Trigeminal neuralgia Zakrzewska, Joanna M; Linskey, Mark E
BMJ (Online),
02/2014, Letnik:
348, Številka:
feb17 9
Journal Article, Book Review
Recenzirano
Sinusitis Extracranial masses along the course of the trigeminal nerve Pathological enhancement of the trigeminal nerve that could indicate perineural spread of malignancy Cavernous sinus masses ...Demyelination plaques that might indicate multiple sclerosis Intrinsic brain lesions in the thalamus or trigeminal brain stem pathways such as lacunar infarctions Cerebellopontine angle mass lesions such as tumour, epidermoid, dermoid, or arachnoid cyst, aneurysm, or arteriovenous malformation.A multidisciplinary evidence based review of the published literature by the American Academy of Neurology and the European Federation of Neurological Societies concluded that MRI is currently too insensitive for detecting vascular compression of the trigeminal nerve to recommend routine use. 31 32 Some small studies with more sophisticated technology have suggested improved correlations but these technologies are not available routinely at present. 36 However, more sophisticated techniques have been used recently, as reported in small series, which have shown actual changes in the trigeminal nerve. 37 38 Biochemical investigations Depending on the drugs chosen to treat trigeminal neuralgia, particularly among antiepileptic drugs, issues related to reductions in white blood cell count, elevation in liver transaminases, and hyponatraemia are well documented....depending on the treatment planned, a complete blood count at baseline with differential, serum electrolytes, and liver function tests are needed to monitor for potential drug toxicity over time.In this case, two sector blocks were used to custom sculpt the radiation fall-off so that the surface of the brain stem received a dose no greater than 16 Gy Only three randomised controlled trials of reasonable quality have investigated surgical procedures although they do not include microvascular decompression. 53 Furthermore, there is considerable variation in the quality of many cohort data studies. 54 According to large surgical series from multiple sites, microvascular decompression provides patients with about 80% chance of being pain-free without need for further treatment for trigeminal neuralgia, with a recurrence rate of about 10% over 10-20 years. 12 31 32 55 56 57 According to a systematic review for trigeminal neuralgia, the best surgical results in the short term (<=4 years) are achieved with microvascular decompression; the next best results come from the palliative destructive procedures, which have roughly equivalent results. 58 59 A meta-analysis suggested that radiofrequency lesioning had a slight outcome advantage for patients with a higher incidence of treatment induced numbness. 55 Although all surgical procedures for trigeminal neuralgia have roughly equal chances of achieving pain relief without the need for drug treatment, microvascular decompression has a recurrence rate of about 4% per year which plateaus to about 1-2% per year by year six; 56 the palliative destructive procedures have a recurrence rate of about 50% after three to five years, increasing linearly thereafter. 55 Even in experienced hands, microvascular decompression does carry the risk of a patient having to undergo general anaesthesia, a risk (<3%) of hearing loss, as well as the risks (<1%) common to elective open cranial microsurgery. 31 32 60 Percutaneous procedures (radiofrequency lesioning, glycerol rhizolysis, and balloon compression) all require brief periods of heavy sedation and are associated with autonomic responses of trigeminal-vagal nerve reflex, which may be important considerations for patients with significant cardiac disease.Carbamazepine or oxcarbazepine are highly effective but need to be titrated up slowly because they cause significant side effects to the central nervous system Patients will have periods of remission, but it is important that they continue to have access to their drugs and learn to titrate the drugs themselves with the use of pain diaries Untreated or poorly treated trigeminal neuralgia could result in weight loss and depression, and can lead to suicide; thus prompt referral to multidisciplinary teams with an interest in this condition (neurosurgeons, neurologists, pain specialist) is important Refer patients with uncontrolled symptoms for consideration of surgical procedures Opioids do not control this pain, and lidocaine injected into trigger points is much more effective in patients who develop severe unremitting pain Additional educational resources Resources for healthcare professionals NICE clinical knowledge summaries ( http://cks.nice.org.uk/trigeminal-neuralgia )-provides evidence based material on the diagnosis and management of trigeminal neuralgia in primary care guideline 173, November 2013.
