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ABSTRACT: BACKGROUND AND PURPOSE: The best management of patients with unruptured brain arteriovenous malformations (BAVM) is controversial. In this study, we analyzed the stroke rate and functional outcomes of patients having stereotactic radiosurgery (SRS) for unruptured BAVM using the same eligibility criteria and primary end points as the ARUBA trial. METHODS: Retrospective observational study of 174 ARUBA-eligible patients having SRS from 1990 to 2005. RESULTS: The median follow-up after SRS was 64 months. Fifteen patients (8.7%) had a hemorrhagic stroke at a median of 21 months after SRS. Six patients (3.5%) had a focal neurological deficit and 4 patients died (2.3%). The risk of stroke or death was 10.3% at 5 years and 11.5% at 10 years. Twelve additional patients (6.9%) had a focal neurological deficit from either radiation-related complications (n=7) or subsequent resection (n=5). The risk of patients' having clinical impairment (modified Rankin Score ≥2) was 8.4% at 5 years and 12.0% at 10 years. Increasing BAVM volume was associated with both stroke or death (hazard ratio=1.06; 95% confidence interval, 1.0-1.11; P=0.04) and clinical impairment (hazard ratio=1.06; 95% confidence interval, 1.01-1.09; P=0.01). The 10-year risk of stroke or death and clinical impairment for patients with BAVM ≤5.6 cm(3) was 5% and 4%, respectively. CONCLUSIONS: The observed risk of stroke or death after SRS was approximately 2% per year for the first 5 years after SRS, declining to 0.2% annually for years 6 to 10. Patients with small volume BAVM may benefit from SRS compared with the natural history of unruptured BAVM over the planned follow-up interval of the ARUBA trial (5-10 years).
Stroke 01/2013; · 5.73 Impact Factor
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ABSTRACT: BACKGROUND:: Esthesioneuroblastoma (ENB) is a rare malignant neuroendocrine tumor considered to be radiation-sensitive. Local recurrence may be treated in a variety of ways, including stereotactic radiosurgery (SRS); however, there is little available information about its effectiveness. OBJECTIVE:: We hypothesize SRS is effective in providing local control for recurrent ENB. METHODS:: This was a retrospective single institutional experience, including 109 patients with ENB treated at our institution (1962-2009). Sixty-three patients presented with Kadish stage C disease, and 21 patients developed local recurrence. Of these 21, 7 underwent SRS at our institution and an additional patient underwent SRS after transnasal biopsy. Therefore, a total of 8 patients are reported. RESULTS:: The median age at time of local recurrence was 50 years. All patients had Kadish C disease at initial diagnosis. Six of 8 patients were found to have Hyams' grade 3 disease; the remaining 2 had grade 2. The median treatment volume was 8.4 cm (mean: 18.9 cm, range 1.4 - 76.3 cm), and the median dose to the tumor margin was 15 Gy (mean 14.4 ± 2.2 Gy, range: 10- 18 Gy). Of the 16 treatments, 13 had adequate follow-up to assess treatment response, with 92% achieving local control over a median follow-up of 42 months from the time of SRS. Five lesions decreased in size, 7 stabilized, and only 1 had in-field progression. There were no documented complications secondary to SRS. CONCLUSION:: SRS appears to be a reasonable and safe option for treatment of intracranial recurrence of ENB.
