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Published by John R. Adler
Guidelines for treating Trigeminal Neuralgia with CyberKnife
Guidelines for treating Trigeminal Neuralgia with CyberKnife

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Published by: John R. Adler on May 11, 2010
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Trigeminal Neuralgia GuidelinesJohn R. Adler, MDStanford UniversityThe following description outlines the CyberKnife rhizotomy method used for trigeminal neuralgia (TN)at Stanford. I welcome comment.
The initial challenge is to meticulously define the retrogasserian sensory root of CN V in the prepontinecistern. Imaging the nerve was originally done with CT contrast enhanced cisternography alone.However, after detailed comparison studies, and now several years of experience, thin section MRIscanning using a thin slice FIESTA (heavily T-2 weighted) sequence has largely replacedcisternography at Stanford for identifying the trigeminal nerve target. Multiplan image fusion is utilizedto develop a composite data set for final target definition.In the occasional patient in whom MR imaging is not possible, most commonly because of a pacemaker,CT cisternography is still performed. In such patients the procedure begins with a lumbar puncture andthe instillation of 5-8 cc of iodinated contrast (IsoView 300M) into the lumbar subarachnoid space. Thepatient is kept in a prone trendelenberg position for 10-20 minutes allowing contrast to traverse theforamen magnum. Ideally, but not necessarily, this can be monitored under fluoroscopy. Subsequentto the dye equilibrating throughout the intracranial cisterns, the patient is expeditiously imaged with thinslice high resolution CT through the entire head as is typically done for any other routine intracranialCyberKnife case.Fig 1 Depicts a typical FIESTA-weighted MR (left) and a CT cisternogram (right) used for identify theright trigeminal nerve prior to CyberKnife rhizotomy
 Target Delineation
Defining the optimal target is generally the biggest technical challenge confronting the novice whoembarks upon the initial treatment of patients with trigeminal neuralgia. Even with ideal MR imaging theanatomy can be far from ideal in some patients. However, with experience it should be possible todelineate the prepontine trigeminal nerve (i.e. retrogasserian sensory root) in all patients. A fewimportant tricks for this include:1) Identify the opposite trigeminal nerve with the understanding that anatomy tends to besymmetric.2) It is almost always possible to find the trigeminal eminence where the dorsal root merges withthe lateral pons.3) It is generally straightforward to find Meckel’s cave in every patient by virtue of its characteristicnotch on CT, and on MRI, the splaying of the three trigeminal divisions.4) Once the nerve has been identified at the brainstem and within Meckel’s cave, it is a fairly safebet to conclude that the trigeminal sensory root will travel from one to the other.5) Don’t just check the target volume on axial slices; it is important to reference the reconstructedcoronal and sagittal images throughout the entire process of target definition.6) Generally speaking the target volume will be encompassed by 2 to 3, two mm thick MR slicesThe most common mistakes include:1) Mistaking adjacent blood vessels for CN V itself; these are often the offending vesselresponsible for producing the disorder in the first place. Note that vessels can be traced fromslice to slice, and will enhance on CT, which is a good reason to use contrast for CT scanning.2) In previously operated (MVD) patients, the delineation of the intracisternal nerve segment canbe quite challenging; in such cases the teflon pledget distorts the normal anatomy and the massitself often obscure the nerve. Such cases require extra diligence but following the above ruleswill generally keep one from going too far astray.It is critical to realize that the process of delineating the trigeminal nerve is never a simple “paint bynumbers” process. In fact, many novices can badly misplace the target resulting in either an ineffectualor dangerous procedure. However, credible target definition by a knowledgeable user is almost alwayspossible utilizing contemporary imaging.
The Target
There is no universally accepted portion of the trigeminal nerve that is best lesioned whenradiosurgically operating on trigeminal neuralgia. Anecdotally, lesions closest to the brainstem result inmore numbness, while those closer to the semilunar ganglia in Meckel’s cave are associated with ahigher incidence of unpleasant dysesthesia. At Stanford we choose to lesion a nerve segment thatspares the proximal 2 to 3 mm adjacent to the brainstem-as measured along the length of the nerve.The lesion should extend over a 6 to 6.5 mm segment of the sensory root within the prepontine cisternas measured on the reconstructed sagittal imagery; generally speaking this is the maximal length of thetarget. We have been reasonably generous in defining the lateral margins of the nerve and ratherroutinely use a width of ~3mm even if the nerve is slightly thinner. We reason that it is safe to begenerous in this dimension, and by doing so, one may be able to compensate for some inaccuracy intreatment delivery. The dimensions of the final target volume are 6.5 x 3 x 3 mm and the volume of thisoften times staircase region (on reconstructed sagittal imaging) varies between 0.035 and 0.040 cc.
 Treatment Planning
The specifics of treatment planning have evolved significantly over the years, and may still evolve in thefuture, but currently are outlined as follows:Node Set: head 650_trigeminal node setCollimator: 5 mm (remember this is defined at a nominal SAD of 80 cm)Targeted segment: ~6.5 mm of prepontine 5
nerve on the
the targetedsegment of nerve begins 2-3 mm from the DREZ.Critical structures: The brain stem (pons) beginning 1 cm above and ending 1 cm below the level of thetrigeminal nerve is delineated. Brainstem dose is kept to <4000 cGy but the constraint index is only setat strict (generally not more than 0.3 cm
receiving a dose of 12 Gy or higher; i.e V12 of 0.3 cm
.Furthermore, the trigeminal/semi-lunar ganglia should be defined as a volume of anatomy within whichdose should be minimized (generally 38-40 Gy maximum point dose). This requirement need not bestrictly followed since only full dose to the ganglia appears problematic. The ipsilateral cochlea and7
nerve complex should also be contoured and limited to approximately 5-8 Gy and 10-15 Gyrespectively.Dose: Performed with a high resolution dose calculation matrixPrescribed dose: 6000 cGy to ~80
percentile, covering 95% of the delineated targetDmax: 73-75 cGy
Target(s) Total Prescription Dose Number of Sessions
left trigeminal nerveright trigeminal nerve60 Gy to 80% ISL 1
Critical Structure Dose volume constraints Maximum dose constraint
0.3 cm
12 Gy 40 Gyleft cochlearight cochlea
Gy 10 GyipsilateralGausserian ganglion
Gy 40 Gy7
and 8
nerve complex
Gy 15 Gy
The above treatment scheme solves in 30 minutes or less and utilizes 140-160 beams with maxMU/beam set between 100 and 140 MU.A range of dose is specified in part because of continued uncertainty regarding optimal dose and toallow users to respond to variable clinical conditions; it remains possible that increased dose mightcorrelate with faster pain relief. In addition, the planning system is rarely able to arrive at a solutionexactly matching too narrowly specified values. Where necessary we compromise on percentage of thetarget covered by the prescribed dose.

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