 120 volunteer diabetic patients with TN of both sexes were diagnosed for the participation in this study by a neurologist (N.=40 in each group). METHODS: For two months, participants in the control group A received the medication only (oral hypoglycemic drugs, Analgesics, vitamin B12), participants in the study group B received the medications as in group A in addition to LLLT, and participants in the study group C received medication as in group A in addition to electromagnetic therapy (EMT). The primary outcome was the amplitude of compound muscle action potentials of temporalis and masseter muscles by using NEXUS 10 (Mind media). The secondary outcome was pain intensity by using the Visual Analog Scale (VAS). RESULTS: According to the results of this study, there is a statistically significant difference in visual analog scale scores and the amplitude of compound muscle action potentials of the temporalis and masseter muscles among groups in favor of group B. CONCLUSIONS: After treatment, all groups improved significantly, with the laser group outperforming the electromagnetic group by a large margin. For irradiation, LLLT was more effective than EMT in reducing diabetic patients' trigeminal pain, and increasing masseter and temporalis muscles compound action potential amplitude in diabetic patients with TN. CLINICAL REHABILITATION IMPACT: LLLT was more effective than EMT at reducing diabetic patient's trigeminal pain, and increasing masseter and temporalis muscles compound action potential amplitude in diabetic patients with TN patients after two months of interventions.