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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">T1 weigthed MRI shows distal target selection to anterior cisternal portion of TGN&#46; Inner circle represent 50&#37; isodose line whereas outer circle represents 20&#37; isodose line&#46; Note that 20&#37; isodose line stays tangential to brainstem surface&#46;</p>"
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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;TGN&#41; is considered as one of the most disturbing and painful conditions in humans&#46; TGN is a common syndrome characterized by episodic severe pain&#44; and the incidence is approximately 4&#46;3&#8211;8 per 100000&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Several treatments are available for patients with TGN&#44; including medical and surgical options&#46; Although the first treatment of choice is antiepileptic drugs&#44; &#62;50&#37; of the patients eventually require surgical intervention for pain relief&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most commonly employed surgical procedures include open surgery &#91;microvascular decompression &#40;MVD&#41;&#93;&#44; percutaneous procedures &#40;percutaneous balloon compression&#44; percutaneous glycerol rhizotomy&#44; and radiofrequency thermocoagulation&#41; and radiosurgery&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Since the first report of radiosurgery for TGN by Lars Leksell with a prototype tool&#44; Gamma Knife radiosurgery &#40;GKRS&#41; has emerged as a minimal invasive method&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;8</span></a> Many prospective and retrospective studies have demonstrated the safety and efficacy of GKRS in TGN&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of the present study is to assess the long-term results and outcome of a series of TGN patients that underwent GKRS in a single center&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients</span><p id="par0020" class="elsevierStylePara elsevierViewall">Between May 2012 and December 2022&#44; 53 patients underwent radiosurgery in our gamma knife center&#46; Of these 53 patients&#44; 45 were successfully followed up and included to the study&#46; The eight patients excluded patients were lost to follow-up or they had a short follow-up &#40;&#60;6 months&#41;&#46; The mean age of the study patients was 59&#46;8&#160;&#177;&#160;11&#46;9 years &#40;range&#44; 34&#8211;85&#41;&#46; Of the 45 patients&#44; 18 &#40;40&#37;&#41; were man and 27 &#40;60&#37;&#41; were women&#46; The mean duration of the symptoms was 9&#46;53&#160;&#177;&#160;7&#46;2 years &#40;range&#44; 1&#8211;30 years&#41;&#46; All patients had a history of extensive medical treatment with multiple drugs&#46; Anticonvulsants such as carbamazepine&#44; gabapentin and phenytoin were the most commonly used drugs&#46; Four patients &#40;8&#46;9&#37;&#41; could not tolerate drugs&#39; side effects&#46; Twenty-four patients &#40;53&#46;3&#37;&#41; had a history of undergoing at least one surgery&#44; with a mean of 1&#46;92 surgical interventions&#46;Two of these 24 patients had a history of undergoing GKRS at another center&#46; Twenty-one patients &#40;46&#46;7&#37;&#41; had no history of undergoing any surgery&#46; All patients had typical TGN&#46; The right side was affected in 21 patients &#40;46&#46;7&#37;&#41;&#44; and the left side was affected in 24 patients &#40;53&#46;3&#37;&#41;&#46; In 14 patients &#40;31&#46;1&#37;&#41;&#44; a single trigeminal division was affected&#46; V2 affection was in 7 patients and V3 affection in 7 patients&#46; Sole V1 involvement was not detected &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46; In 21 patients &#40;46&#46;7&#37;&#41; two different trigeminal divisions were affected &#40;46&#46;7&#37;&#59; V1&#8211;V2&#44; n &#61; 4 &#91;8&#46;9&#37;&#93;&#59; V2&#8211;V3&#44; n &#61; 17 &#91;37&#46;8&#37;&#93;&#41;&#44; and all three divisions were affected in 10 patients &#40;22&#46;2&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Operative technique</span><p id="par0025" class="elsevierStylePara elsevierViewall">All patients underwent GKRS&#46; A Leksell model G stereotactic frame &#40;Elekta Instruments AB&#44; Stockholm&#44; Sweden&#41; was applied under local anesthesia&#46; Thereafter&#44; magnetic resonance imaging &#40;MRI&#41; was performed for planning the treatment with Leksell GammaPlan &#40;Elekta Instruments AB&#44; Stockholm&#44; Sweden&#41;&#46; A stereotactic MRI &#40;non-gap continuous&#44; square matrix&#41; was performed to delineate trigeminal nerve&#44; and T2-weighted&#44; contrast-enhanced T1-weighted and constructive interference steady state &#40;CISS&#41; MRI sequences were obtained&#46; All the GKRS procedures were performed using Leksell Gamma Knife Perfexion &#40;Elekta Instruments AB&#44; Stockholm&#44; Sweden&#41;&#46; Dose selection and planning were performed by a neurological surgeon&#44; radiation