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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Trigeminal neuralgia &#40;TN&#41; is the most common type of neuralgia&#44; typically characterized by recurrent unilateral sharp facial pain&#44; triggered by a non-painful stimulus in certain areas on the same facial side&#44; and can comprise one or more branches of the trigeminal nerve&#44; with the mandibular branch being affected in most cases&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> The third edition of the International Classification of Headache Disorders &#40;ICHD-3&#41; establishes that the diagnosis of TN must be determined clinically&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> The etiology of TN can be highly variable&#44; thus demanding a highly accurate and complete representation of anatomical structures and accompanying deviations during the planning of treatment&#46; When morphological changes of the nerve root are demonstrated on MRI or during surgery&#44; the neuralgia is assigned as &#8220;classical TN&#8221;&#46; While&#44; &#8220;secondary TN&#8221; is reserved when there is evidence of underlying neurological disease&#44; namely multiple sclerosis or neoplasms&#46; When the recurrent paroxysms of unilateral facial pain meets criteria for TN&#44; but does not meet the criteria of classical or secondary TN&#44; the neuralgia is designated as &#8220;idiopathic TN&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Traditionally&#44; the treatment for TN starts with pharmaceutical therapy&#44; and surgical or invasive procedures are considered only in the refractory-to-treatment cases&#46; The first line of treatment for TN includes drugs such as&#58; Carbamazepine&#44; Oxcarbamazepine&#44; or Lamotrigine and Baclofen for second line treatment options&#46; Traditional surgical options include&#58; rhizotomies&#44; stereotactic radiosurgery&#44; and microvascular decompressions &#40;MVD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">2</span></a> At the end of 19th century&#44; Hermann Moritz introduced the use of X-rays in the treatment of TN&#44; relieving pain in most of his cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">3&#44;4</span></a> Even with positive results&#44; it was not until the early 1950s when Lars Leksell introduced the use of radiotherapy for TN&#44; using stereotactic radiosurgery &#40;SRS&#41; with X-rays&#44; and later in the 1970s&#44; by the introduction of the GammaKnife &#40;GK&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">5&#8211;7</span></a> The acceptance and popularity of radiosurgery for the treatment of TN has been growing&#44; with accompanying neurophysiological research on the efficacy&#46; However&#44; most of the experience in these reports is based on radiosurgery by GK&#46; The GK is used almost exclusively for cranial lesions&#59; and therefore many centers decide to acquire a linear accelerator &#40;Linac&#41;&#44; which is more adaptable and has a broader spectrum of applications&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A few studies have reported outcomes in TN using Linac&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a> which is an X-ray based device&#44; unlike the GK that employs Cobalt-60 as an energy source&#46; Unfortunately&#44; the difference in the amount of literature in TN between these SRS modalities is a factor to consider when comparisons are made&#46; For instance&#44; in an extensive systematic review and meta-analysis of SRS for TN&#44; Tuleasca et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> identified merely 11 &#40;8&#37;&#41; Linac studies meeting inclusion criteria&#44; against 45 &#40;88&#37;&#41; GK studies&#46; According to the systemic review published by Varela et al&#46;&#44; the outcomes of the reports that describe the Linac-based SRS in the treatment of TN show evidence of equal&#44; and even better&#44; pain relief &#40;75&#8211;95&#46;7&#37;&#41; and lower recurrence rates &#40;5&#37; to 28&#46;8&#37; in the first year of follow-up&#41;&#44; in comparison to GK&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">8&#44;10</span></a> However&#44; there is not enough data reported on or in agreement about the targeting and radiation doses for TN using Linac&#59; as the dosage varies among the studies from 70 to 90<span class="elsevierStyleHsp" style=""></span>Gy with different isodose lines&#44; as well as the target location which has been reported either at the root entry zone or the Gasserian ganglion&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">9&#44;11&#8211;13</span></a> The anatomical measurements of the fifth nerve have been under reported as well in these previous studies&#44; and to the best of our knowledge&#44; only one study has focused on morphological characteristics&#44; but by GK-based SRS&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">14</span></a> The objective of this study was to determine the relationship between the anatomical measurements of the trigeminal nerve and the radiation dosage delivered by simulation for LINAC-based SRS&#44; targeting the root entry zone &#40;REZ&#41;&#44; with a 30&#37; isodose line tangential to the pons&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design</span><p id="par0020" class="elsevierStylePara elsevierViewall">This cross-sectional analysis was performed from January 2003 to December 2012&#44; at the National Institute of Neurology and Neurosurgery in Mexico City&#44; with prior approval by the Institutional Review Board before collection and analysis of data&#46; Fifty-three patients with the confirmed diagnosis of idiopathic TN&#44; without previous surgery or stereotactic radiosurgery&#44; who had a Fast Imaging Employing Steady-state Acquisition &#40;Fiesta&#41; MRI sequence&#44; were included&#46; Patients without a Fiesta sequence or with any pontocerebellar angle pathology were excluded&#46; Our data collecting was staged in three parts&#58; first&#44; the patients demographic and clinical data&#59; second&#44; the anatomical measures of the trigeminal nerve&#59; and third&#44; the targeting and measurements with the radiation delivery by simulation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients characteristics</span><p id="par0025" class="elsevierStylePara elsevierViewall">The demographic and clinical information was obtained from the medical records&#46; We collected demographic variables&#44; such as gender&#44; age&#44; affected side&#44; and trigeminal nerve branches involved&#44; among others&#46; The pain was measured by the Barrow Neurological Institute &#40;BNI&#41; Pain Intensity Scale&#44; and according to the admission note and the note on the last follow-up visit&#46; Also&#44; the treatment approach&#44; therapeutic responses&#44; time of follow-up&#44; and complications or adverse events&#44; were registered&#46; Those patients without evidence of atrophy or displacement in the nerve root on the