Radiocirugiacutea en las Neuralgia de Trigeacutemino y

Patologia Funcional

Prof Kita Sallabanda

IASP classification paroxysmal unilateral severe pervasive pain of

short duration localized in the distribution of one or more of the

branches of the Vth cranial nerve

Etiology

Vascular Compression

Idiopathic

Herpetic

MEscleroses

Anatomy of the TN

Trigeminal Eminence ( REZ)

Cisternal segment ascending from Rez to the ostium of the Meckelrsquos

cave

Motor root ( portio minor) travels medial and superior to Sensory

root ( portio mayor)

The nerve climbs up to the ostium then descends into the Meckelrsquos cave

The Ganglion of Gasser lies just below the ostium and originates the

trigeminal roots

Peripheral myelin Schwann cells

Central myelin oligodendrocytes

In vitro analysis Radiosensitivity

Central gt Peripheral Myelin

(Ridder et al Root Entry Zone Important in Microvascular

Compression Syndromes Neurosurgery 51(2) 427)

REZ

central ndash peripheral

myelin junction

ldquoShort Circuitrdquo in this Root Entry Zone (REZ)

causes the worse pain man can experience

Barrow Neurological Institute (BNI)

Grade I no pain no medication

Grade II occasional pain no medication

Grade IIIa no pain medication

Grade IIIb pain medication controlled

Grade IV pain not well controlled

Grade V no pain relief

Marseille scale

Class I no pain no medication

Class II no pain medication

Grade III gt90 pain frequency reduction

Grade IV gt50 pain frequency reduction

Grade V no significant pain relief

Grade VI pain worsening

Ovale

V3

Rotundum

V2

Orbit Fissure

V1

90Gy

SCA ndashAICA MVD

Taja JM Tew JM Neurosurgery 1996

1) Age coomorbidity

2) No Vascula Compresion

3) Previous Surgery

4) Patient decision

SCA ndashAICA MVD

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

IASP classification paroxysmal unilateral severe pervasive pain of

short duration localized in the distribution of one or more of the

branches of the Vth cranial nerve

Etiology

Vascular Compression

Idiopathic

Herpetic

MEscleroses

Anatomy of the TN

Trigeminal Eminence ( REZ)

Cisternal segment ascending from Rez to the ostium of the Meckelrsquos

cave

Motor root ( portio minor) travels medial and superior to Sensory

root ( portio mayor)

The nerve climbs up to the ostium then descends into the Meckelrsquos cave

The Ganglion of Gasser lies just below the ostium and originates the

trigeminal roots

Peripheral myelin Schwann cells

Central myelin oligodendrocytes

In vitro analysis Radiosensitivity

Central gt Peripheral Myelin

(Ridder et al Root Entry Zone Important in Microvascular

Compression Syndromes Neurosurgery 51(2) 427)

REZ

central ndash peripheral

myelin junction

ldquoShort Circuitrdquo in this Root Entry Zone (REZ)

causes the worse pain man can experience

Barrow Neurological Institute (BNI)

Grade I no pain no medication

Grade II occasional pain no medication

Grade IIIa no pain medication

Grade IIIb pain medication controlled

Grade IV pain not well controlled

Grade V no pain relief

Marseille scale

Class I no pain no medication

Class II no pain medication

Grade III gt90 pain frequency reduction

Grade IV gt50 pain frequency reduction

Grade V no significant pain relief

Grade VI pain worsening

Ovale

V3

Rotundum

V2

Orbit Fissure

V1

90Gy

SCA ndashAICA MVD

Taja JM Tew JM Neurosurgery 1996

1) Age coomorbidity

2) No Vascula Compresion

3) Previous Surgery

4) Patient decision

SCA ndashAICA MVD

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Anatomy of the TN

Trigeminal Eminence ( REZ)

Cisternal segment ascending from Rez to the ostium of the Meckelrsquos

cave

Motor root ( portio minor) travels medial and superior to Sensory

root ( portio mayor)

The nerve climbs up to the ostium then descends into the Meckelrsquos cave

The Ganglion of Gasser lies just below the ostium and originates the

trigeminal roots

Peripheral myelin Schwann cells

Central myelin oligodendrocytes

In vitro analysis Radiosensitivity

Central gt Peripheral Myelin

(Ridder et al Root Entry Zone Important in Microvascular

Compression Syndromes Neurosurgery 51(2) 427)