oncologist and medical physicist&#46; A single 4-mm isocenter was used in all instances&#44; which is positioned to cover the anterior cisternal portion of the trigeminal nerve &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; or the root entry zone &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The anterior cisternal target was located 4&#8211;8&#46;3&#160;mm &#40;mean 5&#46;35&#160;&#177;&#160;1&#46;5&#160;mm&#41; anterior to the emergence of the nerve&#44; whereas the target for root entry zone target was located 1&#46;6&#8211;3&#46;9&#160;mm &#40;mean 2&#46;95&#160;&#177;&#160;0&#46;7&#160;mm&#41; anterior to the nerve emergence&#46; The dosage used ranged between 80 and 90&#160;Gy &#40;mean 87&#46;5&#160;&#177;&#160;2&#46;8&#160;Gy&#41;&#46; For the anterior cisternal and root entry zone targets&#44; the isocenter was positioned such that the brainstem surface stays tangential to 20&#37; and 50&#37; isodose lines&#44; respectively&#46; Furthermore&#44; beam channel blocking was used to prevent the 15&#160;Gy isodose line to cover &#60;5&#37; of brainstem&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Pain relief</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patients were classified according to their degree of pain experienced using the Barrow Neurological Institute &#40;BNI&#41; Scale as follows&#58; Class I&#44; no pain&#44; no medication&#59; Class II&#44; occasional pain not requiring medication&#59; Class IIIa&#44; no pain&#44; but continued medication&#59; Class IIIb&#44; pain controlled with medication&#59; Class IV&#44; pain not adequately controlled with medication&#59; Class V&#44; no pain relief &#40;severe pain&#41;&#46; BNI score of I-IIIb were indicative of successful treatment&#44; and BNI scores of IV and V were considered as treatment failure&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients were followed up with clinical visits at three months&#44; six months and one year postoperatively&#46; They were then followed up annually&#46; Final treatment outcome was determined via direct conversations during control visits if possible&#44; or via telephonic interviews conducted by physicians who were not involved in patient selection or management&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Data distribution was assessed using skewness and kurtosis tests&#46; After descriptive statistics were analyzed&#44; the categorical variables were analyzed using Pearson chi-square and Fisher&#8217;s exact tests&#46; The correlation between significant categorical variables studied using Pearson&#8217;s correlation test&#46; The independent <span class="elsevierStyleItalic">t</span>-test was used to compare the variable among various subgroups&#46; Interactions between the variables were examined using logistic regression test&#44; and the odds ratio for each factor was calculated&#46; All statistical analysis were conducted using SPSS &#40;version 25&#46;0&#46;&#44; SPSS Inc&#46;&#44;IBM&#44; Chicago&#44; IL&#44; USA&#41;&#46; A p value of &#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Forty-five patients were followed-up by a mean time of 46&#46;8&#160;&#177;&#160;38&#46;5 months &#40;12&#8211;127 months&#41;&#46; The GKRS failed in nine patients &#40;&#37;20&#41;&#46; They did not experience significant pain relief even after 12 months of follow-up&#44; and they continued to have severe pain &#40;BNI Class V&#41;&#46; The initial success rate was 80&#37; &#40; n &#61; 36&#41;&#46; Among these 36 patients in whom a degree of pain control was achieved&#44; 27 patients &#40;60&#37;&#41; belonged to BNI Class I &#40;excellent pain control&#41;&#44; 1 &#40;2&#46;2&#37;&#41; belonged to BNI Class II&#44; 4 &#40;8&#46;9&#37;&#41; belonged to BNI Class IIIa and 4 &#40;8&#46;9&#37;&#41; belonged to BNI Class IIIb&#46; In total&#44; moderate pain control was achieved in eight patients &#40;17&#46;8&#37;&#41;&#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Pain relief is achieved a mean 2&#46;01&#160;&#177;&#160;2&#46;1 months &#40;range 1 day to 10 months&#41; following GKRS&#46; After GKRS&#44; 30 patients &#40;66&#46;7&#37;&#41; experienced hypoesthesia in related dermatome&#46; The target choise did not affect the development of hypoesthesia &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;38&#41;&#46; Furthermore&#44; there were no significant difference in the distance from nerve emergence in the patients with and without hypoesthesia &#40;3&#46;95&#160;&#177;&#160;1&#46;69&#160;mm and 3&#46;57&#160;&#177;&#160;1&#46;17&#160;mm respectively&#44; <span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;48&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">TGN reccured in 11 patients &#40;24&#46;4&#37;&#41;&#46; Mean duration to recurrence was 27&#46;6&#160;&#177;&#160;14&#46;9 months &#40;range&#44; 12&#8211;66&#41;&#46; Among the patients with TGN recurrence&#44; seven had BNI score of I&#44; one had a score of II&#44; two had a score of