Fiesta sequence were treated with SRS-only &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&#44; and the data of the modality used&#44; radiation dosage&#44; and the collimators diameters&#44; was gathered&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Fiesta sequence measurements</span><p id="par0030" class="elsevierStylePara elsevierViewall">For all patients included&#44; the Fiesta and conventional MRI sequences were obtained prior to either surgery or radiosurgery&#46; MRIs were performed on two clinical scanners&#58; GE Signa 1&#46;5T MRI System &#40;General Electric Medical Systems&#44; Milwaukee&#44; WI&#44; USA&#41;&#44; and Avanto-SQ Engine 3T Siemens clinical scanner &#40;Siemens AG&#44; Erlangen&#44; Germany&#41;&#46; The parameters used in the Fiesta sequence were&#58; TR&#44; 8&#46;2<span class="elsevierStyleHsp" style=""></span>ms&#59; TE&#44; 2&#46;3<span class="elsevierStyleHsp" style=""></span>ms&#59; flip angle&#59; 65&#176;&#59; matrix&#44; 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>256&#59; FOV&#44; 24<span class="elsevierStyleHsp" style=""></span>cm&#59; slice thickness&#44; 0&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#59; acquisition time&#44; 4<span class="elsevierStyleHsp" style=""></span>min&#44; and 48&#8211;60 slices&#46; Further&#44; parameters in the CISS sequence were&#58; TR&#44; 7&#46;1<span class="elsevierStyleHsp" style=""></span>ms&#59; TE&#44; 2&#46;8<span class="elsevierStyleHsp" style=""></span>ms&#59; flip angle&#59; 43&#176;&#59; matrix&#44; 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>512&#59; FOV&#44; 25<span class="elsevierStyleHsp" style=""></span>cm&#59; slice thickness&#44; 0&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#59; acquisition time&#44; 3<span class="elsevierStyleHsp" style=""></span>min 43<span class="elsevierStyleHsp" style=""></span>s&#44; and 48&#8211;60 slices&#46; 26 &#40;49&#46;1&#37;&#41; and 27 &#40;50&#46;9&#37;&#41; studies were performed by using the 1&#46;5<span class="elsevierStyleHsp" style=""></span>T or 3<span class="elsevierStyleHsp" style=""></span>T MRI scanner&#44; respectively&#46; The length of the cisternal portion of the trigeminal nerve was measured from its rising at the pons to the Gasserian ganglion&#44; on an axial Fiesta MRI sequence by the Osirix<span class="elsevierStyleSup">&#174;</span> software &#40;Pixmeo SARL&#44; Bernex&#44; Switzerland&#41;&#46; The pontine cistern was measured bilaterally and laterally in its wider portions&#44; as well as in its center through the midline&#46; Similarly&#44; the angle formed between the fifth nerve and brainstem with the midline was estimated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Linac-based SRS simulations</span><p id="par0035" class="elsevierStylePara elsevierViewall">Posteriorly&#44; the simulations were performed by IPlan 4&#46;0 BrainLab<span class="elsevierStyleSup">&#174;</span> software &#40;BrainLab AG&#44; Munich&#44; Germany&#41;&#44; simulating a radiation dosage of 85&#8211;90<span class="elsevierStyleHsp" style=""></span>Gy on the REZ target &#40;isocenter&#41;&#44; with the isodose line of 50&#37; outside&#44; 30&#37; tangentially&#44; and 20&#37; &#8804;1&#46;4<span class="elsevierStyleHsp" style=""></span>mm inside of the pons&#46; Circular collimators of 4- and 6-mm we used&#46; Then&#44; the distance between the pons and the calculated target was measured&#44; as well as the distance between the obtained target and the Gasserian ganglion &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; For patients who received treatment &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#44; the procedure is performed using the stereotactic frame &#40;BrainLab AG&#44; Munich&#44; Germany&#41;&#46; REZ was irradiated by applying beams of 6<span class="elsevierStyleHsp" style=""></span>MeV photons&#44; using a Novalis Linac System &#40;BrainLab AG&#44; Munich&#44; Germany&#41;&#46; The patients underwent the procedure with an average duration of 45&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#46; Once the procedure was completed&#44; the stereotactic frame was removed&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Descriptive analysis was conducted by using central tendency and variability measurements&#44; as well as statistical inference according to the variables behavior&#44; using Microsoft Excel<span class="elsevierStyleSup">&#174;</span> software &#40;Microsoft&#44; Redmond&#44; WA&#44; USA&#41;&#46; The continuous variables were compared by Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test or paired <span class="elsevierStyleItalic">t</span>-test&#44; depending on their distribution in the normality tests&#44; using GraphPad Prism<span class="elsevierStyleSup">&#174;</span>&#44; version 7 &#40;GraphPad software&#44; La Jolla&#44; CA&#44; USA&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Demographic and clinical data</span><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 53 patients were included&#44; 43 &#40;81&#46;1&#37;&#41; women and 10 &#40;18&#46;9&#37;&#41; men &#40;ratio 4&#46;3&#58;1&#41;&#44; with a mean age of 55&#46;8 &#40;range 26&#8211;82&#41;&#46; According to the affected side&#44; 36 cases &#40;67&#46;9&#37;&#41; were on the right side&#44; and 17 &#40;32&#46;1&#37;&#41; were on the left side&#46; The most affected trigeminal branch was V3 &#40;81&#46;1&#37;&#41;&#44; either primarily or combined with other branches&#44; followed by V2 &#40;73&#46;6&#37;&#41; and V1 &#40;15&#46;1&#37;&#41;&#46; The combination of affected branches mostly found was V2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V3 &#40;51&#37;&#41;&#44; followed by V1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V3 &#40;5&#46;7&#37;&#41; and V1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V3 &#40;5&#46;7&#37;&#41;&#46; Regarding the pain intensity score&#44; at the initial evaluation&#44; 58&#46;5&#37; of patients reported a BNI score of V&#44; and 41&#46;5&#37; scored a BNI IV&#46; MVD represented the majority treatment in 73&#46;6&#37; of patients&#44; followed by Linac-based SRS in 15&#46;1&#37; of cases&#44; and 1&#46;8&#37; percutaneous therapy&#46; 3&#46;8&#37; of patients had not yet received surgical procedure at the time of the study&#46; Three patients &#40;5&#46;6&#37;&#41; received combined treatment&#58; a patient underwent MVD&#44; and subsequently SRS&#59; while another patient received percutaneous therapy&#44; and then MVD&#59; and another patient had received percutaneous treatment&#44; posteriorly MVD&#44; and finally&#44; SRS&#46; Ten patients underwent frame-based SRS&#44; eight as a single modality of treatment&#44; and two as a combined modality&#59; a radiation dosage of 85&#8211;90<span class="elsevierStyleHsp" style=""></span>Gy was administered with Linac equipment&#44; using a 4-mm collimator&#46; The mean follow-up time was 23&#46;2 months &#40;range&#58; 7&#8211;126 months&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The