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

  • Original Article - Neurosurgical Techniques
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Abstract

Background

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).

Methods

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.

Results

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).

Conclusions

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.

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Abbreviations

AD:

Axial diffusivity

BNI:

Barrow Neurological Institute

Cl:

Linear anisotropy coefficient

Cp:

Planar anisotropy coefficient

Cs:

Spherical anisotropy coefficient

DREZ:

Dorsal root entry zone

DTI:

Diffuse tensor imaging

FA:

Fractional anisotropy

GKRS:

Gamma knife radiosurgery

Gy:

Gray

MRI:

Magnetic resonance imaging

SRS:

Stereotactic radiosurgery

TN:

Trigeminal neuralgia

RD:

Radial diffusivities

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Authors and Affiliations

  1. Institute of Brain Research, National Yang-Ming University, 155, Li-Nong Street, 112, Taipei, Taiwan

    Cheng-Chia Lee, Huai-Che Yang & Ching-Po Lin

  2. School of Medicine, National Yang-Ming University, Taipei, Taiwan

    Cheng-Chia Lee, Sheng-Che Hung, Huai-Che Yang, Chung-Jung Lin, Chih-Chun Wu, Wen-Yuh Chung, Wan-Yuo Guo & Hsiu-Mei Wu

  3. Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan

    Cheng-Chia Lee, Sheng-Che Hung, Huai-Che Yang, Wen-Yuh Chung & David Hung-Chi Pan

  4. Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan

    Shin Tai Chong & Ching-Po Lin

  5. Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA

    Ching-Jen Chen & Jason P. Sheehan

  6. Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan

    Chung-Jung Lin, Chih-Chun Wu, Wan-Yuo Guo & Hsiu-Mei Wu

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  1. Cheng-Chia Lee
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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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Comments

The authors report on careful DTI studies of trigeminal nerves in trigeminal neuralgia patients treated with radiosurgery. Of special interest to me was the difference in fractional anisotropy between short-term and long-term trigeminal patients that may reflect the extent of myelin damage. Clinical correlation of DTI parameters with the extent of nerve damage may allow for better prediction of outcome in various therapeutic procedures. Serial fractional anisotropy changes in the imaged trigeminal root over time could also optimize the time window for intervention.

DTI is a novel tool in the evaluation of cranial nerve pathology but hints of intriguing possibilities in improving patient follow-up and care.

Zvi Harry Rappaport

Petah Tiqvah, Israel

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Lee, CC., Chong, S.T., Chen, CJ. et al. The timing of stereotactic radiosurgery for medically refractory trigeminal neuralgia: the evidence from diffusion tractography images. Acta Neurochir 160, 977–986 (2018). https://doi.org/10.1007/s00701-017-3449-9

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