REZ

central ndash peripheral

myelin junction

ldquoShort Circuitrdquo in this Root Entry Zone (REZ)

causes the worse pain man can experience

Barrow Neurological Institute (BNI)

Grade I no pain no medication

Grade II occasional pain no medication

Grade IIIa no pain medication

Grade IIIb pain medication controlled

Grade IV pain not well controlled

Grade V no pain relief

Marseille scale

Class I no pain no medication

Class II no pain medication

Grade III gt90 pain frequency reduction

Grade IV gt50 pain frequency reduction

Grade V no significant pain relief

Grade VI pain worsening

Ovale

V3

Rotundum

V2

Orbit Fissure

V1

90Gy

SCA ndashAICA MVD

Taja JM Tew JM Neurosurgery 1996

1) Age coomorbidity

2) No Vascula Compresion

3) Previous Surgery

4) Patient decision

SCA ndashAICA MVD

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Peripheral myelin Schwann cells

Central myelin oligodendrocytes

In vitro analysis Radiosensitivity

Central gt Peripheral Myelin

(Ridder et al Root Entry Zone Important in Microvascular

Compression Syndromes Neurosurgery 51(2) 427)

REZ

central ndash peripheral

myelin junction

ldquoShort Circuitrdquo in this Root Entry Zone (REZ)

causes the worse pain man can experience

Barrow Neurological Institute (BNI)

Grade I no pain no medication

Grade II occasional pain no medication

Grade IIIa no pain medication

Grade IIIb pain medication controlled

Grade IV pain not well controlled

Grade V no pain relief

Marseille scale

Class I no pain no medication

Class II no pain medication

Grade III gt90 pain frequency reduction

Grade IV gt50 pain frequency reduction

Grade V no significant pain relief

Grade VI pain worsening

Ovale

V3

Rotundum

V2

Orbit Fissure

V1

90Gy

SCA ndashAICA MVD

Taja JM Tew JM Neurosurgery 1996

1) Age coomorbidity

2) No Vascula Compresion

3) Previous Surgery

4) Patient decision

SCA ndashAICA MVD

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Barrow Neurological Institute (BNI)

Grade I no pain no medication

Grade II occasional pain no medication

Grade IIIa no pain medication

Grade IIIb pain medication controlled

Grade IV pain not well controlled

Grade V no pain relief

Marseille scale

Class I no pain no medication

Class II no pain medication

Grade III gt90 pain frequency reduction

Grade IV gt50 pain frequency reduction

Grade V no significant pain relief

Grade VI pain worsening

Ovale

V3

Rotundum

V2

Orbit Fissure

V1

90Gy

SCA ndashAICA MVD

Taja JM Tew JM Neurosurgery 1996

1) Age coomorbidity

2) No Vascula Compresion

3) Previous Surgery

4) Patient decision

SCA ndashAICA MVD

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Ovale

V3

Rotundum

V2

Orbit Fissure

V1

90Gy

SCA ndashAICA MVD

Taja JM Tew JM Neurosurgery 1996

1) Age coomorbidity

2) No Vascula Compresion

3) Previous Surgery

4) Patient decision

SCA ndashAICA MVD

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

SCA ndashAICA MVD

Taja JM Tew JM Neurosurgery 1996

1) Age coomorbidity

2) No Vascula Compresion

3) Previous Surgery

4) Patient decision

SCA ndashAICA MVD

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

1) Age coomorbidity

2) No Vascula Compresion

3) Previous Surgery

4) Patient decision

SCA ndashAICA MVD

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

RADIOSURGERY High Doses High Accuracy

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Author Technique Pts Results Follow