overall final BNI score was BNI I in 64&#46;2&#37; of patients&#44; BNI II in 7&#46;5&#37;&#44; BNI III in 13&#46;2&#37;&#44; and BNI IV in 5&#46;7&#37;&#46; According to the treatment offered&#44; the preoperative BNI score for the patients undergoing MVD-only &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39 patients&#41; was a BNI IV in 48&#46;7&#37; and a BNI V in 51&#46;3&#37;&#46; After the surgery&#44; these patients showed a BNI I in 76&#46;9&#37;&#44; a BNI II in 7&#46;7&#37;&#44; and a BNI III in 12&#46;8&#37;&#46; Among the patients treated with SRS-only &#40;8 patients&#41;&#44; the pre-SRS BNI score was IV and V&#44; in 25&#37;&#44; and 75&#37; of cases&#44; respectively&#46; The BNI score post-SRS was a BNI I&#44; II&#44; III and IV&#44; in 50&#44; 12&#46;5&#44; 12&#46;5&#44; and 12&#46;5&#37; of patients&#44; respectively&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">At this point&#44; no patient with BNI V was reported&#59; however&#44; 9&#46;4&#37; of the total of patients did not show up for the follow-up&#46; Complications or adverse events were reported in 12 patients&#44; and all of them belonged to the MVD-treated group &#40;12&#47;39&#44; 30&#46;7&#37;&#41;&#46; No complications were found among the SRS-treated patients&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Morphological measurements</span><p id="par0060" class="elsevierStylePara elsevierViewall">The averages of the trigeminal nerve measurements were grouped and analyzed&#44; first according to the side &#40;left vs&#46; right&#41;&#44; and posteriorly by affected-side &#40;unaffected vs&#46; affected&#41;&#46; The average length of the left nerve was 10&#46;7<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 4&#46;7&#8211;18&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and 9&#46;6<span class="elsevierStyleHsp" style=""></span>mm for the right nerve &#40;range&#58; 5&#46;6&#8211;17&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; with a mean difference of 1&#46;1&#46; The mean length of the affected nerve was 9&#46;8<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 4&#46;6&#8211;16&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and was 10&#46;5<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 5&#46;6&#8211;18&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#41; for the unaffected side&#44; with a mean difference of 0&#46;7&#46; A paired <span class="elsevierStyleItalic">t</span>-test was performed to compare these differences between the left vs&#46; right sides and affected vs&#46; unaffected sides&#44; which showed to be statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 and &#46;02&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Concerning the angle of the trigeminal nerve over the ventral surface of the pons with the midline&#44; the mean left angle was 10&#46;6&#176; &#40;range&#58; 5&#46;0&#176; to 18&#46;4&#176;&#41;&#44; and the mean right angle was 12&#46;1&#176; &#40;range&#58; 6&#46;5&#176; to 30&#46;5&#176;&#41;&#44; with a mean difference of 1&#46;5&#176; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;10&#41;&#46; The mean angle of the affected side was 10&#46;2&#176; &#40;range&#58; 5&#46;0&#176; to 30&#46;5&#176;&#41;&#44; and for the unaffected side was 12&#46;5&#176; &#40;range&#58; 5&#46;4&#176; to 19&#46;5&#176;&#41;&#44; with a mean difference of 2&#46;2&#176;&#44; which were significant on the paired t-test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">For measurements regarding the pontine cistern&#44; the left side had a mean length of 8&#46;1<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 4&#46;4&#8211;13&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; while the right side had a mean length of 7&#46;3<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 3&#46;5&#8211;14&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; being significantly different &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; On the affected side&#44; the mean of the cistern was 7&#46;9<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 4&#46;4&#8211;14&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and on the unaffected side was 7&#46;6<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 3&#46;5&#8211;13&#46;8&#41;&#44; with a mean difference of 0&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#46; However&#44; these differences between means were not statistically significant using paired t-tests &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;26&#41;&#46; The average midline length of the pontine cistern was 7&#46;1<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 3&#46;4&#8211;9&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Simulations findings</span><p id="par0075" class="elsevierStylePara elsevierViewall">First&#44; the simulation with the <span class="elsevierStyleItalic">4-mm collimators</span> was performed&#46; The mean distance from the left target toward the pons was 3&#46;8<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 2&#46;4&#8211;5&#46;7<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; while the right side measured 3&#46;7<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 1&#8211;7&#46;2<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The mean distance from the left target to the ipsilateral Gasserian ganglion was 4&#46;2<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 1&#8211;8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; while the right side measured 3&#46;4<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 1&#46;1&#8211;7&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean distance from the target to the pons on the affected side was 3&#46;7<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 2&#46;4&#8211;7&#46;2<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and from the target to the pons on the unaffected side was 3&#46;8<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 2&#46;5&#8211;6&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; This difference was analyzed with a paired <span class="elsevierStyleItalic">t</span>-test and was not significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;22&#41;&#46; The mean distance from the target to the Gasserian ganglion on the affected side was 3&#46;6<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#8211;6&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and from the target to the Gasserian ganglion on the unaffected side was 4&#46;1<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#8211;7&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The difference was significant on the paired <span class="elsevierStyleItalic">t</span>-test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Secondly&#44; the simulation with the <span class="elsevierStyleItalic">6-mm collimators</span> was conducted&#46; The mean distance from the left target to the pons was 5&#46;5<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 