Predictors of trigeminal neuropathy in patients receiving Gamma Knife stereotactic radiosurgery for vestibular schwannoma.

IF 3.5 2区 医学 Q1 CLINICAL NEUROLOGY
Louise Wade, Hazel Boyce, William J H Brown, Philip J Clamp, Alison L Cameron
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Abstract

Objective: The authors' objective was to validate dosimetric and clinical predictors of the development of trigeminal neuropathy (Tn) in patients treated with stereotactic radiosurgery (SRS) for a diagnosis of vestibular schwannoma (VS).

Methods: In total, 301 patients were treated with SRS for VS at the authors' center between April 2013 and June 2020, with a median prescription dose of 12.5 Gy. Ninety-seven patients were excluded: 78 had pre-existing symptoms of Tn, and 19 had < 2 years of follow-up. At follow-up consultations, trigeminal nerve function was prospectively documented in an institutional database. The median follow-up was 4 years. Data from treatment plans were extracted for factors previously reported as predictors of Tn: volume of cranial nerve (CN) V that received at least 11 Gy, maximum dose to CN V, volume of the cisternal portion of CN V, maximum dose to the brainstem, volume of the brainstem that received at least 12 Gy, and tumor volume. Tumor compression of CN V at baseline was also evaluated. Univariate and multivariate analyses of results were performed to identify significant factors.

Results: In total, 23 (11.3%) patients developed symptoms of Tn after SRS; these symptoms were transitory in 7 (30%) cases. Of the 16 patients with permanent Tn, 13 had objective paresthesia (9 had grade II and 4 grade III) and 5 had pain (2 grade II and 3 grade III); included in this are 2 patients who had both paresthesia and pain. In addition, 44% developed symptoms by 1 year after SRS and 100% by 3 years after SRS. On univariate analysis of patients with permanent symptoms, maximum dose to CN V (p = 0.016) was a significant factor. This was not maintained on multivariate analysis when the volume of CN V that received ≥ 11 Gy became the only significant factor (p = 0.029).

Conclusions: The only significant factor in the risk of development of Tn after SRS for VS was the volume of CN V that received ≥ 11 Gy. This should be routinely incorporated into dosimetric planning constraints and patients should be counseled about the risk of adverse effects if it cannot be met. For those with growing VS and a gap to the trigeminal nerve, it may be prudent to provide earlier treatment with SRS to enable application of this dosimetric constraint and reduced risk of Tn.

接受伽玛刀立体定向放射手术治疗前庭分裂瘤的患者发生三叉神经病变的预测因素。
目的:作者的目的是验证因诊断为前庭裂孔瘤(VS)而接受立体定向放射手术(SRS)治疗的患者发生三叉神经病变(Tn)的剂量学和临床预测因素:2013年4月至2020年6月期间,作者所在中心共对301名VS患者进行了SRS治疗,处方剂量中位数为12.5 Gy。97名患者被排除在外:78名患者之前已有Tn症状,19名患者的随访时间小于2年。在复诊时,三叉神经功能会被前瞻性地记录在机构数据库中。中位随访时间为 4 年。从治疗方案中提取的数据包括之前报道过的预测Tn的因素:接受至少11 Gy治疗的颅神经(CN)V的体积、CN V的最大剂量、CN V的睫状体部分的体积、脑干的最大剂量、接受至少12 Gy治疗的脑干的体积以及肿瘤体积。此外,还对基线时CN V的肿瘤压迫情况进行了评估。对结果进行单变量和多变量分析,以确定重要因素:共有 23 例(11.3%)患者在 SRS 后出现 Tn 症状,其中 7 例(30%)的症状为暂时性。在 16 例永久性 Tn 患者中,13 例有客观麻痹感(9 例为 II 级,4 例为 III 级),5 例有疼痛感(2 例为 II 级,3 例为 III 级);其中包括 2 例既有麻痹感又有疼痛感的患者。此外,44% 的患者在 SRS 术后 1 年出现症状,100% 的患者在 SRS 术后 3 年出现症状。在对永久性症状患者进行单变量分析时,CN V 的最大剂量(p = 0.016)是一个重要因素。但在多变量分析中,当CN V接受的剂量≥11 Gy成为唯一的重要因素时(p = 0.029),这一因素就不存在了:结论:VS SRS 后发生 Tn 风险的唯一重要因素是接受治疗的 CN V 体积≥ 11 Gy。应将这一因素常规纳入剂量规划限制中,如果不能满足这一要求,应告知患者不良反应的风险。对于VS不断增大且与三叉神经有间隙的患者,谨慎的做法可能是尽早进行SRS治疗,以便应用这一剂量限制并降低Tn的风险。
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来源期刊
Journal of neurosurgery
Journal of neurosurgery 医学-临床神经学
CiteScore
7.20
自引率
7.30%
发文量
1003
审稿时长
1 months
期刊介绍: The Journal of Neurosurgery, Journal of Neurosurgery: Spine, Journal of Neurosurgery: Pediatrics, and Neurosurgical Focus are devoted to the publication of original works relating primarily to neurosurgery, including studies in clinical neurophysiology, organic neurology, ophthalmology, radiology, pathology, and molecular biology. The Editors and Editorial Boards encourage submission of clinical and laboratory studies. Other manuscripts accepted for review include technical notes on instruments or equipment that are innovative or useful to clinicians and researchers in the field of neuroscience; papers describing unusual cases; manuscripts on historical persons or events related to neurosurgery; and in Neurosurgical Focus, occasional reviews. Letters to the Editor commenting on articles recently published in the Journal of Neurosurgery, Journal of Neurosurgery: Spine, and Journal of Neurosurgery: Pediatrics are welcome.
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