Neurosurgery 11/2012; · 2.79 Impact Factor
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ABSTRACT: Object The goals of this retrospective cohort study were as follows: 1) to describe the long-term prevalence and timing of hearing deterioration following low-dose (12- to 13-Gy marginal dose) stereotactic radiosurgery (SRS) for vestibular schwannoma (VS); and 2) to identify clinical variables associated with long-term preservation of useful hearing following treatment. Methods Patients with serviceable hearing who underwent SRS for VS between 1997 and 2002 were studied. Data including radiosurgery treatment plans, tumor characteristics, pre- and posttreatment pure tone average, speech discrimination scores, and American Academy of Otolaryngology-Head and Neck Surgery hearing class were collected. Time to nonserviceable hearing was estimated using the Kaplan-Meier method. Univariate and multivariate associations with time to nonserviceable hearing were evaluated using Cox proportional hazards regression models. Results Forty-four patients met the study criteria and were included. The median duration of audiometric follow-up was 9.3 years. Thirty-six patients developed nonserviceable hearing at a mean of 4.2 years following SRS. The Kaplan-Meier estimated rates of serviceable hearing at 1, 3, 5, 7, and 10 years following SRS were 80%, 55%, 48%, 38%, and 23%, respectively. Multivariate analysis revealed that pretreatment ipsilateral pure tone average (p < 0.001) and tumor size (p = 0.009) were statistically significantly associated with time to nonserviceable hearing. Conclusions Durable hearing preservation a decade after low-dose SRS for VS occurs in less than one-fourth of patients. Variables including preoperative hearing capacity and tumor size may be used to predict hearing outcomes following treatment. These findings may assist in pretreatment risk disclosure. Furthermore, these data demonstrate the importance of long-term follow-up when reporting audiometric outcomes following SRS for VS.
Journal of Neurosurgery 10/2012; · 2.96 Impact Factor
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ABSTRACT: : Microvascular decompression (MVD) is the accepted surgical treatment of choice for patients with idiopathic trigeminal neuralgia (TN). The role of MVD in patients with multiple sclerosis (MS)-related TN is controversial.
: Between July 1999 until January 2011, 9 patients (5 men, 4 women) having both areas of increased signal in the trigeminal pathways on long-TR imaging and neurovascular compression demonstrated on pre-operative MRI underwent MVD. All of the patients had failed medical therapy and no patient had other symptoms or signs of MS. One patient had failed prior percutaneous surgery; one patient had Burchiel Type 2 TN. Follow-up (median, 15 months) was censored at the time of additional surgery (n = 6) or last clinic visit (n = 3).
: The patients were similar with regard to age, gender, and pain duration compared to 350 patients with idiopathic TN having a MVD over the same time interval. At surgery, neurovascular compression was from the superior cerebellar artery (SCA) plus adjacent vein (n = 4), venous alone (n = 3), SCA alone (n = 1), and SCA plus anterior inferior cerebellar artery (n = 1). Initially, 7 patients (78%) were pain-free and able to discontinue medication use for TN. Five patients developed recurrent pain at a median of 5 months after surgery (range, 2-23). The actuarial rate of being pain-free without medications was 57% at 3-months and 17% at 2-years. Six patients underwent 9 additional operations including glycerol rhizotomy (n = 4), radiosurgery (n = 2), balloon compression (n = 2), and repeat MVD (n = 1). Five of these 6 patients were pain-free at last contact.
: The facial pain outcomes after MVD in patients suspected to have MS-related TN are worse compared to patients with idiopathic TN. These results support the hypothesis of a central mechanism of pain production for some patients with suspected or proven MS-related TN.
Neurosurgery 08/2012; 71(2):E577. · 2.79 Impact Factor
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ABSTRACT: Stereotactic radiosurgery (SRS) of benign intracranial meningiomas is an accepted management option for well-selected patients.
To analyze patients who had single-fraction SRS for benign intracranial meningiomas to determine factors associated with tumor control and neurologic complications.
Retrospective review was performed of 416 patients (304 women/112 men) who had single-fraction SRS for imaging defined (n = 252) or confirmed World Health Organization grade I (n = 164) meningiomas from 1990 to 2008. Excluded were patients with radiation-induced tumors, multiple meningiomas, neurofibromatosis type 2, and previous or concurrent radiotherapy. The majority of tumors (n = 337; 81%) involved the cranial base or tentorium. The median tumor volume was 7.3 cm; the median tumor margin dose was 16 Gy. The median follow-up was 60 months.
The disease-specific survival rate was 97% at 5 years and 94% at 10 years. The 5- and 10-year local tumor control rate was 96% and 89%, respectively. Male sex (hazard ratio [HR]: 2.5, P = .03), previous surgery (HR: 6.9, P = .002) and patients with tumors located in the parasagittal/falx/convexity regions (HR: 2.8, P = .02) were negative risk factors for local tumor control. In 45 patients (11%) permanent radiation-related complications developed at a median of 9 months after SRS. The 1- and 5-year radiation-related complication rate was 6% and 11%, respectively. Risk factors for permanent radiation-related complication rate were increasing tumor volume (HR: 1.05, P = .008) and patients with tumors of the parasagittal/falx/convexity regions (HR: 3.0, P = .005).