3&#46;8&#8211;10<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and the distance from the right target to the pons was 5&#46;3<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 3&#46;7&#8211;9<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; Additionally&#44; the mean distance from the left target to the ipsilateral Gasserian ganglion was 3<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#8211;7&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; while the right side measured 2&#46;2<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#8211;6&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The mean distance from the target to pons on the affected side was 5&#46;3<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 3&#46;7&#8211;9<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and on the unaffected side was 5&#46;5<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 4&#8211;10<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The paired t-test was not significant for this difference &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;11&#41;&#46; The mean distance on the affected side from the target to the Gasserian ganglion was 2&#46;4<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#8211;6&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and on the unaffected side was 2&#46;8<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#8211;7&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; with a difference that was not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The variations in the measurements obtained with the <span class="elsevierStyleItalic">change of the 4- and 6-mm collimators</span> were calculated&#46; An average variation on the distance from the left target to the pons of 1&#46;7<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#46;4&#8211;4&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#41; was found&#44; in order to set a 30&#37; isodose line tangential to the pons&#46; On the right side&#44; the average variation was 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#46;1&#8211;3&#46;1<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; In the same manner&#44; the change of collimators brought the left target closer to the ipsilateral Gasserian ganglion an average distance of 1&#46;3<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#46;2&#8211;3&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; while on the right side was 1&#46;1<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 0&#46;1&#8211;3&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The variation on the affected and unaffected sides with the change of collimators was subsequently calculated&#46; On the affected side&#44; the variation of the distance from the target to the pons was 1&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2<span class="elsevierStyleHsp" style=""></span>mm closer to pons for the 4-mm collimator &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44; and from the target to the Gasserian ganglion was a mean of 1&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>mm closer to the ganglion for the 6-mm collimator &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; Both variations were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 in both cases&#41;&#46; On the unaffected side&#44; the variation of distance between both collimators&#44; from the target to the pons was of 1&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2<span class="elsevierStyleHsp" style=""></span>mm closer to the pons for the 4-mm collimator&#46; And from the target to the ganglion&#44; the variation was of 1&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>mm closer to the ganglion for the 6-mm collimator &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 in both cases&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Demographic and clinical data</span><p id="par0105" class="elsevierStylePara elsevierViewall">TN is a disease characterized by intense intermittent pain and has a significant burden on those who have it&#46; Although reports regarding the epidemiology of the TN are scarce&#44; one of the most recent reviews indicates a prevalence of 0&#46;1&#8211;0&#46;2 per thousand&#44; and an incidence of 4&#8211;5&#47;100&#44;000&#47;year that increases up to 20&#47;100&#44;000&#47;year after age 60&#44; women affected more than men in a proportion of 3&#58;2&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a> Our demographic data coincided with most of the literature&#44; being hit in a higher proportion the women &#40;ratio 4&#46;3&#58;1&#41;&#44; the right side &#40;68&#37;&#41;&#44; and the V2 and V3 branches &#40;51&#37;&#41;&#46; Even though TN is a relatively rare condition&#44; it unquestionably has a high negative impact on the quality of life in those who suffer from it&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In the same manner&#44; the initial pain relief that we found in the patients treated&#44; neither by MVD or SRS&#44; was similar to other reports&#46; A satisfactory pain relief was considered a BNI score I&#8211;III&#46; In the group undergone MVD&#44; a satisfying pain relief rate was achieved in all patients&#44; which agrees with larger case series that have reported an initial pain relief of 98&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> A satisfactory pain relief was reached in 75&#37; of the patients treated with SRS&#44; similar to the range of 75&#8211;95&#46;7&#37; reported by Varela-Lama et al&#46; reviewing Linac for TN&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The dose of radiation given in the SRS group was 85&#8211;90<span class="elsevierStyleHsp" style=""></span>Gy&#44; pursuing an equilibrium risk-benefit&#46; The experience with Linac in the treatment of TN is limited&#59; therefore a broad range of the radiation dosage between different reports has been observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">11&#44;12&#44;18&#44;19</span></a> The decision of the dosage applied by the Linac has been largely based on the knowledge using GK&#46; In general&#44; the basic principal is that the dosage is directly linked to the desired outcome and with the potential adverse effects&#46; In other words&#44; the higher the dose given - the better&#44; earlier and longer the pain is relieved&#44; yet at the higher risk of trigeminal dysfunction&#46; This principle was proposed initially for GK <a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a>&#59; however&#44; some studies are not in agreement as they have not found that a radiation dosage &#62;75<span class="elsevierStyleHsp" style=""></span>Gy was related to either a better outcome or a higher toxicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">10&#44;21</span></a> In the Linac-based reports&#44; it has been considered the multifactorial origin of the trigeminal dysfunction&#44; proposing additional prospective studies to elucidate