IIIa&#44; and one had a score of IIIb&#46; Two of the patients with recurrence &#40;4&#46;4&#37;&#41; deteriorated from BNI Class I to BNI Class II&#46; So&#44; these two patients still have a good pain control and they differ from the other patients who developed a recurrence&#46; At the end of the follow-up period&#44; 20 patients &#40;44&#46;4&#37;&#41; remained in the BNI Class I &#40;excellent pain control&#41;&#46; The mean follow-up of this subgroup was 72&#46;35&#160;&#177;&#160;38&#46;3 months &#40;range&#44; 15-127&#41;&#46; Eight patients &#40;17&#46;8&#37;&#41; remained in the BNI Class IIIa or IIIb &#40;moderate pain control&#41;&#46; At the end of the mean 46&#46;8 months follow-up&#44; excellent to moderate pain control was achieved in 31 patients &#40;68&#46;9&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The followings were considered the factors affecting the treatment success rate and recurrence&#58; age&#44; the segment of TGN&#44; history of previous surgery&#44; existence of multiple sclerosis&#44; TGN duration&#44; radiation dose&#44; and target distance from nerve emergence&#46; Statistical analysis revealed that the treatments&#39; success rate was not affected by target choice &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;35&#41;&#46; Furthermore&#44; the target distance from the nerve emergence did not change the success rate&#46; The mean distance in the success and failure group was 3&#46;85&#160;&#177;&#160;1&#46;63&#160;and 3&#46;59&#160;&#177;&#160;1&#46;08&#160;mm&#44; respectively &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;65&#41;&#46; The target choice is not determinative for recurrence rate&#46; The radiation dose was 87&#46;6&#160;&#177;&#160;2&#46;6&#160;and 87&#160;&#177;&#160;3&#46;4&#160;Gy in the treatment success and failure groups&#44; respectively &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;56&#41;&#46; Additionally&#44; there was no statistically significance between the patients exposed to a dose of 90&#160;Gy and those exposed a dose of &#60;90&#160;Gy &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;77&#41;&#46; At the end of the follow-up period&#44; the rate of permanent pain control was 55&#46;2&#37; and 56&#46;2&#37; when targeting the anterior cisternal portion and root entry zone of the nerve&#44; respectively &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;56&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Comparing to the other factors&#44; the history of previous surgery demonstrated medium statistical significance as a predictor of both treatment failure &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;002 and <span class="elsevierStyleItalic">R</span>&#160;&#61;&#160;0&#46;47&#41; and recurrence &#40; <span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;002 and <span class="elsevierStyleItalic">R</span>&#160;&#61;&#160;0&#46;54&#41;&#46; &#40;&#46; A younger age was also a statistically significant predictor a recurrence &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;01&#41;&#46; In our study&#44; surgical intervention for TGN was preferred for younger patients &#40;56&#46;3&#160;&#177;&#160;11&#46;8 and 63&#46;8&#160;&#177;&#160;10&#46;9 years old&#44; <span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;03&#41;&#46; Regression model analysis revealed that age was not a significant predictor of recurrence &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;18&#41; &#44; whereas a history of previous surgery was a significant predictor &#40; &#40;<span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;02&#41; &#40;OR&#58; 0&#46;11 &#40;95&#37;CI&#58; 0&#46;017&#8722;0&#46;739&#41;&#46; Regression model analysis also revealed that the disease duration was not determinant of history of previous surgery&#40; &#40;8&#46;64&#160;&#177;&#160;7&#46;3 vs 12&#46;9&#160;&#177;&#160;8 years&#44; <span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;16&#41; or the recurrence &#40;8&#46;64&#160;&#177;&#160;7&#46;3 vs 8&#46;82&#160;&#177;&#160;5&#46;9 years&#44; <span class="elsevierStyleItalic">p</span>&#160;&#61;&#160;0&#46;95 &#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Since the first case report of TGN treated with radiosurgery using a prototype guiding device linked to a dental X-ray machine by Lars Leksell in 1971&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and Lindquist&#8217;s publication on the progress of TGN patients following GKRS in 1991&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> GKRS has become an established surgical treatment modality for medically refractory TGN&#46; Due to its minimally invasive nature and very low complication rates&#44; it is currently considered a treatment option initially as well as for disease recurrence&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11&#8211;13</span></a> Although there are no randomized controlled trials that have compared the efficacy of GKRS and other surgical procedures&#44; other