Single-fraction SRS at the studied dose range provided a high rate of tumor control for patients with benign intracranial meningiomas. Patients with small volume, nonoperated cranial base or tentorial meningiomas had the best outcomes after single-fraction SRS.
Neurosurgery 06/2012; 71(3):604-12; discussion 613. · 2.79 Impact Factor
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World Neurosurgery 06/2012; · 0.68 Impact Factor
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Jason P Sheehan,
Shota Tanaka,
Michael J Link, Bruce E Pollock,
Douglas Kondziolka,
David Mathieu,
Christopher Duma,
A Byron Young,
Anthony M Kaufmann,
Heyoung McBride,
Peter A Weisskopf,
Zhiyuan Xu,
Hideyuki Kano,
Huai-che Yang,
L Dade Lunsford
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ABSTRACT: Glomus tumors are rare skull base neoplasms that frequently involve critical cerebrovascular structures and lower cranial nerves. Complete resection is often difficult and may increase cranial nerve deficits. Stereotactic radiosurgery has gained an increasing role in the management of glomus tumors. The authors of this study examine the outcomes after radiosurgery in a large, multicenter patient population.
Under the auspices of the North American Gamma Knife Consortium, 8 Gamma Knife surgery centers that treat glomus tumors combined their outcome data retrospectively. One hundred thirty-four patient procedures were included in the study (134 procedures in 132 patients, with each procedure being analyzed separately). Prior resection was performed in 51 patients, and prior fractionated external beam radiotherapy was performed in 6 patients. The patients' median age at the time of radiosurgery was 59 years. Forty percent had pulsatile tinnitus at the time of radiosurgery. The median dose to the tumor margin was 15 Gy. The median duration of follow-up was 50.5 months (range 5-220 months).
Overall tumor control was achieved in 93% of patients at last follow-up; actuarial tumor control was 88% at 5 years postradiosurgery. Absence of trigeminal nerve dysfunction at the time of radiosurgery (p = 0.001) and higher number of isocenters (p = 0.005) were statistically associated with tumor progression-free tumor survival. Patients demonstrating new or progressive cranial nerve deficits were also likely to demonstrate tumor progression (p = 0.002). Pulsatile tinnitus improved in 49% of patients who reported it at presentation. New or progressive cranial nerve deficits were noted in 15% of patients; improvement in preexisting cranial nerve deficits was observed in 11% of patients. No patient died as a result of tumor progression.
Gamma Knife surgery was a well-tolerated management strategy that provided a high rate of long-term glomus tumor control. Symptomatic tinnitus improved in almost one-half of the patients. Overall neurological status and cranial nerve function were preserved or improved in the vast majority of patients after radiosurgery.
Journal of Neurosurgery 06/2012; 117(2):246-54. · 2.96 Impact Factor
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World Neurosurgery 05/2012; · 0.68 Impact Factor
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ABSTRACT: Approximately 1% to 2% of patients with multiple sclerosis (MS) develop trigeminal neuralgia (TN). Percutaneous surgery is commonly performed in medically refractory cases.
To analyze the pain outcomes and complications of patients with MS-related trigeminal neuralgia (MS-TN) having percutaneous surgery.
Patients having balloon microcompression (BMC; n = 69) or glycerol rhizotomy (PRGR; n = 67) from 1997 to 2010 were reviewed retrospectively. Patients in the 2 groups were similar with regard to age, sex, pain location, and pain quality. Mean pain duration was longer in the PRGR group (54.6 vs 16 months; P < .001); more patients having BMC had prior surgery (87% vs. 48%; P < .001). Outcomes were defined as excellent (no pain, no medications), good (no pain with medications), and poor. Median follow-up was 13 months (range, 0.25-132 months).