the optimal dosage administered and the more efficient target location&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">12&#44;13&#44;18&#44;19&#44;22&#44;23</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Morphological measurements</span><p id="par0120" class="elsevierStylePara elsevierViewall">Of the measurements that were taken&#44; the differences of the mean length of the trigeminal nerves and the mean angle of the fifth nerves in relation with the pons&#44; were statistically significant when the affected side was compared with the unaffected one &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#44; respectively&#41;&#46; A comparison with previous reports is difficult due to differences in the characterization of the measurements&#44; such as the number of sides measured&#44; MRI projection used &#40;axial or sagittal&#41;&#44; among others pertinent variables&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Regarding the length of the nerves&#44; we found a mean length of the affected nerve of 9&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#44; and on the unaffected nerve of 10&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3<span class="elsevierStyleHsp" style=""></span>mm&#44; with the mean difference &#40;0&#46;7<span class="elsevierStyleHsp" style=""></span>mm&#41; statistically significant&#46; Previously&#44; Park et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a> reported this difference between the mean length of the affected and unaffected side of the cisternal segment of the trigeminal nerve&#46; They found a nerve 17&#37; shorter on the affected side in 25 of 26 patients with TN who were undergone GK surgery &#40;7&#46;9<span class="elsevierStyleHsp" style=""></span>mm vs&#46; 9&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#44; mean difference of 1&#46;7<span class="elsevierStyleHsp" style=""></span>mm&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a> Later&#44; Parise et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">25</span></a> corroborated this finding in their series of 26 patients with essential TN&#46; They found a shorter trigeminal nerve cisternal length on the affected than on the unaffected side &#40;6&#46;3<span class="elsevierStyleHsp" style=""></span>mm vs&#46; 7&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#44; mean difference of 1&#46;1<span class="elsevierStyleHsp" style=""></span>mm&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">25</span></a> In other reports&#44; it has been mentioned that the mean length of the trigeminal nerve on the affected side in patients with TN who were undergone GK surgery&#44; with no comparison with the contralateral and unaffected side&#46; Regis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> found a mean length of 11&#46;6<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 3&#46;3&#8211;21&#46;2<span class="elsevierStyleHsp" style=""></span>mm&#41; in their 100-patients study&#59; and Hung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">14</span></a> stated an average length of 9&#46;6<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 6&#46;0&#8211;20&#46;7<span class="elsevierStyleHsp" style=""></span>mm&#41; on the affected side in their 106-cases series&#46; Additionally&#44; in another report of 110 asymptomatic individuals using an oblique sagittal view&#44; Kakizawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">27</span></a> calculated the mean length of the trigeminal nerve and compared the measurements between women and men&#44; and the difference was significant &#40;9&#46;7<span class="elsevierStyleHsp" style=""></span>mm in total&#59; 9&#46;2<span class="elsevierStyleHsp" style=""></span>mm in women vs&#46; 10&#46;3<span class="elsevierStyleHsp" style=""></span>mm in men&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In our study&#44; the angulation of the trigeminal nerve was significantly different between the affected and unaffected sides &#40;10&#46;2&#176; vs&#46; 12&#46;5&#176;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; which has yet to be reported in the literature&#46; As a manner of comparison&#44; we found in the Kakizawa et al&#46;&#8217;s report in asymptomatic patients&#44; a mean angle between the fifth nerve and the midline of 9&#46;7&#176;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;8&#176; &#40;9&#46;7&#176; in women and 9&#46;8&#176; in men&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">27</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The difference between cisternal lengths was not statistically significant between the affected and unaffected sides in our study &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;26&#41; even though that the mean length of the affected side was shorter than the unaffected one&#44; corroborating the Parise et al&#46;&#8217;s report&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Simulations findings</span><p id="par0140" class="elsevierStylePara elsevierViewall">The use of radiosurgery for TN&#44; either GK- or Linac-based&#44; has demonstrated its effectiveness to obtain pain relief&#59; however&#44; it is still required to analyze the variation of the target change between 4- and 6-mm collimators&#44; to help to elucidate the optimal dosage and the more efficient target location&#46; For that purpose&#44; after the anatomical measurements were done and analyzed&#44; we performed simulations by IPlan BrainLab<span class="elsevierStyleSup">&#174;</span> &#40;BrainLab AG&#44; Munich&#44; Germany&#41; estimating a radiation dosage of 90<span class="elsevierStyleHsp" style=""></span>Gy&#44; with both collimators&#44; with the 30&#37; isodose line located tangentially to the pons&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">It is important to take into consideration the significant difference that we found in the trigeminal nerve length and its angulation on the affected side&#44; as it is a morphological variant that we could observe in any patient&#44; between the nerve with TN and the unaffected one&#46; The simulations showed a difference in the distance from the target to the pons between the affected and unaffected side&#44; with both collimators&#44; but with no statistical significance&#46; The distance from the target to the site where the trigeminal nerve emerges is critical to analyze&#44; since it determines the radiation dosage that the brainstem receives&#46; The ideal target location is still in debate&#44; and the controversy remains essentially between using either the retrogasserian zone &#40;distal&#41; or the REZ &#40;proximal&#41;&#46; Studies suggested that a target closer to the REZ offers better outcomes in pain relief&#44; but with an increased risk of sensory sequels&#46; R&#233;gis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">28</span></a> reported long-term outcomes of 130 TN patients who receive a radiation dosage from 70 to 90<span class="elsevierStyleHsp" style=""></span>Gy