Acta Neurochirurgica

, Volume 160, Issue 5, pp 977–986 | Cite as

The timing of stereotactic radiosurgery for medically refractory trigeminal neuralgia: the evidence from diffusion tractography images

  • Cheng-Chia Lee
  • Shin Tai Chong
  • Ching-Jen Chen
  • Sheng-Che Hung
  • Huai-Che Yang
  • Chung-Jung Lin
  • Chih-Chun Wu
  • Wen-Yuh Chung
  • Wan-Yuo Guo
  • David Hung-Chi Pan
  • Hsiu-Mei Wu
  • Jason P. Sheehan
  • Ching-Po Lin
Original Article - Neurosurgical Techniques



Diffusion tensor imaging (DTI) is a novel MRI technique that enables noninvasive evaluation of microstructural alterations in white matter of brain. Initially, DTI was used in intra- or inter-hemispheric association bundles. Recent technical advances are overcoming the challenges of imaging small white matter bundles, such as the cranial nerves. In this study, we use DTI to shed more light on the microstructure changes in long-standing trigeminal neuralgia. We also utilize DTI to study the effect of early stereotactic radiosurgery (SRS) on the microstructures of the trigeminal nerve and to predict the effectiveness of early SRS in the treatment of medically refractory trigeminal neuralgia (TN).


To analyze the presentation of trigeminal nerve, the DTI was reconstructed in 21 cases pre- and post-SRS. DTI parameters recorded include fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), axial diffusivity (AD), linear anisotropy coefficient (Cl), planar anisotropy coefficient (Cp), and spherical anisotropy coefficient (Cs). Comparisons between ipsilateral (symptomatic) and contralateral (asymptomatic) trigeminal nerves and symptom durations of < 5 and ≧ 5 years were performed.


The study cohort comprised 21 patients with TN with a median age of 66 years. Initial adequate facial pain relief (Barrow Neurological Institute facial pain scores I–IIIb) was achieved in 16 (76%) patients. For the pre-SRS DTI findings, ipsilateral trigeminal nerve was associated with higher baseline root entry zone (REZ) Cs compared to contralateral nerve (0.774 vs. 0.743, p = 0.04). Ipsilateral trigeminal nerve with symptoms of < 5 years was associated with higher baseline FA compared to trigeminal nerve with symptoms of ≧ 5 years (0.314 vs. 0.244, p = 0.02). For the post-SRS DTI findings, ipsilateral trigeminal nerves with symptoms of <5 years demonstrated decrease in Cl, while those with symptoms ≧ 5 years demonstrated increase in Cl after SRS at the ipsilateral REZ (− 0.025 vs. 0.018, p = 0.04). At the cisternal segment of ipsilateral trigeminal nerve, symptoms of < 5 years were associated with decreased FA and increased λ2, while symptoms of ≧ 5 years were associated with increased FA and decreased λ2 after SRS (FA − 0.068 vs. 0.031, p = 0.04, λ2 0.0003 vs. − 0.0002, p = 0.02).


SRS provides high rates of initial pain relief with moderate rates of facial hypoesthesia. Ipsilateral trigeminal nerve was associated with higher baseline REZ Cs, and baseline FA was associated with duration of symptoms. There were significant associations between duration of symptoms and changes in ipsilateral REZ Cl, cisternal segment FA, and cisternal segment λ2 after SRS. These preliminary findings serve as comparisons for future studies investigating the use of DTI in radiosurgical planning for patients with TN.


Diffusion tensor imaging Fractional anisotropy Radial diffusivity Axial diffusivity Trigeminal neuralgia Stereotactic radiosurgery Radiation Facial pain 



Axial diffusivity


Barrow Neurological Institute


Linear anisotropy coefficient


Planar anisotropy coefficient


Spherical anisotropy coefficient


Dorsal root entry zone


Diffuse tensor imaging


Fractional anisotropy


Gamma knife radiosurgery




Magnetic resonance imaging


Stereotactic radiosurgery


Trigeminal neuralgia


Radial diffusivities


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.


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Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Cheng-Chia Lee
    • 1
    • 2
    • 3
  • Shin Tai Chong
    • 4
  • Ching-Jen Chen
    • 5
  • Sheng-Che Hung
    • 2
    • 3
  • Huai-Che Yang
    • 1
    • 2
    • 3
  • Chung-Jung Lin
    • 2
    • 6
  • Chih-Chun Wu
    • 2
    • 6
  • Wen-Yuh Chung
    • 2
    • 3
  • Wan-Yuo Guo
    • 2
    • 6
  • David Hung-Chi Pan
    • 3
  • Hsiu-Mei Wu
    • 2
    • 6
  • Jason P. Sheehan
    • 5
  • Ching-Po Lin
    • 1
    • 4
  1. 1.Institute of Brain ResearchNational Yang-Ming UniversityTaipeiTaiwan
  2. 2.School of MedicineNational Yang-Ming UniversityTaipeiTaiwan
  3. 3.Department of NeurosurgeryTaipei Veterans General HospitalTaipeiTaiwan
  4. 4.Institute of NeuroscienceNational Yang-Ming UniversityTaipeiTaiwan
  5. 5.Department of Neurological SurgeryUniversity of Virginia Health SystemCharlottesvilleUSA
  6. 6.Department of RadiologyTaipei Veterans General HospitalTaipeiTaiwan

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