Trigeminal neuralgia Zakrzewska, Joanna M; Linskey, Mark E
BMJ (Online),
03/2015, Letnik:
350, Številka:
mar12 4
Journal Article
Recenzirano
The bottom line Trigeminal neuralgia is characterised by sharp stabbing pains that are usually unilateral, last for less than a minute, and occur within the distribution of the fifth cranial nerve ...Few high quality, large randomised control trials are available to guide practice Initial treatment is usually medical with a single first line agent (such as carbamazepine or oxcarbazepine) Consider surgical treatment if an adequate trial of a single first line agent at maximum tolerable dose has failed Trigeminal neuralgia is a characteristic pain in the distribution of one or more branches of the fifth cranial nerve. Effects Treatment Likely to be beneficial Systematic reviews, randomised controlled trials, or the best alternative source of information have shown some effectiveness, although this has not been fully established; benefits are likely to be greater than harms Carbamazepine Oxcarbazepine* Baclofen (in people with multiple sclerosis who develop trigeminal neuralgia)* Trade off between benefits and harms Clinicians and patients should weigh up beneficial and harmful effects according to individual circumstances and priorities Microvascular decompression* Non-percutaneous destructive neurosurgical techniques (stereotactic radiosurgery)* Percutaneous destructive neurosurgical techniques (radiofrequency thermocoagulation, glycerol rhizolysis, and balloon compression)* Unknown effectiveness Data are currently insufficient or of inadequate quality Lamotrigine Gabapentin *Categorisation based on observational studies or consensus, or both.
TRIM11 (tripartite motif-containing protein 11), an E3 ubiquitin ligase, is known to be involved in the development of the central nervous system. However, very little is known regarding the role of ...TRIM11 in cancer biology. Here, we examined the expression profile of TRIM11, along with two stem cell markers CD133 and nestin, in multiple glioma patient specimens, glioma primary cultures derived from tumors taken at surgery and normal neural stem/progenitor cells (NSCs). The oncogenic function of TRIM11 in glioma biology was investigated by knockdown and/or overexpression in vitro and in vivo experiments. Our results showed that TRIM11 expression levels were upregulated in malignant glioma specimens and in high-grade glioma-derived primary cultures, whereas remaining low in glioblastoma multiforme (GBM) stable cell lines, low-grade glioma-derived primary cultures and NSCs. The expression pattern of TRIM11 strongly correlated with that of CD133 and nestin and differentiation status of malignant glioma cells. Knock down of TRIM11 inhibited proliferation, migration and invasion of GBM cells, significantly decreased epidermal growth factor receptor (EGFR) levels and mitogen-activated protein kinase activity, and downregulated HB-EGF (heparin-binding EGF-like growth factor) mRNA levels. Meanwhile, TRIM11 overexpression promoted a stem-like phenotype in vitro (tumorsphere formation) and enhanced glial tumor growth in immunocompromised mice. These findings suggest that TRIM11 might be an indicator of glioma malignancy and has an oncogenic function mediated through the EGFR signaling pathway. TRIM11 overexpression potentially leads to a more aggressive glioma phenotype, along with increased malignant tumor growth and poor survival. Taken together, clarification of the biological function of TRIM11 and pathways it affects may provide novel therapeutic strategies for treating malignant glioma patients.
We report a case of pituicytoma, a rare primary tumor of the neurohypophysis. A 64-year-old man presented with progressive visual complaints, bitemporal hemianopsia, and headache. Imaging studies ...revealed distinctive features of a mass lesion that thickened the pituitary stalk with a bilobed protrusion extending into the hypothalamus. Angiography demonstrated tumor vascular supply from the superior hypophyseal arteries representing the diencephalic branches of the internal carotid arteries. We discuss the imaging and pathology of this unusual tumor.
By definition, the term "radiosurgery" refers to the delivery of a therapeutic radiation dose in a single fraction, not simply the use of stereotaxy. Multiple-fraction delivery is better termed ..."stereotactic radiotherapy." There are compelling radiobiological principles supporting the biological superiority of single-fraction radiation for achieving an optimal therapeutic response for the slowly proliferating, late-responding, tissue of a schwannoma. It is axiomatic that complication avoidance requires precise three-dimensional conformality between treatment and tumor volumes. This degree of conformality can only be achieved through complex multiisocenter planning. Alternative radiosurgery devices are generally limited to delivering one to four isocenters in a single treatment session. Although they can reproduce dose plans similar in conformality to early gamma knife dose plans by using a similar number of isocenters, they cannot reproduce the conformality of modern gamma knife plans based on magnetic resonance image-targeted localization and five to 30 isocenters. A disturbing trend is developing in which institutions without nongamma knife radiosurgery (GKS) centers are championing and/or shifting to hypofractionated stereotactic radiotherapy for vestibular schwannomas. This trend appears to be driven by a desire to reduce complication rates to compete with modern GKS results by using complex multiisocenter planning. Aggressive advertising and marketing from some of these centers even paradoxically suggests biological superiority of hypofractionation approaches over single-dose radiosurgery for vestibular schwannomas. At the same time these centers continue to use the term radiosurgery to describe their hypofractionated radiotherapy approach in an apparent effort to benefit from a GKS "halo effect." It must be reemphasized that as neurosurgeons our primary duty is to achieve permanent tumor control for our patients and not to eliminate complications at the expense of potential late recurrence. The answer to minimizing complications while maintaining maximum tumor control is improved conformality of radiosurgery dose planning and not resorting to homeopathic radiosurgery doses or hypofractionation radiotherapy schemes.