targeting at 7&#46;5<span class="elsevierStyleHsp" style=""></span>mm &#40;retrogasserian&#41; from the emergence of the trigeminal nerve&#44; with an initial pain control of 94&#37;&#44; and 68&#37; at 10 years&#59; but the hypesthesia rate was 21&#37; at 12 months&#46; In another study&#44; Xu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a> reported the results of two matched groups&#58; proximal vs&#46; distal target&#46; The proximal target was located 1&#8211;3<span class="elsevierStyleHsp" style=""></span>mm anterior to the pons with 50&#37; isodose line&#44; and the distal target was 3&#8211;5<span class="elsevierStyleHsp" style=""></span>mm anterior to the pons with 30&#37; isodose line&#59; and a maximum radiation dosage of 80<span class="elsevierStyleHsp" style=""></span>Gy in both groups&#46; In this study&#44; they found that the proximal target was associated with a similar pain relief rate as compared to the distal target&#44; but longer pain relief duration&#44; and an increased risk of facial numbness&#46; Although the better pain-related outcomes are present on proximal targets&#44; the complications of SRS in TN are strongly associated with the radiation dosage extending into the pons&#46; Therefore&#44; the isocenter location should not be determined considering the distance from the target to the pons as a unique factor&#44; but prioritizing the dose of radiation that the brainstem will take&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Additionally&#44; we analyzed the variation of distances from the target to the pons and the Gasserian ganglion&#44; when collimators were changed&#46; We observed a significant difference in all distances between 4- and 6-mm collimators&#46; These findings lead us to consider both the difference between affected and unaffected nerve lengths and the collimators to be used&#44; during the planning of the radiosurgical procedure for TN&#46; It has been described that the REZ of the trigeminal nerve resides at 3<span class="elsevierStyleHsp" style=""></span>mm anterior to the pons surface&#44; and therefore the target to the REZ is usually situated on the 2&#8211;4<span class="elsevierStyleHsp" style=""></span>mm area anterior to the brainstem&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;30&#44;31</span></a> trying to affect the central oligodendrocyte myelin that it is assumed to be more radiosensitive than the peripheral myelin produced by Schwann cells&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a> It is worth pointing out that the REZ is not a fixed area&#44; and its position can differ from 0 to 3<span class="elsevierStyleHsp" style=""></span>mm from the nerve&#39;s emergence in the pons and is not readily detectable on in vivo imaging&#44; as histology is required to distinguish it&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> Due to the susceptibility of the REZ&#44; the proximal isocenter has been targeted despite the jeopardies related to brainstem irradiation&#44; with some results already commented above&#46; However&#44; the current consensus is toward a more anterior approach&#44; as recently comparative studies exhibited relatively similar outcomes between the retrogasserian &#40;distal&#41; and the REZ &#40;proximal&#41; target regarding pain relief&#44; but with fewer complications&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Study limitations</span><p id="par0155" class="elsevierStylePara elsevierViewall">Our study is a retrospective analysis&#44; which reaches its objective of describing anatomical measurements of the trigeminal nerve and their relationship with the simulations during the radiosurgical planning&#46; Using empirical data collected from this study&#44; future prospective studies will hope to address the relationship of morphological measurements with clinical outcomes with a high degree certainty&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Furthermore&#44; the MRI scans were obtained from two different MRI scanners &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>T and 3<span class="elsevierStyleHsp" style=""></span>T&#41;&#46; To minimize the impact of this variable&#44; in a subset of 7 patients who had 1&#46;5<span class="elsevierStyleHsp" style=""></span>T and 3&#46;0<span class="elsevierStyleHsp" style=""></span>T images&#44; the dimensions of the trigeminal nerves were measured and compared on both scans&#44; showing consistency between evaluations and with difference not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; Previously it has been described in some patients the advantages of the 3<span class="elsevierStyleHsp" style=""></span>T over the 1&#46;5T for a better delineating of cranial nerves and identification of vascular compression in TN<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">32</span></a>&#59; however&#44; the 3<span class="elsevierStyleHsp" style=""></span>T is equipment that is not always available in all the medical centers&#44; or replaced the 1&#46;5<span class="elsevierStyleHsp" style=""></span>T during the period of the research projects&#44; as is the case here&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0165" class="elsevierStylePara elsevierViewall">We presented a morphological analysis of the trigeminal nerve in patients with TN on Fiesta MRI sequences&#44; additionally to measurements performed during the simulations by IPlan BrainLab<span class="elsevierStyleSup">&#174;</span> estimating a Linac-based radiation dosage of 90<span class="elsevierStyleHsp" style=""></span>Gy&#44; with 4- and 6-mm collimators&#44; with the 30&#37; isodose line located tangentially to the brainstem&#46; Based on our findings&#44; radiosurgical planning needs to take into account the shorter length of the trigeminal nerve&#44; as well as its more acute angle on the affected side&#46; Distinguishing these anatomical differences are not enough&#44; as we also found that the location of the REZ target changes significantly between using the 4- or 6-mm collimators&#46; Despite these interesting anatomical features&#44; the main factor that will determine the location of the target on the trigeminal nerve in SRS planning for TN is the dose of radiation that the brainstem will be exposed&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">No funding&#44; financial support or industry affiliations were used for this work&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors report no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2018-06-07"
    "fechaAceptado" => "2018-10-04"
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            0 => "Trigeminal neuralgia"
            1 => "Stereotactic radiosurgery"
            2 => "Linac"
            3 => "Simulations"
            4 => "Fiesta sequence"
            5 => "Morphological measurements"
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          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1104621"
          "palabras" => array:8 [