Ninety-five patients initially had excellent (n = 45, 33%) or good (n = 50, 37%) outcomes. Pain relief was maintained in 58% of patients at 3 months and 28% at 2 years. There was no difference in excellent/good outcomes between the surgical groups (hazard ratio = 0.73; P = .14). No correlation was noted between pain relief and new or increased facial numbness (hazard ratio = 0.78; P = .19). Forty-four BMC patients (64%) had additional surgery compared with 36 PRGR patients (54%; P = .19). Complications were more frequent after BMC (17.4% vs 3.0%; P < .01).
Percutaneous surgery for patients with MS-TN is less likely to provide pain relief than similar operations performed for patients with idiopathic TN. New trigeminal deficits did not correlate with better facial pain outcomes, supporting the concept that many patients with MS-TN have centrally mediated pain.
Neurosurgery 05/2012; 71(3):581-6; discussion 586. · 2.79 Impact Factor
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ABSTRACT: This article describes in detail the uses of and distinctions between stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) for vestibular schwannoma (VS). The authors discuss devices and techniques used in SRS and SRT and, additionally, present readers the approach used by surgeons at Mayo Clinic. They discuss indications and results for both approaches in patients with vestibular schwannoma. Treatment of small and large tumors is discussed, along with cystic tumors and NF2-associated VS. Repeating SRS for vestibular schwannoma is also mentioned.
Otolaryngologic Clinics of North America 04/2012; 45(2):353-66, viii-ix. · 1.65 Impact Factor
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ABSTRACT: The objective of the study is to define the tumor control rate and complications associated with stereotactic radiosurgery (SRS) for patients with recurrent intracranial ependymoma. Retrospective review of 26 patients (49 tumors) having SRS between 1990 and 2008. Twenty-five patients (96 %) had undergone one or more craniotomies; one patient underwent SRS for a metastatic tumor after resection of a spinal ependymoma. Nineteen patients (73 %) had received cranial external beam radiotherapy (median dose, 54 Gy). Eight patients (31 %) were less than 18 years old. The median target volume was 2.2 cm(3) (range, 0.3-66.6); the median tumor margin dose was 18 Gy (range, 12-24). The median follow-up after SRS was 3.1 years (range, 3 months-13.1 years). The median overall survival after SRS was 5.5 years. The 1-year and 3-year survival rates were 96 and 69 %, respectively. Local tumor control (LC) was achieved in 33 of 49 lesions (67 %) with a median time to progression of 14.7 months (range, 2.9 months-11.2 years). The 1-year and 3-year progression-free survival rates were 80 and 66 %, respectively. The 1-year and 3-year LC rate was 85 and 72 %, respectively. On univariate analysis, higher tumor grade was associated with worse OS (grade 3-4, 27 % vs grade 2, 82 %, p = 0.04). Seven patients (27 %) had distant tumor progression and two patients (8 %) had symptomatic radiation necrosis after SRS. SRS for recurrent intracranial ependymoma provided good LC and may improve survival for patients with limited recurrent disease after prior treatment.
Journal of Neuro-Oncology 03/2012; 108(3):507-12. · 3.21 Impact Factor
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ABSTRACT: OBJECTIVE: To assess the outcome of stereotactic radiosurgery (SRS) for patients with benign skull base tumors and trigeminal-related facial pain. METHODS: We undertook a retrospective review of 31 consecutive patients (25 women, 6 men) with benign skull base tumors and trigeminal pain who underwent SRS between 1991 and 2008. The tumors included 17 posterior fossa meningiomas, 9 cavernous sinus meningiomas, and 5 trigeminal schwannomas. The median patient age was 62 years (range, 17-81 years). In all cases the tumor was the primary target for SRS. The median follow-up after SRS was 50 months (range, 12-184 months). RESULTS: The actuarial tumor control rate after SRS was 95% at both 3 years and 5 years. Eighteen patients (58%) initially achieved complete resolution of trigeminal pain. Higher maximum dose was associated with initial complete pain resolution on a multivariate analysis. However, 7 patients had recurrent pain during follow-up. At last follow-up, only 7 patients (23%) remained pain-free off medications. Further treatment in addition to medical therapy was required for 6 patients (19%). CONCLUSION: Although SRS offers excellent radiographic tumor control for benign skull base tumors, durable relief of tumor-related trigeminal pain without medication was noted in only one-fourth of patients at last follow-up.
