title: Repeat Gamma Knife surgery for recurrent trigeminal neuralgia: long-term outcomes and systematic review.
abstract: OBJECTIVE
  The purpose of this study was to establish the safety and efficacy of repeat Gamma Knife surgery (GKS) for recurrent trigeminal neuralgia (TN).
  
  
  METHODS
  Using the prospective database of TN patients treated with GKS in Timone University Hospital (Marseille, France), data were analyzed for 737 patients undergoing GKS for TN Type 1 from July 1992 to November 2010. Among the 497 patients with initial pain cessation, 34.4% (157/456 with ≥ 1-year follow-up) experienced at least 1 recurrence. Thirteen patients (1.8%) were considered for a second GKS, proposed only if the patients had good and prolonged initial pain cessation after the first GKS, with no other treatment alternative at the moment of recurrence. As for the first GKS, a single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 7.6 mm (range 4-14 mm) anterior to the emergence of the nerve (retrogasserian target). A median maximum dose of 90 Gy (range 70-90 Gy) was delivered. Data for 9 patients with at least 1-year followup were analyzed. A systematic review of literature was also performed, and results are compared with those of the Marseille study.
  
  
  RESULTS
  The median time to retreatment in the Marseille study was 72 months (range 12-125 months) and in the literature it was 17 months (range 3-146 months). In the Marseille study, the median follow-up period was 33.9 months (range 12-96 months), and 8 of 9 patients (88.9%) had initial pain cessation with a median of 6.5 days (range 1-180 days). The actuarial rate for new hypesthesia was 33.3% at 6 months and 50% at 1 year, which remained stable for 7 years. The actuarial probabilities of maintaining pain relief without medication at 6 months and 1 year were 100% and 75%, respectively, and remained stable for 7 years. The systematic review analyzed 20 peer-reviewed studies reporting outcomes for repeat GKS for recurrent TN, with a total of 626 patients. Both the selection of the cases for retreatment and the way of reporting outcomes vary widely among studies, with a median rate for initial pain cessation of 88% (range 60%-100%) and for new hypesthesia of 33% (range 11%-80%).
  
  
  CONCLUSIONS
  Results from the Marseille study raise the question of surgical alternatives after failed GKS for TN. The rates of initial pain cessation and recurrence seem comparable to, or even better than, those of the first GKS, according to different studies, but toxicity is much higher, both in the Marseille study and in the published data. Neither the Marseille study data nor literature data answer the 3 cardinal questions regarding repeat radiosurgery in recurrent TN: which patients to retreat, which target is optimal, and which dose to use.
authors.affiliation: INSERM U 751 (Université de la Méditerranée), Functional and Stereotactic Neurosurgery Unit;
authors.forename: Constantin
authors.initials: C
authors.lastname: Tuleasca
authors.forename: Romain
authors.initials: R
authors.lastname: Carron
authors.forename: Noémie
authors.initials: N
authors.lastname: Resseguier
authors.forename: Anne
authors.initials: A
authors.lastname: Donnet
authors.forename: Philippe
authors.initials: P
authors.lastname: Roussel
authors.forename: Jean
authors.initials: J
authors.lastname: Gaudart
authors.forename: Marc
authors.initials: M
authors.lastname: Levivier
authors.forename: Jean
authors.initials: J
authors.lastname: Régis
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011829:Radiation Dosage; D016634:Radiosurgery / Q000009:adverse effects / Q000379:methods*; D012008:Recurrence; D012086:Reoperation / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014277:Trigeminal Neuralgia / Q000601:surgery*
keywords: BNI = Barrow Neurological Institute; DREZ = dorsal root entry zone; GKS = Gamma Knife surgery; Gamma Knife surgery; MVD = microvascular decompression; TN = trigeminal neuralgia; retreatment; stereotactic radiosurgery; trigeminal neuralgia