studies indicate that they provide similar success rates&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Young individuals with minimal comorbidities are eligible for MVD surgery as a first line of treatment&#44; especially in patients with microvascular conflict&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> MVD provides a higher initial success rates &#40;approximately 90&#37;&#41; as well as highest long-term pain control &#40;61&#8211;88&#37; after 10 years&#41; than GKRS&#46; However&#44; MVD is a posterior fossa surgery&#44; which may be associated with major complications such as cerebrospinal fluid leakage&#44; hearing loss&#44; hydrocephalus&#44; extraocular muscle palsy&#44; facial palsy&#44; cerebellar edema&#44; aseptic or bacterial meningitis&#44; hemorrhage&#44; brainstem infarction and&#44; and rarely&#44; even death&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;8&#44;12&#44;14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Percutaneous procedures provide an initial success rates of 73&#37; to 100&#37; and a recurrence free interval of 20&#8211;22 months&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Percutaneous ablative procedures are associated with morbidities such as hypoesthesia&#44; dysesthesia&#44; corneal keratitis&#44; masseter muscle weakness and anesthesia dolorosa&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However&#44; GKRS is generally associated with only mild complications&#44; including trigeminal nerve sensory disturbance&#44; which is related with dose and target location&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The brainstem irradiation dose and the length of the irradiated nerve segment are the other predisposing factors&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Most patients do not find this complication disabling or bothersome&#44; and consider as a good tradeoff for pain relief&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Post-GKRS hypoesthesia in the trigeminal nerve distribution is predictive of pain relief&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">15</span></a> making it a &#8220;desired&#8221; postoperative complication&#46; Regis et al&#46; reported only 11 cases &#40;2&#46;2&#37;&#41; of bothersome facial numbness in their study of 497 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Prk et al&#46; reported dysesthesia &#40;1&#46;4&#37;&#41; and dry eye syndrome &#40;2&#46;8&#37;&#41; following GKRS&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> No other complications have been reported following GKRS for TGN&#46; According to Urgosik et al&#46;&#44; TGN sensory disturbance is the only significant post-GKRS side effect in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> Similar to the findigns of previous publications&#44; postoperative numbness or hypoesthesia was the only post-GKRS complication in our study &#40;n &#61; 30&#59; 66&#46;7&#37;&#41;&#46; No other complications were encountered&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Various studies have reported an initial success rate&#44; in terms of pain relief&#44; of 70&#37; to 98&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Kondziolka et al&#46;&#44; Regis et al&#46;&#44; Marshall et al&#46;&#44; and Lucas et al&#46;reported 89&#37; pain relief in 503 patients&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> 91&#46;75&#37; in 497 patients&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> 86&#37; in 448 patients<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">17</span></a>&#44; and 84&#46;5&#37; in 446 patients<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">18</span></a>&#44; respectively&#46; Although having a slight lower initial success rate compared to these four largest series in the published literature&#44; our study demostrates an 80&#37; pain relief in 45 patients&#46; Exellent pain control was achieved in 60&#37; of the patients &#40;BNI score I&#41;&#44; and moderate pain control was achieved in 20&#37; &#40;BNI scores II&#44; IIIa and IIIb&#41;&#46; Among these patients&#44; 20 patients &#40;44&#46;4&#37;&#41; remained pain- and drug-free for a mean of 72&#46;4 months&#46; Fourteen of these 20 patients &#40;70&#37;&#41;&#160;had not previously undergone surgery&#46; Thus&#44; GKRS might provide a much longer pain-free follow-up as the first line of treatment&#46; As our statistical analysis revealed&#44; the history of previous surgery was a significant factor influencing both recurrence and initial failure rates&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Other surgical treatments prior to GKRS are associated with lesser pain relief&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> Additionally&#44; failure of one surgical treatment reduced the expectation of complete pain relief&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> We found a significant correlation between the initial success rate and the absence of a previous