Trigeminal neuralgia Zakrzewska, Joanna M; Linskey, Mark E
Clinical evidence (London : 2006),
10/2014, Letnik:
2014
Journal Article
Recenzirano
Trigeminal neuralgia is a sudden, unilateral, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve. Pain occurs in paroxysms, which can last from a ...few seconds to several minutes. The frequency of the paroxysms ranges from a few to hundreds of attacks a day. Periods of remission can last for months to years, but tend to shorten over time. The condition can impair activities of daily living and lead to depression.
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of ongoing treatments in people with trigeminal neuralgia? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found seven studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: baclofen; carbamazepine; gabapentin; lamotrigine; oxcarbazepine; microvascular decompression; and destructive neurosurgical techniques (radiofrequency thermocoagulation, glycerol rhizolysis, balloon compression, and stereotactic radiosurgery).
Summary CNS metastases are the most common cause of malignant brain tumours in adults. Historically, patients with brain metastases have been excluded from most clinical trials, but their inclusion ...is now becoming more common. The medical literature is difficult to interpret because of substantial variation in the response and progression criteria used across clinical trials. The Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) working group is an international, multidisciplinary effort to develop standard response and progression criteria for use in clinical trials of treatment for brain metastases. Previous efforts have focused on aspects of trial design, such as patient population, variations in existing response and progression criteria, and challenges when incorporating neurological, neuro-cognitive, and quality-of-life endpoints into trials of patients with brain metastases. Here, we present our recommendations for standard response and progression criteria for the assessment of brain metastases in clinical trials. The proposed criteria will hopefully facilitate the development of novel approaches to this difficult problem by providing more uniformity in the assessment of CNS metastases across trials.
Thirty-one (2%) of 1404 consecutive patients with typical trigeminal neuralgia who underwent microvascular decompression between 1972 and 1993 were found to have vascular compression by the vertebral ...artery (VA) or the basilar artery (BA). Compared to the remaining 1373 patients, this subgroup was older (mean age 62 vs. 55 years, p < 0.001), was predominantly male (68% vs. 39%, p < 0.002), demonstrated left-sided predominance (65% vs. 39%, p < 0.002), was more likely to be hypertensive (65% vs. 18%, p < 0.001), and was more likely to have ipsilateral hemifacial spasm (16% vs. 0.6%, p < 0.001). The trigeminal nerve was compressed by the VA in 18 cases (the VA alone in three and the VA plus other vessels in 15), the BA in 12 cases (the BA alone in four and the BA plus other vessels in eight), and the vertebrobasilar junction in one case. Twenty-nine of the 31 patients underwent vascular decompression of the trigeminal nerve, one had a complete trigeminal root section, and one underwent partial root section with vascular decompression of the remaining nerve. All 31 patients were pain-free, off medication immediately after surgery, and this pain-free, medication-free status was maintained at 1 year after surgery in 96% of cases, at 3 years in 92%, and at 10 years in 86%, based on life-table analysis. Minor trigeminal hypesthesia/hypalgesia was present preoperatively in 52%. New or worsened minor hypesthesia/hypalgesia developed in 41% of patients, while transient diplopia as well as hearing loss developed in 23% and 13% in the overall series, respectively. No patient developed major trigeminal sensory loss or masseter weakness after vascular decompression alone. There was no operative mortality. Vascular decompression is an effective treatment for patients with trigeminal neuralgia who have vertebrobasilar compression of the trigeminal nerve. Patients should be warned that decompression of a tortuous vertebrobasilar system carries a higher risk of mild trigeminal dysfunction, diplopia, and hearing loss than standard microvascular decompression.
The objective of this article is to present a concise summary of the most recent evidence-based guidelines in the management of metastatic brain tumors developed by the American Association of ...Neurologic Surgeons (AANS), Congress of Neurologic Surgeons (CNS), and the AANS/CNS Joint Section on Tumors in 2010. Target populations include patients with newly diagnosed metastases as well as recurrent or progressive lesions. The roles of radiotherapy, surgical resection, and stereotactic radiosurgery along with combination therapies are reviewed. Other topics include the role of chemotherapy, anticonvulsants, steroids, and investigational therapies.
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