Barker96 MVD 1555 70 10y

Broggi90 RF 1000 767 93y

Brown97 Balloon 141 92 22mo

JhoLundsford97 Glycerol 523 77 11y

Maesawa2001

SmithhellipDeSalles2011

GK

D-Novalis

220

133

75

79

3y

3y

Literature Results

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Kondziolka et al used a primate model to explore

the effects of 80 or 100Gy to trigeminal nerves and

observed a combination of axonal degeneration and

edema

Necrosis was seen in nerves that received the

higher dose and both myelinated and unmyelinated

fibers were equally affected

Why the functional improvement is seen in patients

before these histologic changes are seen is

unknown but an effect of GK-SRS on ephaptic

transmission provides a possible mechanism

Prof KSallabanda

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

The relationship between postprocedure numbness and

efficacy suggests that SRS works by blocking axonal

transmission

As predicted by models of radiation injury both the time to

effective pain relief and numbness are delayed although pain

relief frequently occurs many months before any side effects

are experienced

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

90 Gy Demyelinization

Medin amp De Salles ndash Chapter 2007

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Estudios sobre el efecto de la radiacioacuten en el trigeacutemino

bullTractografiacutea para el estudio del efecto de la radiacioacuten sobre el

nervio

bullPermite el estudio de la microestructura de la materia blanca

bullPodemos averiguar si el efecto es debido a cambios en la mielina

axones o

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Individual variability in the effect of radiation on the nerve

Diffusivity assessment suggests the effect is primarily related to myelin

rather than axons

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

QUESTION TO RESOLVE

Doses

Target Localization

Previous Treatment

Recurrency time what to do

Side effects

Prof KSallabanda

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Treatment planning tips

1-Cisternal spaces are large enough to accomodate higher

isodoses

2Pay attention to the brainstem cochlea VII-VIII complex

gasserian ganglion and mesial temporal structures( amygdalo-

hippocampal complex) 3Doses above 10 Gy over the dominant hippocampus are known

to destroy neural progenitors and induce dementia

Prof KSallabanda

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

bull Neurosurgery 2005 Mar56(3)E628 Three-dimensional fast imaging employing steady-state acquisition magnetic resonance imaging for stereotactic radiosurgery of trigeminal neuralgia Chavez GD De Salles AA Solberg TD Pedroso A Espinoza D Villablanca

P Division of Neurosurgery University of California at Los Angeles Los Angeles California USA

A 3-D-FIESTA sequence for visualization of cranial nerves in the cranial base was added to the routine magnetic resonance imaging scan to enhance the treatment planning

VII VIII

Targets TN

REZ

Retrogasserian

Intracysternal segment

Prof KSallabanda

Treatment Planning Target

Selection

Isocenter

NEZ just distal to Pons

50 IDL

Tangential to the brainstem

20 IDL

Just inside

20

30

PONS AXIAL MR

50

80 Gy 1 a 2 a 4 a

DREZ target 96 92 82

Retrogasser 83 69 60

Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille

RadioSurgical Treatments of Trigeminal Neuralgia

Pain Cessation Recurrences

Global 934 (99106) 343 (3499)

MS 100 (77) 571 (47)

Without MS 92 (9299) 217 (2092)

Previous Surg 889 (4045) 275 (1140)

No Prev Surg 967 (5961) 220 (1359)

No Ms No Surg 967 (5860) 207 (1258)

Results 1 a 2a 3a 4a 5a

764 714 679 661 600

No significant diference Previus surgery or not

Better result in umlde novouml patient (no siginificant)

No significant diference diferent doses (70-85Gy)

503 cases Anaacutelises

Barrow Neurological Institute Cl

73 No pain the first year

30 No pain in 10ordm year

105 disesthesias

Conclusioacuten GK SRS is an effective and

safe treatment for TN

More recurrence than in MVD

bull 27 pts F-up=4323mo after 1st2nd SRS

bull Median Doses = 7564Gy for 1st2nd SRS

bull Results Excellent = 5 Fair = 10

Good = 8 Poor = 4

bull Numbness new = 74 worsening = 127

bullNo anesthesia dolorosa

TARGET 2ND SRS

ANTERIOR TO THE TARGET

OF THE 1ST SRS (50 volume overlap between 2 SRS)

23 (852) cases

ge 50 pain relief

Surg Neurol 2006 Oct66(4)350-6

Gorgulho AA De Salles AA

Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA

BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method

Impact of radiosurgery

on the surgical treatment of trigeminal

neuralgia

Treatment Planning Target

Selection

Isocenter

NEZ just distal to Pons

50 IDL

Tangential to the brainstem

20 IDL

Just inside

20

30

PONS AXIAL MR

50

80 Gy 1 a 2 a 4 a

DREZ target 96 92 82

Retrogasser 83 69 60

Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille

RadioSurgical Treatments of Trigeminal Neuralgia

Pain Cessation Recurrences

Global 934 (99106) 343 (3499)