surgical intervention&#46; In the study by Regis et al&#46;&#44; 65&#46;2&#37; of 497 patients had no history of previous surgery&#46; They found that GKRS was a rational first line of treatment for TGN&#44; considering itsminimally invasive nature&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In different publications&#44; two or more surgeries was associated with treatment failure or higher recurrence rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11</span></a> Therefore&#44; we believe that GKRS is a safe and efficient primary treatment for TGN&#44; which produces pain control for a sufficient duration&#46; However&#44; prospective controlled randomized studies with greater sample size must be conducted to validate our findings&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Although the pathophysiology of TGN is not fully understood&#44; both central and peripheral mechanisms were considered in pathogenesis&#46; Neurovascular compression due to aberrant blood vessel loops in the cisternal segment of trigeminal nerve is most frequently responsible for TGN&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13&#44;20</span></a> Chronic neurovascular compression causes demyelination of the sensory fibers within the proximal nerve root&#44; which leads to hyperexcitability and clinical symptoms&#46; GKRSmost probably causes ionic channel blockage&#47;destruction in addition to focal axonal degeneration&#44; which reduces paroxysms and pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;21&#44;22</span></a> Additionally&#44; irradiation is presumed to be responsible for delayed axonal degeneration&#44; which may account for the significant amount of patients experiencing late pain relief&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">23</span></a> Regis et al&#46; reported a median latency of 10 days &#40;range&#44; 1&#8211;180 days&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> whereas Kondziolka et al&#46; reported a median latency of 1 month &#40;range&#44; 1 day&#8211;1&#160;year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Although current studies report a latency of 15&#8211;78 days after GKRS until pain relief&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">24</span></a> a latency of up to 6 months even 1&#160;year has been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> In our study&#44; the mean latency period was 2 months &#40;range&#44; 1 day&#8211;10 months&#41;&#44; which is similar to the findings in literature&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Another significant parameter&#44; which might affect the outcomes&#44; is the target selection&#46; The trigeminal root entry zone is the transition zone between the peripheral and central myelinization&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a> Oligodendrocytes are more radiosensitivethan Schwann cells&#44; which are responsible of peripheral myelinization&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore&#44; targeting the root entry zone may result in superior pain relief&#44; which is associated with the greater brainstem volumes receiving higher irridation doses&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20&#44;21</span></a> However&#44; some studies propose that targeting the anterior cisternal portionreduces the doses to the brainstem and the associated complications&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> Targeting the distal portion of the nerve is as effective as targeting the proximal portion in producing pain relief&#46; Furthermore&#44; the complication rates are lower when targeting the distal target&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;20</span></a> In our study&#44; the neurosurgeons &#40;MOA&#44; DU&#44; SK&#41; chose the target according to their own understanding of the disease and treatment strategy&#46; Our retrospective study spanned 10 years&#44; and included both anterior cisternal portion and the root entry zone as targets&#46; We did not find any significant association between target selection and outcomes in this wide period&#46; Although proximal target selection reportedly significantly affects the development of post-GKRS hypoesthesia&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">27&#44;28</span></a> we did not find a difference in hypoesthesia development between proximal and distal targeting&#46; This may be attributed to the fact that patients were partially interviewed telephonically regarding their latest clinical condition&#44; as mentioned by Urgosik et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> The limited number of patients may have also played a role in this result&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Previous studies have demostrated that the doses of &#60;70&#160;Gy do not relieve TGN-related pain&#44; and they produce a limited structural effect on the trigeminal nerve&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">29&#44;30</span></a> Doses