Trigeminal Neuralgia
Ronald Brisman, M.D.

Gamma Knife Radiosurgery for Trigeminal Neuralgia


 

What is Gamma Knife Radiosurgery (GKRS) for trigeminal neuralgia?

This is a minimally invasive procedure that is done as an out-patient and requires a few hours in the hospital facility. The trigeminal nerve is treated with highly focused cobalt 60 sources of  radiation (that does not affect other parts of the body). Special equipment (the Gamma Knife is the gold standard for such focused radiation treatment) includes a computer driven system that provides extremely precise delivery of radiation to the trigeminal nerve. Although many patients may obtain pain relief within the first two weeks of Gamma Knife radiosurgery, most take about 4 to 6 weeks to get relief. A few get facial numbness, which is not usually bothersome. Recurrent trigeminal neuralgia pain may occasionally occur but can be treated by either a repeat Gamma Knife radiosurgery or another procedure.

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Why is Gamma Knife called a “Knife?” Is there any cutting?

There is no cutting. There is no knife. Gamma Knife radiosurgery for trigeminal neuralgia involves the very precise delivery of radiation energy (photons) from about 200 Cobalt 60 sources (192 sources in the newest Gamma Knife [Perfexion]) that is done instead of a formal, open surgical, “knife-cutting” procedure.

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Is Gamma Knife Radiosurgery for trigeminal neuralgia painless?

Yes. The actual delivery of radiation by the Gamma Knife system to the trigeminal nerve is painless. It is also quiet. Before the radiation can be given, a special frame is fixed to the head. This application is very brief. Before the frame is placed, local anesthetic medicine is given to numb the scalp. The patient is also offered medicine by mouth to make them comfortable and relaxed.

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Who is a Candidate for Gamma Knife Radiosurgery for Trigeminal Neuralgia?

Patients with trigeminal neuralgia who are bothered by pain or medicines used to relieve the pain are excellent candidates for Gamma Knife radiosurgery for trigeminal neuralgia. Even the elderly or medically infirm patients with trigeminal neuralgia can undergo Gamma Knife radiosurgery because it is minimally invasive.  Patients who are concerned about the possibility of bothersome numbness are particularly good candidates for Gamma Knife radiosurgery, because the chance of this occurring is very small. Patients who can’t tolerate medicines given for sedation and relief of pain during a procedure are also very good candidates, because these medicines are not necessary for Gamma Knife radiosurgery. Patients who have pain in the eye or forehead are also particularly good candidates for Gamma Knife radiosurgery, because the risk of impairing feeling to the outer part of the eye (cornea), which can cause impaired vision, is less with Gamma Knife radiosurgery than the other nerve damaging procedures. Gamma Knife radiosurgery is most appropriate for patients with trigeminal neuralgia who are interested in the neurosurgical procedure with the fewest risks.

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Can patients who have had a previous procedure for trigeminal neuralgia undergo Gamma Knife Radiosurgery?

Yes. Patients who have recurrent trigeminal neuralgia pain after a prior procedure (either a previous Gamma Knife radiosurgery, needle rhizotomy with either radiofrequency, glycerol or balloon, or a microvascular decompression) have an excellent chance for pain relief with a subsequent Gamma Knife radiosurgery.

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Can patients who are taking anti-coagulating (blood thinning) medicines undergo Gamma Knife Radiosurgery for trigeminal neuralgia?

Yes. Patients who are taking anticoagulation for other medical conditions do not have to stop or reverse the anticoagulation prior to Gamma Knife radiosurgery, but they could stop  those medicines (Coumadin, aspirin or Plavix) a few days before the Gamma Knife radiosurgery if their internist feels that this can be done safely.

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Can patients who are unable to have an MRI (because they have an implanted pacemaker or defibrillator or other reason) undergo Gamma Knife radiosurgery for trigeminal neuralgia?

Yes. Although Gamma Knife radiosurgery for trigeminal neuralgia is usually done with Magnetic Resonance Imaging (MRI), it can be done with very high resolution CT scanning.

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Can patients who are very claustrophobic (and very uncomfortable with MRI) undergo Gamma Knife radiosurgery for trigeminal neuralgia?

Yes. Dr. Ronald Brisman is very sensitive to this issue (having treated almost 1000 patients with Gamma Knife radiosurgery for trigeminal neuralgia) and will give his patients as much sedation as they need to be comfortable. Even the most claustrophobic patient can be made comfortable.

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What is the Perfexion that is used to do Gamma Knife Radiosurgery for trigeminal neuralgia?