MS 100 (77) 571 (47)

Without MS 92 (9299) 217 (2092)

Previous Surg 889 (4045) 275 (1140)

No Prev Surg 967 (5961) 220 (1359)

No Ms No Surg 967 (5860) 207 (1258)

Results 1 a 2a 3a 4a 5a

764 714 679 661 600

No significant diference Previus surgery or not

Better result in umlde novouml patient (no siginificant)

No significant diference diferent doses (70-85Gy)

503 cases Anaacutelises

Barrow Neurological Institute Cl

73 No pain the first year

30 No pain in 10ordm year

105 disesthesias

Conclusioacuten GK SRS is an effective and

safe treatment for TN

More recurrence than in MVD

bull 27 pts F-up=4323mo after 1st2nd SRS

bull Median Doses = 7564Gy for 1st2nd SRS

bull Results Excellent = 5 Fair = 10

Good = 8 Poor = 4

bull Numbness new = 74 worsening = 127

bullNo anesthesia dolorosa

TARGET 2ND SRS

ANTERIOR TO THE TARGET

OF THE 1ST SRS (50 volume overlap between 2 SRS)

23 (852) cases

ge 50 pain relief

Surg Neurol 2006 Oct66(4)350-6

Gorgulho AA De Salles AA

Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA

BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method

Impact of radiosurgery

on the surgical treatment of trigeminal

neuralgia

80 Gy 1 a 2 a 4 a

DREZ target 96 92 82

Retrogasser 83 69 60

Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille

RadioSurgical Treatments of Trigeminal Neuralgia

Pain Cessation Recurrences

Global 934 (99106) 343 (3499)

MS 100 (77) 571 (47)

Without MS 92 (9299) 217 (2092)

Previous Surg 889 (4045) 275 (1140)

No Prev Surg 967 (5961) 220 (1359)

No Ms No Surg 967 (5860) 207 (1258)

Results 1 a 2a 3a 4a 5a

764 714 679 661 600

No significant diference Previus surgery or not

Better result in umlde novouml patient (no siginificant)

No significant diference diferent doses (70-85Gy)

503 cases Anaacutelises

Barrow Neurological Institute Cl

73 No pain the first year

30 No pain in 10ordm year

105 disesthesias

Conclusioacuten GK SRS is an effective and

safe treatment for TN

More recurrence than in MVD

bull 27 pts F-up=4323mo after 1st2nd SRS

bull Median Doses = 7564Gy for 1st2nd SRS

bull Results Excellent = 5 Fair = 10

Good = 8 Poor = 4

bull Numbness new = 74 worsening = 127

bullNo anesthesia dolorosa

TARGET 2ND SRS

ANTERIOR TO THE TARGET

OF THE 1ST SRS (50 volume overlap between 2 SRS)

23 (852) cases

ge 50 pain relief

Surg Neurol 2006 Oct66(4)350-6

Gorgulho AA De Salles AA

Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA

BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method

Impact of radiosurgery

on the surgical treatment of trigeminal

neuralgia

Stereotactic and Functional Neurosurgery-APM -CHU Timone-Marseille

RadioSurgical Treatments of Trigeminal Neuralgia

Pain Cessation Recurrences

Global 934 (99106) 343 (3499)

MS 100 (77) 571 (47)

Without MS 92 (9299) 217 (2092)

Previous Surg 889 (4045) 275 (1140)

No Prev Surg 967 (5961) 220 (1359)

No Ms No Surg 967 (5860) 207 (1258)

Results 1 a 2a 3a 4a 5a

764 714 679 661 600

No significant diference Previus surgery or not

Better result in umlde novouml patient (no siginificant)

No significant diference diferent doses (70-85Gy)

503 cases Anaacutelises

Barrow Neurological Institute Cl

73 No pain the first year

30 No pain in 10ordm year

105 disesthesias

Conclusioacuten GK SRS is an effective and

safe treatment for TN

More recurrence than in MVD

bull 27 pts F-up=4323mo after 1st2nd SRS

bull Median Doses = 7564Gy for 1st2nd SRS

bull Results Excellent = 5 Fair = 10

Good = 8 Poor = 4

bull Numbness new = 74 worsening = 127

bullNo anesthesia dolorosa

TARGET 2ND SRS

ANTERIOR TO THE TARGET

OF THE 1ST SRS (50 volume overlap between 2 SRS)