            0 => "TN"
            1 => "REZ"
            2 => "Fiesta"
            3 => "MVD"
            4 => "SRS"
            5 => "GK"
            6 => "Linac"
            7 => "BNI"
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            0 => "Neuralgia trigeminal"
            1 => "Radiocirug&#237;a estereot&#225;ctica"
            2 => "linac"
            3 => "Simulaci&#243;n"
            4 => "Secuencia FIESTA"
            5 => "Mediciones morfol&#243;gicas"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the anatomical measurements of the trigeminal nerve in patients with trigeminal neuralgia &#40;TN&#41; during Linac &#40;linear accelerator&#41;-based stereotactic radiosurgery &#40;SRS&#41; simulation&#44; targeting the root entry zone &#40;REZ&#41;&#44; with a 30&#37; isodose line tangential to the pons&#44; using 4-mm and 6-mm collimators&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this retrospective study&#44; 53 TN patients&#44; who underwent Fiesta sequence scanning prior to any treatment modality&#44; were assessed&#46; Bilateral measurements were obtained from the cisternal segment of the trigeminal nerve&#44; the trigeminal-pontine angle&#44; and the lateral width of the pontine cistern on the Fiesta MRI sequence&#46; Linac-based SRS simulations were estimated with a radiation dosage of 90<span class="elsevierStyleHsp" style=""></span>Gy to 30&#37; isodose line tangential to the pons&#44; with both 4- and 6-mm collimators&#46; Distances from the calculated targets to the pons and the Gasserian ganglion were measured for later analysis&#46; The statistical analysis was performed comparing the affected side against the unaffected side&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Right trigeminal nerve was affected in 36 patients &#40;67&#46;9&#37;&#41;&#44; and left one in 17 &#40;32&#46;1&#37;&#41; patients&#46; The mean length of the trigeminal nerve was 9&#46;8<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 4&#46;6&#8211;16&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#41; on the affected side&#44; and 10&#46;5<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 5&#46;6&#8211;18&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#41; on the unaffected side &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46; The mean trigeminal-pontine angle was 12&#46;5&#176; &#40;range&#58; 5&#46;4&#176; to 19&#46;5&#176;&#41; on the affected side&#44; and 10&#46;2&#176; &#40;range&#58; 5&#46;0&#176; to 30&#46;5&#176;&#41; on the unaffected side &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; In the simulations&#44; the distances from the estimated targets to the pons and the Gasserian ganglion were not statistically different between sides&#46; The variation of target-pons and target-ganglion distances was statistically significant on the affected side with the change of collimators &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In this anatomical study&#44; significant differences were identified in the length of the affected trigeminal nerve and trigeminal-pontine angle compared to the unaffected side in TN patients in Fiesta sequences prior to surgery or radiosurgery&#46; Significant variation of the target location was found on the REZ between the 4- and 6-collimators during the Linac-based SRS simulations with the estimated radiation dosage of 90<span class="elsevierStyleHsp" style=""></span>Gy and 30&#37; isodose line tangential to the pons&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir las mediciones anat&#243;micas del nervio trig&#233;mino en pacientes con neuralgia del trig&#233;mino &#40;NT&#41; en la simulaci&#243;n para radiocirug&#237;a estereot&#225;ctica &#40;SRS&#41; con acelerador lineal &#40;LINAC&#41;&#44; utilizando como blanco la zona de entrada de la ra&#237;z &#40;REZ&#41;&#44; con una l&#237;nea de isodosis del 30&#37; tangencial al puente&#44; usando colimadores de 4 y 6<span class="elsevierStyleHsp" style=""></span>mm&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En este estudio retrospectivo&#44; fueron evaluados 53 pacientes con NT con una secuencia FIESTA de RM previo a recibir alguna modalidad de tratamiento&#46; Las mediciones obtenidas bilateralmente fueron la longitud de la porci&#243;n cisternal del nervio trig&#233;mino&#44; del &#225;ngulo trig&#233;mino-pontino y la anchura lateral de la cisterna pontina&#46; Las simulaciones de SRS con LINAC fueron estimadas con una dosis de radiaci&#243;n de 90<span class="elsevierStyleHsp" style=""></span>Gy a una l&#237;nea de isodosis del 30&#37; tangencial al puente&#44; tanto con colimadores de 4 y 6<span class="elsevierStyleHsp" style=""></span>mm&#46; Las distancias desde los blancos calculados al puente y al ganglio de Gasser&#44; bajo estos par&#225;metros&#44; fueron medidas&#46; El an&#225;lisis estad&#237;stico fue realizado comparando el lado afectado contra el lado no afectado&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El nervio trig&#233;mino derecho se encontr&#243; afectado en 36 pacientes &#40;67&#44;9&#37;&#41;&#44; y el izquierdo en 17 &#40;32&#44;1&#37;&#41; pacientes&#46; La longitud media del nervio trig&#233;mino fue 9&#44;8<span class="elsevierStyleHsp" style=""></span>mm &#40;rango&#58; 4&#44;6-16&#44;8<span class="elsevierStyleHsp" style=""></span>mm&#41; en el lado afectado&#44; y 10&#44;5<span class="elsevierStyleHsp" style=""></span>mm &#40;rango&#58; 5&#44;6-18&#44;4<span class="elsevierStyleHsp" style=""></span>mm&#41; en el lado no afectado&#44; con una diferencia media estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46; El &#225;ngulo trig&#233;mino-pontino fue 12&#44;5&#176; &#40;rango&#58; 5&#44;4-19&#44;5&#176;&#41; en el lado afectado y 10&#44;2&#176; &#40;rango&#58; 5&#44;0-30&#44;5&#176;&#41; en el lado no afectado&#44; con una diferencia media significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; En las simulaciones&#44; las distancias desde los blancos estimados al puente y al ganglio de Gasser no fueron significativamente diferentes entre ambos lados&#46; La variaci&#243;n de las distancias blanco-puente y blanco-ganglio fue estad&#237;sticamente significativa en el lado afectado con el cambio de colimadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En este estudio anat&#243;mico&#44; diferencias significativas fueron identificadas en la longitud del nervio trig&#233;mino y el &#225;ngulo trig&#233;mino-pontino en el lado afectado al compararse con el lado no afectado en pacientes con NT idiop&#225;tica en secuencias FIESTA previo a cirug&#237;a o radiocirug&#237;a&#46; Se observ&#243; variaci&#243;n en la localizaci&#243;n del blanco sobre la REZ en las simulaciones de SRS con LINAC entre los colimadores de 4 y 6<span class="elsevierStyleHsp" style=""></span>mm&#44; con una dosis de radiaci&#243;n estimada de 90<span class="elsevierStyleHsp" style=""></span>Gy y una l&#237;nea de isodosis del 30&#37; paralela al