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Radiocirugiacutea en las Neuralgia de Trigeacutemino y
Patologia Funcional
Prof Kita Sallabanda
IASP classification paroxysmal unilateral severe pervasive pain of
short duration localized in the distribution of one or more of the
branches of the Vth cranial nerve
Etiology
Vascular Compression
Idiopathic
Herpetic
MEscleroses
Anatomy of the TN
Trigeminal Eminence ( REZ)
Cisternal segment ascending from Rez to the ostium of the Meckelrsquos
cave
Motor root ( portio minor) travels medial and superior to Sensory
root ( portio mayor)
The nerve climbs up to the ostium then descends into the Meckelrsquos cave
The Ganglion of Gasser lies just below the ostium and originates the
trigeminal roots
Peripheral myelin Schwann cells
Central myelin oligodendrocytes
In vitro analysis Radiosensitivity
Central gt Peripheral Myelin
(Ridder et al Root Entry Zone Important in Microvascular
Compression Syndromes Neurosurgery 51(2) 427)
REZ
central ndash peripheral
myelin junction
ldquoShort Circuitrdquo in this Root Entry Zone (REZ)
causes the worse pain man can experience
Barrow Neurological Institute (BNI)
Grade I no pain no medication
Grade II occasional pain no medication
Grade IIIa no pain medication
Grade IIIb pain medication controlled
Grade IV pain not well controlled
Grade V no pain relief
Marseille scale
Class I no pain no medication
Class II no pain medication
Grade III gt90 pain frequency reduction
Grade IV gt50 pain frequency reduction
Grade V no significant pain relief
Grade VI pain worsening
Ovale
V3
Rotundum
V2
Orbit Fissure
V1
90Gy
SCA ndashAICA MVD
Taja JM Tew JM Neurosurgery 1996
1) Age coomorbidity
2) No Vascula Compresion
3) Previous Surgery
4) Patient decision
SCA ndashAICA MVD
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
IASP classification paroxysmal unilateral severe pervasive pain of
short duration localized in the distribution of one or more of the
branches of the Vth cranial nerve
Etiology
Vascular Compression
Idiopathic
Herpetic
MEscleroses
Anatomy of the TN
Trigeminal Eminence ( REZ)
Cisternal segment ascending from Rez to the ostium of the Meckelrsquos
cave
Motor root ( portio minor) travels medial and superior to Sensory
root ( portio mayor)
The nerve climbs up to the ostium then descends into the Meckelrsquos cave
The Ganglion of Gasser lies just below the ostium and originates the
trigeminal roots
Peripheral myelin Schwann cells
Central myelin oligodendrocytes
In vitro analysis Radiosensitivity
Central gt Peripheral Myelin
(Ridder et al Root Entry Zone Important in Microvascular
Compression Syndromes Neurosurgery 51(2) 427)
REZ
central ndash peripheral
myelin junction
ldquoShort Circuitrdquo in this Root Entry Zone (REZ)
causes the worse pain man can experience
Barrow Neurological Institute (BNI)
Grade I no pain no medication
Grade II occasional pain no medication
Grade IIIa no pain medication
Grade IIIb pain medication controlled
Grade IV pain not well controlled
Grade V no pain relief
Marseille scale
Class I no pain no medication
Class II no pain medication
Grade III gt90 pain frequency reduction
Grade IV gt50 pain frequency reduction
Grade V no significant pain relief
Grade VI pain worsening
Ovale
V3
Rotundum
V2
Orbit Fissure
V1
90Gy
SCA ndashAICA MVD
Taja JM Tew JM Neurosurgery 1996
1) Age coomorbidity
2) No Vascula Compresion
3) Previous Surgery
4) Patient decision
SCA ndashAICA MVD
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Anatomy of the TN
Trigeminal Eminence ( REZ)
Cisternal segment ascending from Rez to the ostium of the Meckelrsquos
cave
Motor root ( portio minor) travels medial and superior to Sensory
root ( portio mayor)
The nerve climbs up to the ostium then descends into the Meckelrsquos cave
The Ganglion of Gasser lies just below the ostium and originates the
trigeminal roots
Peripheral myelin Schwann cells
Central myelin oligodendrocytes
In vitro analysis Radiosensitivity
Central gt Peripheral Myelin
(Ridder et al Root Entry Zone Important in Microvascular
Compression Syndromes Neurosurgery 51(2) 427)
REZ
central ndash peripheral
myelin junction
ldquoShort Circuitrdquo in this Root Entry Zone (REZ)
causes the worse pain man can experience
Barrow Neurological Institute (BNI)
Grade I no pain no medication
Grade II occasional pain no medication