World Neurosurgery 02/2012; · 0.68 Impact Factor
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ABSTRACT: To define the rate of tumor control and factors associated with radiation-related complications after single-fraction radiosurgery (SRS) for patients with imaging defined intracranial meningiomas.
Retrospective review of 251 patients (192 women, 59 men) having SRS for imaging-defined intracranial meningiomas between 1990 and 2008. Excluded were patients with radiation-induced tumors, meningiomatosis, or neurofibromatosis. The mean patient age was 58.6 ± 13.4 years. The majority of tumors involved the skull base/tentorium (n = 210, 83.7%). The mean treatment volume was 7.7 ± 6.2 cm(3); the mean tumor margin dose was 15.8 ± 2.0 Gy. Follow-up (mean, 62.9 ± 43.9 months) was censored at last evaluation (n = 224), death (n = 22), or tumor resection (n = 5).
No patient died from tumor progression or radiation-related complications. Tumor size decreased in 181 patients (72.1%) and was unchanged in 67 patients (26.7%). Three patients (1.2%) had in-field tumor progression noted at 28, 145, and 150 months, respectively. No patient had a marginal tumor progression. The 3- and 10-year local control rate was 99.4%. One patient had distant tumor progression at 105 months and underwent repeat SRS. Thirty-one patients (12.4%) had either temporary (n = 8, 3.2%) or permanent (n = 23, 9.2%) symptomatic radiation-related complications including cranial nerve deficits (n = 14), headaches (n = 5), hemiparesis (n = 5), new/worsened seizure (n = 4), cyst-formation (n = 1), hemifacial spasm (n = 1), and stroke (n = 1). The 1- and 5-year complication rates were 8.3% and 11.5%, respectively. Radiation-related complications were associated with convexity/falx tumors (HR = 2.8, 95% CI 1.3-6.1, p = 0.009) and increasing tumor volume (HR = 1.05, 95% CI 1.0-1.1, p = 0.04) on multivariate analysis. No patient developed a radiation-induced tumor.
Single-fraction SRS at the used dose range provides a high rate of tumor control for patients with imaging defined intracranial meningiomas. However, treatment failures were noted after 10 years emphasizing the need for long-term imaging follow-up after meningioma SRS.
International journal of radiation oncology, biology, physics 12/2011; 83(5):1414-8. · 4.59 Impact Factor
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Bruce E Pollock
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ABSTRACT: The role of surgery for patients with medically refractory trigeminal neuralgia (TN) is well established. High-quality magnetic resonance imaging, including gadolinium-enhanced and volume acquisition sequences, should be performed to exclude intracranial tumors or demyelinating disease as the cause of the pain, as well as to clearly demonstrate the trigeminal nerve and adjacent blood vessels. For physiologically healthy patients with Type 1 TN, a microvascular decompression (MVD) is the preferred surgical approach because of its high rate of complete pain relief, the durability of the pain relief, and the fact that trigeminal injury is not required for pain relief. Patients with recurrent TN after a failed MVD, patients with significant medical comorbidities, and patients with multiple sclerosis-related TN are generally recommended to undergo less invasive, destructive surgical techniques aimed at providing pain relief by damaging the trigeminal nerve.
Current Neurology and Neuroscience Reports 12/2011; 12(2):125-31. · 3.45 Impact Factor
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ABSTRACT: γ knife surgery (GKS) for vestibular schwannoma (VS) is an accepted treatment for small- to medium-sized tumors, generally smaller than 2.5 cm in the maximum posterior fossa dimension. The purpose of this study was to evaluate the efficacy and toxicity of GKS for larger tumors.
Prospectively collected data were analyzed for 22 patients who had undergone GKS for VSs larger than 2.5 cm in the posterior fossa diameter between 1997 and 2006. No patient had symptomatic brainstem compression at the time of GKS. The median treated tumor volume was 9.4 cm(3) (range 5.3-19.1 cm(3)). The median maximum posterior fossa diameter was 2.8 cm (range 2.5-3.8 cm). The median tumor margin dose was 12 Gy (range 12-14 Gy). Serial imaging, audiometry (10 patients with serviceable hearing pre-GKS), and clinical follow-up were available for a median of 66 months (range 26-121 months). Tumor control failure was defined as either a progressive increase in tumor diameter of at least 2 mm in any dimension or a later resection.