23 (852) cases

ge 50 pain relief

Surg Neurol 2006 Oct66(4)350-6

Gorgulho AA De Salles AA

Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA

BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method

Impact of radiosurgery

on the surgical treatment of trigeminal

neuralgia

Results 1 a 2a 3a 4a 5a

764 714 679 661 600

No significant diference Previus surgery or not

Better result in umlde novouml patient (no siginificant)

No significant diference diferent doses (70-85Gy)

503 cases Anaacutelises

Barrow Neurological Institute Cl

73 No pain the first year

30 No pain in 10ordm year

105 disesthesias

Conclusioacuten GK SRS is an effective and

safe treatment for TN

More recurrence than in MVD

bull 27 pts F-up=4323mo after 1st2nd SRS

bull Median Doses = 7564Gy for 1st2nd SRS

bull Results Excellent = 5 Fair = 10

Good = 8 Poor = 4

bull Numbness new = 74 worsening = 127

bullNo anesthesia dolorosa

TARGET 2ND SRS

ANTERIOR TO THE TARGET

OF THE 1ST SRS (50 volume overlap between 2 SRS)

23 (852) cases

ge 50 pain relief

Surg Neurol 2006 Oct66(4)350-6

Gorgulho AA De Salles AA

Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA

BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method

Impact of radiosurgery

on the surgical treatment of trigeminal

neuralgia

503 cases Anaacutelises

Barrow Neurological Institute Cl

73 No pain the first year

30 No pain in 10ordm year

105 disesthesias

Conclusioacuten GK SRS is an effective and

safe treatment for TN

More recurrence than in MVD

bull 27 pts F-up=4323mo after 1st2nd SRS

bull Median Doses = 7564Gy for 1st2nd SRS

bull Results Excellent = 5 Fair = 10

Good = 8 Poor = 4

bull Numbness new = 74 worsening = 127

bullNo anesthesia dolorosa

TARGET 2ND SRS

ANTERIOR TO THE TARGET

OF THE 1ST SRS (50 volume overlap between 2 SRS)

23 (852) cases

ge 50 pain relief

Surg Neurol 2006 Oct66(4)350-6

Gorgulho AA De Salles AA

Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA

BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method

Impact of radiosurgery

on the surgical treatment of trigeminal

neuralgia

bull 27 pts F-up=4323mo after 1st2nd SRS

bull Median Doses = 7564Gy for 1st2nd SRS

bull Results Excellent = 5 Fair = 10

Good = 8 Poor = 4

bull Numbness new = 74 worsening = 127

bullNo anesthesia dolorosa

TARGET 2ND SRS

ANTERIOR TO THE TARGET

OF THE 1ST SRS (50 volume overlap between 2 SRS)

23 (852) cases

ge 50 pain relief

Surg Neurol 2006 Oct66(4)350-6

Gorgulho AA De Salles AA

Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA

BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method

Impact of radiosurgery

on the surgical treatment of trigeminal

neuralgia

Surg Neurol 2006 Oct66(4)350-6

Gorgulho AA De Salles AA

Division of Neurosurgery David Geffen School of Medicine at UCLA University of California at Los Angeles (UCLA) Los Angeles CA 90095 USA

BACKGROUND The history of the development of current available techniques to treat TN was reviewed METHODS The largest peer-reviewed publications on the surgical treatment of refractory TN were analyzed considering the pros and cons of each technique Results of modern peer-reviewed radiosurgery series were presented taking into consideration the approach of each research article Radiation doses and targets for radiosurgery were discussed to maximize the understanding of this technique RESULTS It is concluded that radiosurgery is the least invasive modality with the fewest side effects although to match the results of the competing techniques a substantial number of patients still need some medication intake CONCLUSION Further studies determining the ideal target and radiation dose may bring radiosurgery results to the level of the ones achieved with microvascular decompression currently considered the gold-standard method