puente&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Illustrations are showing an axial view of pons at the level of the trigeminal nerve&#39;s origin&#46; A&#58; a<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>angle of the fifth nerve with the midline&#46; b<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>length of the trigeminal nerve&#46; B&#58; c<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>medial cistern width in the midline&#46; d<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>lateral cistern width&#46; A and B&#58; P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>pons&#44; M<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>midline&#44; C<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>cerebellum&#44; VCN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>fifth cranial nerve&#44; BA<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>basilar artery&#44; MC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Meckel&#39;s cave&#44; FV<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>fourth ventricle&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparison between the 4-mm &#40;A&#41; and 6-mm &#40;B&#41; collimators&#46; Target with the 6-mm collimator &#8220;gets away&#8221; from pons and &#8220;gets closer&#8221; to Gasserian ganglion&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Graph comparing the mean length of both cisternal trigeminal nerves&#44; affected side vs&#46; unaffected side &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparison of the target-to-pons distance between the 4-mm and 6-mm collimators on the affected side &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; V1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>ophthalmic nerve&#59; V2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>maxillary nerve&#59; V3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>mandibular nerve&#59; MVD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>microvascular decompression&#44; SRS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>stereotactic radiosurgery&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Value &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Female&#58; male ratio</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;3&#58; 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean&#47;median age in years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#47;57 &#40;26&#8211;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Side of Pain&#58; Right&#47;Left</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#47;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Distribution of Pain</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>V1 only&#47;V2 only&#47;V3 only&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;5&#47;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>V2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>V1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>V1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>V3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean maximal dose of Gy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean&#47;median follow-up in months</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#46;2&#47;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Type of Treatment</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>MVD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SRS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SRS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>MVD<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>SRS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Percutaneous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "The International Classification of Headache Disorders&#44; 3rd edition"
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "Headache Classification Committee of the International Headache Society &#40;IHS&#41;"
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                    0 => array:2 [
                      "doi" => "10.1177/0333102418789865"
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                        "volumen" => "38"
                        "paginaInicial" => "1"
                        "paginaFinal" => "211"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30185059"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Treatment options in trigeminal neuralgia"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46; Obermann"
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                    0 => array:2 [
                      "doi" => "10.1177/1756285609359317"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21179603"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "1897 &#8211; celebrating the centennial &#8211; Hermann Moritz Gocht and radiation therapy in the treatment of trigeminal neuralgia"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Artico"
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                            3 => "R&#46; Giuffre"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                      "Revista" => array:5 [
                        "tituloSerie" => "Acta Neurochir &#40;Wien&#41;"
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                        "volumen" => "139"
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                        "paginaFinal" => "763"
                      ]
                    ]
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Radiosurgery in trigeminal neuralgia"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
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                        ]
                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "The stereotaxic method and radiosurgery of the brain"
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                        "tituloSerie" => "Acta Chir Scand"
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                      "titulo" => "Stereotactic radiosurgery"
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Clinical Research
Analysis of morphological measurements of the trigeminal nerve in the linac stereotactic radiosurgery simulation targeting the root entry zone in trigeminal neuralgia
Análisis de las mediciones morfológicas del nervio trigémino en la simulación de radiocirugía estereotáctica con LINAC considerando como blanco la zona de entrada de la raíz en neuralgia trigeminal
Rafael Medélez-Borbonioa,1, Alexander Perdomo-Pantojaa,b,1, Alejandro Apolinar Serrano-Rubioa, Colson Tomberlinc, Rogelio Revuelta-Gutiérreza, Sergio Moreno-Jiméneza,d,
Corresponding author
radioneurocirugia@gmail.com

Corresponding author.
a Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suarez”, Mexico City, Mexico
b Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
c University of Colorado, Boulder, USA
d Department of Radioneurosurgery, ABC Medical Center, Mexico City, Mexico

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