Grade IIIa no pain medication
Grade IIIb pain medication controlled
Grade IV pain not well controlled
Grade V no pain relief
Marseille scale
Class I no pain no medication
Class II no pain medication
Grade III gt90 pain frequency reduction
Grade IV gt50 pain frequency reduction
Grade V no significant pain relief
Grade VI pain worsening
Ovale
V3
Rotundum
V2
Orbit Fissure
V1
90Gy
SCA ndashAICA MVD
Taja JM Tew JM Neurosurgery 1996
1) Age coomorbidity
2) No Vascula Compresion
3) Previous Surgery
4) Patient decision
SCA ndashAICA MVD
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Peripheral myelin Schwann cells
Central myelin oligodendrocytes
In vitro analysis Radiosensitivity
Central gt Peripheral Myelin
(Ridder et al Root Entry Zone Important in Microvascular
Compression Syndromes Neurosurgery 51(2) 427)
REZ
central ndash peripheral
myelin junction
ldquoShort Circuitrdquo in this Root Entry Zone (REZ)
causes the worse pain man can experience
Barrow Neurological Institute (BNI)
Grade I no pain no medication
Grade II occasional pain no medication
Grade IIIa no pain medication
Grade IIIb pain medication controlled
Grade IV pain not well controlled
Grade V no pain relief
Marseille scale
Class I no pain no medication
Class II no pain medication
Grade III gt90 pain frequency reduction
Grade IV gt50 pain frequency reduction
Grade V no significant pain relief
Grade VI pain worsening
Ovale
V3
Rotundum
V2
Orbit Fissure
V1
90Gy
SCA ndashAICA MVD
Taja JM Tew JM Neurosurgery 1996
1) Age coomorbidity
2) No Vascula Compresion
3) Previous Surgery
4) Patient decision
SCA ndashAICA MVD
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Barrow Neurological Institute (BNI)
Grade I no pain no medication
Grade II occasional pain no medication
Grade IIIa no pain medication
Grade IIIb pain medication controlled
Grade IV pain not well controlled
Grade V no pain relief
Marseille scale
Class I no pain no medication
Class II no pain medication
Grade III gt90 pain frequency reduction
Grade IV gt50 pain frequency reduction
Grade V no significant pain relief
Grade VI pain worsening
Ovale
V3
Rotundum
V2
Orbit Fissure
V1
90Gy
SCA ndashAICA MVD
Taja JM Tew JM Neurosurgery 1996
1) Age coomorbidity
2) No Vascula Compresion
3) Previous Surgery
4) Patient decision
SCA ndashAICA MVD
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Ovale
V3
Rotundum
V2
Orbit Fissure
V1
90Gy
SCA ndashAICA MVD
Taja JM Tew JM Neurosurgery 1996
1) Age coomorbidity
2) No Vascula Compresion
3) Previous Surgery
4) Patient decision
SCA ndashAICA MVD
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
SCA ndashAICA MVD
Taja JM Tew JM Neurosurgery 1996
1) Age coomorbidity
2) No Vascula Compresion
3) Previous Surgery
4) Patient decision
SCA ndashAICA MVD
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
1) Age coomorbidity
2) No Vascula Compresion
3) Previous Surgery
4) Patient decision
SCA ndashAICA MVD
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
RADIOSURGERY High Doses High Accuracy
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Author Technique Pts Results Follow
Barker96 MVD 1555 70 10y
Broggi90 RF 1000 767 93y
Brown97 Balloon 141 92 22mo
JhoLundsford97 Glycerol 523 77 11y
Maesawa2001
SmithhellipDeSalles2011
GK
D-Novalis
220
133
75
79
3y
3y
Literature Results
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Kondziolka et al used a primate model to explore
the effects of 80 or 100Gy to trigeminal nerves and
observed a combination of axonal degeneration and
edema
Necrosis was seen in nerves that received the
higher dose and both myelinated and unmyelinated
fibers were equally affected
Why the functional improvement is seen in patients
before these histologic changes are seen is
unknown but an effect of GK-SRS on ephaptic
transmission provides a possible mechanism
Prof KSallabanda
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
The relationship between postprocedure numbness and
efficacy suggests that SRS works by blocking axonal
transmission
As predicted by models of radiation injury both the time to
effective pain relief and numbness are delayed although pain
relief frequently occurs many months before any side effects
are experienced
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
90 Gy Demyelinization
Medin amp De Salles ndash Chapter 2007