Impact of radiosurgery

on the surgical treatment of trigeminal

neuralgia

Clinical Study Stereotact Funct Neurosurg 201189220ndash225

DOI 101159000325672

Outcome for Patients with Essential Trigeminal Neuralgia Treated with

Linear Accelerator Stereotactic Radiosurgery

Marcos Antonio dos Santos Joseacute Bustos Peacuterez de Salcedo

Joseacute Angel Gutieacuterrez Diaz Gorka Nagore a Felipe A Calvo

Joseacute Samblaacutes Hugo Marsiglia Kita Sallabanda

Stereotactic radiosurgery (SRS) is one option for treatment of trigeminal neuralgia after

unsuccessful

conservative approaches Objectives The objective of this study was to retrospectively evaluate

our institutional results in the management of patients with idiopathic trigeminal neuralgia treated

with linear accelerator SRS Methods Fifty-two patients were treated between January 1998 and

December 2009 and were followed for more than 6 months(median 266 months) Forty-seven

patients (90) had undergone previous surgery before SRS The target dose ranged from 50 to

80 Gy Results After SRS 9 patients presented complete remission of the pain and 21 were pain

free but still under medication Eleven patients reported a relief of more than 50 in crisis

frequency In 9 patients no significant improvements were seen and 2 presented an exacerbation

of the pain After an average period of 20 months 15 patients reported pain recurrence Results

were better in patients older than 60 years (p = 0019) Nineteen patients presented facial

numbness after SRS with a trend towardfavorable treatment response (p = 006) Conclusionan

effective alternative to the treatment of essential trigeminal neuralgia with long-lasting

pain relief in more than 50 of the patients Better results were seen with patients aged

more than 60 years Copyright copy 2011 S Karger AG Basel

J Neurosurg 1241079ndash1087 2016

Pain Free without Medication

Initially Pain Free Hypersthesia

Recurrence without Surgery

Jean Regise CONCLUSION

Long term follow up is needed

Randomize Studies is needed

SRS demostrate less morbidity and good results ( 70-90

Gy)

SRS can become a first treatment choise

However MVD remains as the reference technique and

further prospective randomized studies are still needed to

compare the long-term efficacy of radiosurgery with MVD

Is very important the patient decision

Prof KSallabanda

143 Patients 103 treated by conventional RC

39 treated with Cyberknife

Follow up

˃ 6 months

91 patients pretreatment

diathermocoagulation

REZ (16 px)

Retro Gasser ganglion (51 px)

Cysternal (75 px)

TARGET LOCATION

Prof KSallabanda

8

22

58 54

15

0

10

20

30

40

50

60

70

50-60 GY 60-70 GY 70-80 GY gt80 GY

Dose

Prof KSallabanda

114

16 12

0 0

20

40

60

80

100

120

Favorable Partial improvement

Unfavorable

RESULTADOS

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

J Neurosurg 1241079ndash1087 2016

Pain Free without Medication

Initially Pain Free Hypersthesia

Recurrence without Surgery

Jean Regise CONCLUSION

Long term follow up is needed

Randomize Studies is needed

SRS demostrate less morbidity and good results ( 70-90

Gy)

SRS can become a first treatment choise

However MVD remains as the reference technique and

further prospective randomized studies are still needed to

compare the long-term efficacy of radiosurgery with MVD

Is very important the patient decision

Prof KSallabanda

143 Patients 103 treated by conventional RC

39 treated with Cyberknife

Follow up

˃ 6 months

91 patients pretreatment

diathermocoagulation

REZ (16 px)

Retro Gasser ganglion (51 px)

Cysternal (75 px)

TARGET LOCATION

Prof KSallabanda

8

22

58 54

15

0

10

20

30

40

50

60

70

50-60 GY 60-70 GY 70-80 GY gt80 GY

Dose

Prof KSallabanda

114

16 12

0 0

20

40

60

80

100

120

Favorable Partial improvement

Unfavorable

RESULTADOS

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Jean Regise CONCLUSION

Long term follow up is needed

Randomize Studies is needed

SRS demostrate less morbidity and good results ( 70-90

Gy)

SRS can become a first treatment choise

However MVD remains as the reference technique and

further prospective randomized studies are still needed to

compare the long-term efficacy of radiosurgery with MVD

Is very important the patient decision

Prof KSallabanda

143 Patients 103 treated by conventional RC

39 treated with Cyberknife

Follow up

˃ 6 months

91 patients pretreatment

diathermocoagulation

REZ (16 px)

Retro Gasser ganglion (51 px)

Cysternal (75 px)

