Docstoc

Peripheral Vascular Disease Fulltext Headache Volume

Document Sample
Peripheral Vascular Disease Fulltext Headache Volume Powered By Docstoc
					LINAC - STEREOTACTIC RADIOSURGERY
   (LSRS) IN THE MANAGEMENT OF
       TRIGEMINAL NEURALGIA


 Rufus Mark, MD, Paul Anderson, MD,
 Thomas Neumann, MD, Murali Nair, PhD,
 Robin Akins, MD, David White, CMD,
 Steve Gurley, CMD

     Joe Arrington Cancer Center and
    Texas Tech University Medical Center
              Lubbock, TX
TYPICAL TRIGEMINAL NEURALGIA
1. Classic Symptoms : Intermittent,
   burning, electric shocks, sharp,
   often triggered pain

2. Responsive to medications : e.g.
   Tegretol, Dilantin, Baclofen, Neurontin

3. No atypical features : e.g. constant pain,
                                no triggers
4. No tumor
TRIGEMINAL NEURALGIA
      ETIOLOGY

- VASCULAR COMPRESSION

- TUMOR

- IDIOPATHIC
  TRIGEMINAL NEURALGIA
  VASCULAR COMPRESSION
         (Janetta)
As patients age, the brain begins to sag

in the skull, and the cranial nerves

elongate. This brings the nerves into

contact with pulsating vessels, which

may in turn, cause pain.
TRIGEMINAL NEURALGIA
 TREATMENT OPTIONS

-   Medical
-   Glycerol Rhizotomy
-   Radiofrequency Rhizotomy
-   Balloon Compression
-   Nerve Sectioning
-   Microvascular Decompression
-   Stereotactic Radiosurgery
TRIGEMINAL NEURALGIA
     PRE - MVD
TRIGEMINAL NEURALGIA
     POST - MVD
   TRIGEMINAL NEURALGIA
     GKRS TECHNIQUE
- Single Isocenter

- 4 mm collimator

- Target : CN V Entry Root Zone into Pons

- Optimal targeting done thru MRI with
  inversion recovery images.

- Dose : 87 Gy, 20% IDL at Pons
    TRIGEMINAL NEURALGIA
        LSRS TECHNIQUE
- Single Isocenter

- 5 mm collimator

- Target : CN V Entry Root Zone into Pons

- Optimal targeting done thru MRI and
  CT Cisternogram images.

- Dose : 87 Gy, 20% IDL at Pons
TRIGEMINAL NEURALGIA
   LSRS TECHNIQUE

- 20% IDL touching the brainstem

- 6 arcs

- Dose Rate : 400 MU/min.

- Average Arc Length 130 degrees
TRIGEMINAL NEURALGIA
 GKRS T-1 AXIAL PLAN
TRIGEMINAL
NEURALGIA      LSRS T-
1 AXIAL PLAN
TRIGEMINAL NEURALGIA
    LSRS RESULTS

-   51 Patients with Typical TN
-   Mean Age 64 yrs (46 - 83)
-   F : M = 1.71
-   Mean Pain Duration : 6.8 yrs
-   Median F/U : 46 mo. (6 – 84 mo.)
-   Mean # prior surgeries : 1.2
TRIGEMINAL NEURALGIA
    LSRS RESULTS
 OUTCOME ASSESSMENT

Excellent : No pain off medications

Good : No pain on medications,
       No side effects

Failure : All others
TYPICAL TRIGEMINAL NEURALGIA
       LSRS Tx RESULTS
            n = 51
               PAIN RELIEF
                  48 mo.
   Excellent      43% (22/51)

   Good           31% (16/51)

   Failure        26% (13/51)
TYPICAL TRIGEMINAL NEURALGIA
       GKRS Tx RESULTS
            n = 441

                PAIN RELIEF
               6 mo.  4.8 yrs
   Excellent   65%     54%

   Good        26%     23%

   Failure     9%      23%
TYPICAL TRIGEMINAL NEURALGIA
      LSRS COMPLICATIONS
             n = 51
  COMPLICATION             %PTS

  Temporary Numbness       7.8% (4/51)
  Permanent Numbness       2.0% (1/51)
  Loss of Corneal Reflex   0%
  Painful Dysethesias      0%
  Anesthesia Dolorosa      0%
TYPICAL TRIGEMINAL NEURALGIA
      GKRS COMPLICATIONS
             n = 441
  COMPLICATION             %PTS

  Temporary Numbness       18%
  Permanent Numbness       5.2%
  Loss of Corneal Reflex   1.3%
  Painful Dysethesias      2.7%
  Anesthesia Dolorosa      0%
   TRIGEMINAL NEURALGIA
  OUTCOME WITH LSRS vs. GKRS
                 PAIN   PAIN
STUDY     # PTS RELIEF RELAPSE NUMB
Petit      112   77%     16%     nr
Pollock    117   57%      2%    25%
Kondziolka 220   86%     30%    10%
Rogers      54   96%      nr    10%
Young      110   95%      3%     3%
Mehta      250   75%     11%     3%
Mark       441   91%     14%     5%
Mark*       51   85%     10%     2%
      TRIGEMINAL NEURALGIA
      COMPARATIVE OUTCOMES
                   PAIN         PAIN
Tx        # PTS   RELIEF       RELAPSE        NUMB
GR        1,217    91%           54%           60%
RFR       6,205    98%           23%           98%
Balloon   759      93%           21%           72%
MVD       1,417    98%           15%           2%
PR        250      92%           18%          100%
Rx*         -      70%           75%           0%
GKRS*     441      91%           14%           3%
LSRS*      51      85%           10%           2%
           (Neurosurg, 1996 ; 38 [5] : 865)
           LSRS FOR TN
           CONCLUSIONS
1. LSRS may be an effective Tx option
   for patients with intractable pain from
   TN which is refractory to medical Rx.

5. LSRS is a safe alternative to MVD.
   Results compare favorably to MVD
   and GKRS.