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Estudios sobre el efecto de la radiacioacuten en el trigeacutemino
bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el
nervio
bullPermite el estudio de la microestructura de la materia blanca
bullPodemos averiguar si el efecto es debido a cambios en la mielina
axones o
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Individual variability in the effect of radiation on the nerve
Diffusivity assessment suggests the effect is primarily related to myelin
rather than axons
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
QUESTION TO RESOLVE
Doses
Target Localization
Previous Treatment
Recurrency time what to do
Side effects
Prof KSallabanda
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Treatment planning tips
1-Cisternal spaces are large enough to accomodate higher
isodoses
2Pay attention to the brainstem cochlea VII-VIII complex
gasserian ganglion and mesial temporal structures( amygdalo-
hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known
to destroy neural progenitors and induce dementia
Prof KSallabanda
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca
P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA
A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning
VII VIII
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Targets TN
REZ
Retrogasserian
Intracysternal segment
Prof KSallabanda
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Treatment Planning Target
Selection
Isocenter
NEZ just distal to Pons
50 IDL
Tangential to the brainstem
20 IDL
Just inside
20
30
PONS AXIAL MR
50
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
80 Gy 1 a 2 a 4 a
DREZ target 96 92 82
Retrogasser 83 69 60
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille
RadioSurgical Treatments of Trigeminal Neuralgia
Pain Cessation Recurrences
Global 934 (99106) 343 (3499)
MS 100 (77) 571 (47)
Without MS 92 (9299) 217 (2092)
Previous Surg 889 (4045) 275 (1140)
No Prev Surg 967 (5961) 220 (1359)
No Ms No Surg 967 (5860) 207 (1258)
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Results 1 a 2a 3a 4a 5a
764 714 679 661 600
No significant diference Previus surgery or not
Better result in umlde novouml patient (no siginificant)
No significant diference diferent doses (70-85Gy)
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
503 cases Anaacutelises
Barrow Neurological Institute Cl
73 No pain the first year
30 No pain in 10ordm year
105 disesthesias
Conclusioacuten GK SRS is an effective and
safe treatment for TN
More recurrence than in MVD
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
bull 27 pts F-up=4323mo after 1st2nd SRS
bull Median Doses = 7564Gy for 1st2nd SRS
bull Results Excellent = 5 Fair = 10
Good = 8 Poor = 4
bull Numbness new = 74 worsening = 127
bullNo anesthesia dolorosa
TARGET 2ND SRS
ANTERIOR TO THE TARGET
OF THE 1ST SRS (50 volume overlap between 2 SRS)
23 (852) cases
ge 50 pain relief
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Surg Neurol 2006 Oct66(4)350-6
Gorgulho AA De Salles AA
Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA
BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method
Impact of radiosurgery
on the surgical treatment of trigeminal
neuralgia
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Clinical Study Stereotact Funct Neurosurg 201189220ndash225
DOI 101159000325672
Outcome for Patients with Essential Trigeminal Neuralgia Treated with
Linear Accelerator Stereotactic Radiosurgery
Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo
Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo
Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda
Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after
unsuccessful
conservative approaches Objectives The objective of this study was to retrospectively evaluate
our institutional results in the management of patients with idiopathic trigeminal neuralgia treated
with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and
December 2009 and were followed for more than 6 months(median 266 months) Forty-seven
patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to
80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain
free but still under medication Eleven patients reported a relief of more than 50 in crisis
frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation
of the pain After an average period of 20 months 15 patients reported pain recurrence Results
were better in patients older than 60 years (p = 0019) Nineteen patients presented facial
numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan
effective alternative to the treatment of essential trigeminal neuralgia with long-lasting
pain relief in more than 50 of the patients Better results were seen with patients aged
more than 60 years Copyright copy 2011 S Karger AG Basel
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
J Neurosurg 1241079ndash1087 2016
Pain Free without Medication
Initially Pain Free Hypersthesia
Recurrence without Surgery
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Jean Regise CONCLUSION
Long term follow up is needed
Randomize Studies is needed
SRS demostrate less morbidity and good results ( 70-90
Gy)
SRS can become a first treatment choise
However MVD remains as the reference technique and
further prospective randomized studies are still needed to
compare the long-term efficacy of radiosurgery with MVD
Is very important the patient decision
Prof KSallabanda
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
143 Patients 103 treated by conventional RC
39 treated with Cyberknife
Follow up
˃ 6 months
91 patients pretreatment
diathermocoagulation
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
REZ (16 px)
Retro Gasser ganglion (51 px)
Cysternal (75 px)
TARGET LOCATION
Prof KSallabanda
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
8
22
58 54
15
0
10
20
30
40
50
60
70
50-60 GY 60-70 GY 70-80 GY gt80 GY
Dose
Prof KSallabanda
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
114
16 12
0 0
20
40
60
80
100
120
Favorable Partial improvement
Unfavorable
RESULTADOS
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Treatment Plan
Max Dose 85Gy Prescpt Dose 60Gy 83 66
of the volumen recive 70Gy( 17022014)
WE APPLY MEDIAL TARGET
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
MRI 8 Months latter HIGT ACCURACY
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Vallerian Degenariton 1 year after SRS
Prof KSallabanda
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Prof KSallabanda
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Failures
Are we treating TN
Finding the nerve can be difficult due to compressiondistorsion atrophyetc
Are we hitting the nerve Take into account MR distorsion and treatment accuracy
MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm
How often do we get the ideal overlap of isodoses and anatomy
Prof KSallabanda
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard
Target
Pollock et al REZ region
Jean Regise retrogasserian we have not yet the gold standtart
Dosis Maximum dose 100Gy
More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)
Surgery
Inmediate effects
Less recurrency
Less face numbness
Ablative Procedures
Less complications
Can be apply in all the patients
Radiosurgery
2ordm liacutene
When surgery can not be apply
Less invasive
Patientes umlde novoumlbest results
Prof KSallabanda
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Discusioacuten Good prognostic
Age
One branch pain No significant
Right part
De Novo patients
Type of TN
Bad prognostic Significant
Multiple Escleroses
Atipic
Prof KSallabanda
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Trigeminal Neuralgia
No Perfect Method of Treatment
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Caso Clinico HamartomaEpilepsia
32 years old woman
Prof KSallabanda
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Caso Cliacutenico Trastornos de MovimientoDolor Intratable
52 years old woman
Prof KSallabanda
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
RMN Cerebral 17102017
Clara mejoriacutea cliacutenica sin medicacioacuten
Prof KSallabanda
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
Lesioning in the treatment of
movement disorders
bullInvasive procedures provide the
opportunity of electrophysiological
mapping
bullDirect lesioning of stimulation
bullNot all patients can have invasive
procedures
bullAge Medical co-morbidities
bullIncreasing number of non-invasive
options
bullRadiosurgery
bullFocused Ultrasound
Prof KSallabanda
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in
collaboration with ALATRO
Goiacircnia - Brazil
SAVE THE DATE 2018
Nov 15-17th
GRACIAS
GRACIAS
Recommended