TARGET LOCATION

Prof KSallabanda

8

22

58 54

15

0

10

20

30

40

50

60

70

50-60 GY 60-70 GY 70-80 GY gt80 GY

Dose

Prof KSallabanda

114

16 12

0 0

20

40

60

80

100

120

Favorable Partial improvement

Unfavorable

RESULTADOS

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

143 Patients 103 treated by conventional RC

39 treated with Cyberknife

Follow up

˃ 6 months

91 patients pretreatment

diathermocoagulation

REZ (16 px)

Retro Gasser ganglion (51 px)

Cysternal (75 px)

TARGET LOCATION

Prof KSallabanda

8

22

58 54

15

0

10

20

30

40

50

60

70

50-60 GY 60-70 GY 70-80 GY gt80 GY

Dose

Prof KSallabanda

114

16 12

0 0

20

40

60

80

100

120

Favorable Partial improvement

Unfavorable

RESULTADOS

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

REZ (16 px)

Retro Gasser ganglion (51 px)

Cysternal (75 px)

TARGET LOCATION

Prof KSallabanda

8

22

58 54

15

0

10

20

30

40

50

60

70

50-60 GY 60-70 GY 70-80 GY gt80 GY

Dose

Prof KSallabanda

114

16 12

0 0

20

40

60

80

100

120

Favorable Partial improvement

Unfavorable

RESULTADOS

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

8

22

58 54

15

0

10

20

30

40

50

60

70

50-60 GY 60-70 GY 70-80 GY gt80 GY

Dose

Prof KSallabanda

114

16 12

0 0

20

40

60

80

100

120

Favorable Partial improvement

Unfavorable

RESULTADOS

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

114

16 12

0 0

20

40

60

80

100

120

Favorable Partial improvement

Unfavorable

RESULTADOS

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Treatment Plan

Max Dose 85Gy Prescpt Dose 60Gy 83 66

of the volumen recive 70Gy( 17022014)

WE APPLY MEDIAL TARGET

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

MRI 8 Months latter HIGT ACCURACY

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Vallerian Degenariton 1 year after SRS

Prof KSallabanda

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Prof KSallabanda

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Failures

Are we treating TN

Finding the nerve can be difficult due to compressiondistorsion atrophyetc

Are we hitting the nerve Take into account MR distorsion and treatment accuracy

MR distorsion + CT-MR fusion+ Clinical accuracy gt2mm

How often do we get the ideal overlap of isodoses and anatomy

Prof KSallabanda

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Discusioacuten SRS effectiv and safe treatment MVD ldquo gold standard

Target

Pollock et al REZ region

Jean Regise retrogasserian we have not yet the gold standtart

Dosis Maximum dose 100Gy

More usefool 85-90 Gy no significant difference between 70-90Gy (12-13)

Surgery

Inmediate effects

Less recurrency

Less face numbness

Ablative Procedures

Less complications

Can be apply in all the patients

Radiosurgery

2ordm liacutene

When surgery can not be apply

Less invasive

Patientes umlde novoumlbest results

Prof KSallabanda

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Discusioacuten Good prognostic

Age

One branch pain No significant

Right part

De Novo patients

Type of TN

Bad prognostic Significant

Multiple Escleroses

Atipic

Prof KSallabanda

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Trigeminal Neuralgia

No Perfect Method of Treatment

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Caso Clinico HamartomaEpilepsia

32 years old woman

Prof KSallabanda

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Caso Cliacutenico Trastornos de MovimientoDolor Intratable

52 years old woman

Prof KSallabanda

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

RMN Cerebral 17102017

Clara mejoriacutea cliacutenica sin medicacioacuten

Prof KSallabanda

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

Lesioning in the treatment of

movement disorders

bullInvasive procedures provide the

opportunity of electrophysiological

mapping

bullDirect lesioning of stimulation

bullNot all patients can have invasive

procedures

bullAge Medical co-morbidities

bullIncreasing number of non-invasive

options

bullRadiosurgery

bullFocused Ultrasound

Prof KSallabanda

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

III Ibero-Latin American Radiosurgery Congress VI Brazilian Radiosurgery Society Congress in

collaboration with ALATRO

Goiacircnia - Brazil

SAVE THE DATE 2018

Nov 15-17th

GRACIAS

GRACIAS