Central Nervous System

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MO_4_2549 - A Novel Fractionated Regimen Using Stereotactic Radiosurgery for Trigeminal Neuralgia

Monday, October 22
10:45 AM - 12:15 PM
Location: Innovation Hub, Exhibit Hall 3

A Novel Fractionated Regimen Using Stereotactic Radiosurgery for Trigeminal Neuralgia
S. A. Castaneda1,2, and S. A. Shah1; 1Department of Radiation Oncology, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, 2Department of Radiation Oncology, Cancer Center, Hahnemann University Hospital and Drexel University College of Medicine, Philadelphia, PA

Purpose/Objective(s): Medication-refractory trigeminal neuralgia (TN) is a debilitating pain disorder traditionally treated with microvascular decompression in cases of nerve impingement by the cerebellar artery. Stereotactic radiosurgery (SRS) has emerged as an attractive non-invasive alternative to microvascular decompression; however, facial numbness as significant treatment-related complication that has a strong impact on patients’ quality of life. Our goal in this study was to assess pain response and facial numbness rates in patients with medication-refractory TN treated with fractionated SRS.

Materials/Methods: Between August 2016 and December 2017, 17 consecutive patients treated at Christiana Healthcare System with diagnosis of severe medication-refractory TN were analyzed retrospectively using the Barrow Neurological Institute (BNI) pain intensity score of V (scale from I to V). All patients were treated with a novel regimen that employed three fractions instead of the conventional single fraction. The total dose was 99 Gy prescribed to the 80% isodose line (range 75-82). These patients were treated with robotic radiosurgery using a fractionated modification of the Stanford technique (6-8-mm segment of the trigeminal nerve was targeted, excluding the proximal 3 mm at the brainstem). BNI facial numbness scores were documented (from I to IV). Descriptive statistics were used to analyze the data.

Results: We had eight females (47%) and nine males (53%) patients with median age of 58 years (range 25-89 years). After an initial median follow up of 2.5 months (range 1-14 months), 14 out of 17 (82%) of these TN patients achieved a BNI pain score of ≤III with a median response time of one month (range 0.5-2 months) and a median response duration of 4 months (range 0-14 months). BNI facial numbness scores were the following: I in eight patients (47%), II in four patients (23%), III in two patients (12%), and IV in three patients (18%). One patient with recurrent TN after robotic radiosurgery, with total dose of 80Gy in one fraction using the Stanford technique four years prior, underwent retreatment after initial good and sustained pain response. None of the patients had any additional CNS injuries including cranial nerves, brainstem, or brain parenchyma.

Conclusion: In this consecutive group of patients with severe TN, our novel fractionation of the Stanford technique allow us to safely achieve favorable pain responses with significant sparing of facial numbness rates in the majority of them. Our cohort requires longer follow up to better define these findings. Fractionated SRS to treat severe medication-refractory TN warrants further prospective investigation.

Author Disclosure: S.A. Castaneda: None. S. Shah: Independent Contractor; Christiana Care Health System. Advisory Board; Novocure.

Serguei Castaneda, MD

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Hahnemann University Hospital: resident: Employee

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