title: The clinical significance of persistent trigeminal nerve contrast enhancement in patients who undergo repeat radiosurgery.
abstract: OBJECTIVE Contrast enhancement of the retrogasserian trigeminal nerve on MRI scans frequently develops after radiosurgical ablation for the management of medically refractory trigeminal neuralgia (TN). The authors sought to evaluate the clinical significance of this imaging finding in patients who underwent a second radiosurgical procedure for recurrent TN. METHODS During a 22-year period, 360 patients underwent Gamma Knife stereotactic radiosurgery (SRS) as their first surgical procedure for TN at the authors' center. The authors retrospectively analyzed the data from 59 patients (mean age 72 years, range 33-89 years) who underwent repeat SRS for recurrent pain at a median of 30 months (range 6-146 months) after the first SRS. The isocenter was 4 mm, and the median maximum doses for the first and second procedures were 80 Gy and 70 Gy, respectively. A neuroradiologist and a neurosurgeon blinded to the treated side evaluated the presence of nerve contrast enhancement on MRI series at the time of the repeat procedure. The authors correlated the presence of this imaging change with clinical outcomes. Pain outcomes and development of trigeminal sensory dysfunction were evaluated with the Barrow Neurological Institute (BNI) Pain Scale and BNI Numbness Scale, respectively. The mean length of follow-up after the second SRS was 58 months (95% CI 49-68 months). RESULTS At the time of the repeat SRS, contrast enhancement of the trigeminal nerve on MRI scans was observed in 31 patients (53%). Five years after the SRS, patients with this enhancement had lower actuarial rates of complete pain relief after the repeat SRS (27% [95% CI 7%-47%]) than patients without the enhancement (76% [95% CI 58%-94%]) (p < 0.001). At the 5-year follow-up, patients with the contrast enhancement also had a higher risk for trigeminal sensory loss after repeat SRS (75% [95% CI 59%-91%]) than patients without contrast enhancement (26% [95% CI 10%-42%]) (p = 0.001). Dysesthetic pain after repeat SRS was observed for 8 patients with and for 2 patients without contrast enhancement. CONCLUSIONS Trigeminal nerve contrast enhancement on MRI scans observed at the time of a repeat SRS for TN was associated with less satisfactory pain control and more frequently detected facial sensory loss. Residual contrast enhancement at the time of a repeat SRS may warrant consideration of dose reduction or further separation of the radiosurgical targets.
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Seyed H
authors.initials: SH
authors.lastname: Mousavi
authors.affiliation: University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and.
authors.forename: Berkcan
authors.initials: B
authors.lastname: Akpinar
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Ajay
authors.initials: A
authors.lastname: Niranjan
authors.affiliation: Radiology, and.
authors.forename: Vikas
authors.initials: V
authors.lastname: Agarwal
authors.affiliation: University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Cohen
authors.affiliation: Radiation Oncology, University of Pittsburgh Medical Center.
authors.forename: John C
authors.initials: JC
authors.lastname: Flickinger
authors.affiliation: Department of Neurological Surgery, New York University Medical Center, New York, New York.
authors.forename: Douglas
authors.initials: D
authors.lastname: Kondziolka
authors.affiliation: Departments of 1 Neurological Surgery.|Radiation Oncology, University of Pittsburgh Medical Center.
authors.forename: L Dade
authors.initials: LD
authors.lastname: Lunsford
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003287:Contrast Media; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016634:Radiosurgery / Q000379:methods; D012008:Recurrence; D019233:Retreatment; D012189:Retrospective Studies; D016896:Treatment Outcome; D014277:Trigeminal Neuralgia / Q000000981:diagnostic imaging* / Q000532:radiotherapy*
chemical_list: D003287:Contrast Media
keywords: BNI = Barrow Neurological Institute; BNI-NS = BNI Numbness Scale; BNI-PS = BNI Pain Scale; MRI; SRS = stereotactic radiosurgery; TN = trigeminal neuralgia; contrast enhancement; pain; stereotactic radiosurgery; trigeminal neuralgia