Four patients met the criteria for GKS failure, including 1 patient who demonstrated sarcomatous degeneration more than 7 years after GKS and died 3 months after microsurgical debulking. An enlarging cystic component was the surgical indication in 1 of the 2 patients who required resection, although 27% of tumors (6 lesions) were cystic before GKS. The 3-year actuarial rate of tumor control, freedom from new facial neuropathy, and preservation of functional hearing were 86%, 92%, and 47%, respectively. At 5 years post-GKS, these rates decreased to 82%, 85%, and 28%, respectively. At the most recent follow-up, 91% of tumors were smaller than at the time of GKS and the median maximum posterior fossa diameter reduction was 26%. On multivariate analysis, none of the following factors was associated with GKS failure, new facial weakness, new trigeminal neuropathy, or loss of serviceable hearing: patient age, tumor volume, tumor margin dose, and preoperative cranial nerve dysfunction.
Single-session radiosurgery is a successful treatment for the majority of patients with larger VSs. Although tumor control rates are lower than those for smaller VSs managed with GKS, the cranial nerve morbidity of GKS is significantly lower than that typically achieved via resection of larger VSs.
Journal of Neurosurgery 12/2011; 116(3):598-604. · 2.96 Impact Factor
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Bruce E Pollock
World Neurosurgery 11/2011; 78(1-2):58-9. · 0.68 Impact Factor
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ABSTRACT: To report the outcomes in patients with recurrent or unresectable pilocytic astrocytoma (PA) treated with Gamma Knife stereotactic radiosurgery (SRS).
Retrospective review of 18 patients (20 lesions) with biopsy-confirmed PA having SRS at our institution from 1992 through 2005.
The median patient age at SRS was 23 years (range, 4-56). Thirteen patients (72%) had undergone one or more previous surgical resections, and 10 (56%) had previously received external-beam radiation therapy (EBRT). The median SRS treatment volume was 9.1 cm(3) (range, 0.7-26.7). The median tumor margin dose was 15 Gy (range, 12-20). The median follow-up was 8.0 years (range, 0.5-15). Overall survival at 1, 5, and 10 years after SRS was 94%, 71%, and 71%, respectively. Tumor progression (local solid progression, n = 4; local solid progression + distant, n = 1; distant, n = 2; cyst development/progression, n = 4) was noted in 11 patients (61%). Progression-free survival at 1, 5, and 10 years was 65%, 41%, and 17%, respectively. Prior EBRT was associated with inferior overall survival (5-year risk, 100% vs. 50%, p = 0.03) and progression-free survival (5-year risk, 71% vs. 20%, p = 0.008). Nine of 11 patients with tumor-related symptoms improved after SRS. Symptomatic edema after SRS occurred in 8 patients (44%), which resolved with short-term corticosteroid therapy in the majority of those without early disease progression.
SRS has low permanent radiation-related morbidity and durable local tumor control, making it a meaningful treatment option for patients with recurrent or unresectable PA in whom surgery and/or EBRT has failed.
International journal of radiation oncology, biology, physics 10/2011; 83(1):107-12. · 4.59 Impact Factor
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ABSTRACT: A study was undertaken to define the variables associated with tumor control and survival after single-session stereotactic radiosurgery (SRS) for patients with atypical and malignant intracranial meningiomas.
Fifty patients with World Health Organization (WHO) grade II (n = 37) or grade III (n = 13) meningiomas underwent SRS from 1990 to 2008. Most tumors were located in the falx/parasagittal region or cerebral convexities (n = 35, 70%). Twenty patients (40%) had progressing tumors despite prior external beam radiation therapy (EBRT) (median dose, 54.0 grays [Gy]). The median treatment volume was 14.6 cm(3) ; the median tumor margin dose was 15.0 Gy. Seven patients (14%) received concurrent EBRT (median dose, 50.4 Gy). Follow-up (median, 38 months) was censored at last evaluation (n = 28) or death (n = 22).