The Perfexion is the latest and most advanced system for Gamma Knife radiosurgery. As all other Gamma Knife radiosurgery devices, this is also made by Elekta and is used by Dr. Ronald Brisman at the New York Presbyterian Hospital of Columbia University in New York City.

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Is the Gamma Knife the only device that can be used for radiosurgery treatment of trigeminal neuralgia?

No. There are other radiosurgery systems. But the Gamma Knife is the gold standard for radiosurgery of trigeminal neuralgia because it has the overwhelmingly largest track record of safe and effectively performed procedures.

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What are the results of Gamma Knife radiosurgery for treatment of trigeminal neuralgia?

For patients who have typical trigeminal neuralgia (without a brain tumor or multiple sclerosis) and no prior procedure, pain relief that is 50 percent or greater will occur in 90 percent of patients and will persist for at least 12 months in 85 percent of the original patients. Patients who have trigeminal neuralgia and a brain tumor or multiple sclerosis or have had a previous procedure also have an excellent chance of pain relief following Gamma Knife radiosurgery although the chance is a little less than those who have typical trigeminal neuralgia and no previous procedure.

A recent article from France of a large series (497 patients) with trigeminal neuralgia who were followed for a long time median of 43.8 months (range 12 – 174.4 months) indicates that Gamma Knife radiosurgery is safe and effective for long-term treatment of trigeminal neuralgia (J Neurosurg 2015 Sept 4:1-9 [Epub ahead of print]). Dr. Ronald Brisman’s experience with more than 1000 Gamma Knife radiosurgery procedures for trigeminal neuralgia confirms this.

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What complications may result from Gamma Knife radiosurgery for treatment of trigeminal neuralgia?

No major complications occurred in any patients treated by Dr. Ronald Brisman with Gamma Knife radiosurgery for trigeminal neuralgia. A few patients (3 percent) developed bothersome numbness, but even this improved with time.

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Can Gamma Knife radiosurgery for treatment of trigeminal neuralgia be repeated?


Yes. But not for at least 6 months after the original Gamma Knife radiosurgery.

A third Gamma Knife radiosurgery can also be done although at least a few years after the second one. In a recent report from 4 medical centers, 17 patients with trigeminal neuralgia (without multiple sclerosis) underwent a third Gamma Knife radiosurgery. At an average follow up of 22.9 months after the last (third) Gamma Knife radiosurgery, 6 patients (35%) reported complete pain relief, while 7 others (41%) reported pain improvement (J Neurosurg 2015 Jan; 122(1):169-79. doi: 10.3171/2014.9.JNS132779.) Ronald Brisman M.D. has done a third Gamma Knife radiosurgery on 22 patients with typical trigeminal neuralgia and another 5 with trigeminal neuralgia and multiple sclerosis and has had similar results: improved pain relief in most patients with few added side effects.

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Can Gamma Knife radiosurgery be used to treat trigeminal neuralgia if it is being caused by a blood vessel pressing on the trigeminal nerve?

Yes. Gamma Knife radiosurgery is very effective for treating trigeminal neuralgia that is caused by blood vessel compression.

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Can Gamma Knife radiosurgery be used to treat trigeminal neuralgia that is caused by a brain tumor?

Yes. Approximately 5 percent of patients with trigeminal neuralgia will have a brain tumor as the cause of their trigeminal neuralgia. Gamma Knife radiosurgery is very effective in treating brain tumors and is very effective for treating trigeminal neuralgia that is caused by a brain tumor. The MRI will almost always identify a brain tumor if it is the cause of trigeminal neuralgia.

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Can Gamma Knife radiosurgery be used to treat trigeminal neuralgia that is caused by multiple sclerosis?

Yes. Approximately 5 percent of patients with trigeminal neuralgia will have multiple sclerosis. Gamma Knife radiosurgery is very effective for treating the trigeminal neuralgia that is caused by multiple sclerosis. In patients with multiple sclerosis and trigeminal neuralgia, the cause of the trigeminal neuralgia is multiple sclerosis and not vascular compression. It is not necessary to undergo a major neurosurgical operation to treat this trigeminal neuralgia. A minimally invasive procedure such as Gamma Knife radiosurgery is preferred.

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Does an initial Gamma Knife radiosurgery procedure affect the results of another subsequent procedure such as needle rhizotomy or microvascular decompression that may be considered for treatment of trigeminal neuralgia that recurs after the initial Gamma Knife radiosurgery?

No. Patients with trigeminal neuralgia who are treated with a Gamma Knife radiosurgery procedure as their first neurosurgical procedure and then develop recurrent pain have an excellent chance of being relieved by a subsequent procedure whether it be a repeat Gamma Knife radiosurgery, a needle rhizotomy (RFE and or glycerol or balloon) or a microvascular decompression.

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