Tumor grade correlated with disease-specific survival (DSS) (hazard ratio [HR], 3.4; P = .008), local tumor control (HR, 2.4; P = .02), and progression-free survival (PFS) (HR, 2.6; P = .02) on univariate analysis, but not on multivariate analysis. Multivariate analysis showed that having failed EBRT and tumor volume >14.6 cm(3) were negative predictors of DSS and local control (HR, 3.0; P = .02 and HR, 4.4; P = .01; HR, 3.3; P = .001 and HR, 2.3; P = .02;, respectively). Having failed EBRT was a negative predictor of PFS (HR, 3.5; P = .002). Thirteen patients (26%) had radiation-related complications at a median of 6 months after radiosurgery.
Tumor progression despite prior EBRT and larger tumor volume are negative predictors of tumor control and survival for patients having SRS for WHO grade II and III intracranial meningiomas.
Cancer 07/2011; 118(4):1048-54. · 4.77 Impact Factor
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ABSTRACT: Glossopharyngeal neuralgia (GPN) is a rare pain disorder characterized by severe, stabbing pain of the ear, posterior tongue, and throat. The authors report their early experience of using stereotactic radiosurgery (SRS) as an alternative to posterior fossa surgery for patients with medically resistant GPN.
Five patients (3 men, 2 woman) with medically resistant GPN underwent Gamma Knife surgery. The radiosurgical target was the distal portion of the glossopharyngeal and vagus nerves at the jugular foramen (glossopharyngeal meatus). The maximum radiation dose in all cases was 80 Gy. The median follow-up after radiosurgery was 13 months (range 2-19 months).
Three patients became pain-free at 2 days, 3 days, and 2 weeks, respectively, and were able to discontinue the medications taken preoperatively for their pain. None of these patients have suffered recurrent pain since becoming pain free. Two patients experienced no benefit from the procedure and underwent posterior fossa surgery 2 and 5 months after SRS. Both of these patients continued to have pain after posterior fossa surgery. One of these patients was later discovered to have a head and neck cancer as the cause of his pain. No patient developed hoarseness or dysphagia after radiosurgery.
This preliminary experience demonstrates that SRS is an option for patients with medically resistant GPN. Additional follow-up and a larger number of patients are needed to demonstrate the long-term safety and optimal radiation dosimetry for this indication.
Journal of Neurosurgery 07/2011; 115(5):936-9. · 2.96 Impact Factor
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ABSTRACT: Patients with medically unresponsive trigeminal neuralgia (TN) who are >70 years of age often undergo operations that typically provide pain relief for <5 years despite having a life expectancy that can exceed 15 years.
To review the safety and efficacy of posterior fossa exploration (PFE) for TN patients > 70 years of age.
From 1999 to 2009, 67 TN patients >70 years of age (median, 74 years) underwent a PFE. Thirty-seven patients (55%) had failed ≥ 1 prior surgeries (median, 2). Fifty-nine patients (88%) had a microvascular decompression, and 8 patients (12%) underwent a partial sensory rhizotomy. Follow-up (median, 40 months) was censored at the time of last contact (n = 51), additional surgery (n = 12), or death (n = 4).
Complete pain relief (no pain, no medications) was 87% at 1 year and 78% at 5 years. Facial pain outcomes did not correlate with patient age, sex, prior surgery, or pain duration. Postoperative complications were noted in 10 patients (15%) and included ataxia (10%), hearing loss (5%), trigeminal dysesthesias (5%), facial weakness (3%), aseptic meningitis (2%), and pulmonary embolus (2%). Factors associated with postoperative complications were prior PFE (P = .01) and neurovascular compression from a dolicoectatic basilar artery (P = .03).
Posterior fossa exploration is safe and effective for physiologically healthy TN patients >70 years of age. It should be deferred in older patients with TN secondary to a dolicoectatic basilar artery and patients who have persistent/recurrent pain after a previous PFE unless simpler procedures prove ineffective at controlling their facial pain.
Neurosurgery 06/2011; 69(6):1255-9; discussion 1259-60. · 2.79 Impact Factor