of &#62;80&#160;Gy might cause partial degeneration with axonal degeneration and demyelination&#44; which is associated with pain relief&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> Although doses of &#62;90&#160;Gy produces similar pain relief&#44; it is associated with higher complication rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Therefore&#44; a dose between 80 and 90&#160;Gy is generally used&#46; We administered 80&#160;Gy to only two patients&#44; who experienced moderate pain relief and initial failure&#44; respectively&#46; However&#44; this finding cannot be solely attributed to the treatment dose because of the limited number of patients and numerous associated factors&#46; In the remaining 43 patients&#44;a dose of 85to 90&#160;Gy were used&#46; We did not find any correlation between the treatment dose and outcome&#46; Similarly&#44; we did not find any statistically significant relation with the treatment dose and complications&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Recurrence rates in the published literature vary greatly&#46; In one study&#44; recurrence rate was 3&#46;3&#37; within a relatively short-term follow-up of 19&#46;8 months&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">31</span></a> Recently&#44; Zhao et al&#46; reported a recurrence rate of 3&#46;6&#37; in 49&#46;7 months&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">32</span></a> However&#44; higher recurrence rates were reported in some series with shorter follow-up&#46; Kondziolka et al&#46; reported a recurrence rate of 42&#46;9&#37; among 503 patients in 24 months&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Lucas et al&#46; reported a recurrence rate of 45&#46;6&#37; among 446 patients in 21&#46;2 months&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">18</span></a> In our study&#44; the recurrence rate was 27&#46;5&#37; within 46&#46;8 months&#44; which was similar to the findings of previous studies in which the recurrence rate was 25&#8211;31&#46;2&#37; within 30&#8211;64&#46;7 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">16&#44;33&#44;34</span></a> The statistically significant factors affecting recurrence rates were younger age and a history of previous surgeries&#46; However&#44; regression model analysis revealed that a history of the previous surgeries was the only statistically significant factor&#59; the statistical significance of age was diminshed&#46; Additionally&#44; we found a correlation between younger age and increased number of previous surgeries&#46; There is a tendency of more aggressive selection of surgical options in the management of younger patients&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> whereas elderly patients were commonly managed with conservative medical treatment&#46; As a result of it&#44; there was overlapping in history of previous surgeries and younger age in our study&#46; We believe this explains why we identified younger age as a significant factor in recurrence rates during the single-factor analysis&#44; but the regression model excluded younger age as a recurrence factor by detecting this co-occurrence&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">This study had several limitations&#46; First&#44; despite the considerably long follow-up period&#44; the sample size is relatively small&#44; the treatment was performed on different targets with different doses&#46; Second&#44; this is a retrospective study&#46; Although we had not initally aimed to compare the different treatment groups&#44; we attempted to draw some calculations using the data collected&#46; Third&#44; most patients were interviewed telephonically to determine their latest condition&#46; There may be some subjectivity involved&#44; as certain complaints that seem unimportant to the patientmay be significant for the physician&#44; such as the presence of hypoesthesia&#46; If the patient did not mention it or attribute importance to it&#44; it cannot be reported&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">GKRS is a safe and efficient method to manage medically refractory trigeminal neuralgia both as a primary or non-primary treatment option&#46; Despite all the precautions&#44; sensory impairment may occur following the procedure&#46; However&#44; GKRS is associated with better pain control in long term&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">No funding&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">Mehmet Osman Akcakaya&#44; Muyassar Mirkhasilova&#44; Onur Ozturk&#44; Doga Ugurlar&#44; Mehmet Tonge&#44; Gul Alco&#44; Tulay Ercan&#44; Sefik Igdem and Selhan Karadereler declare that they have no conflict of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We aimed to assess the outcomes of patients with trigeminal neuralgia &#40;TGN&#41; who underwent Gamma Knife radiosurgery &#40;GKRS&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Fifty-three patients with typical TGN underwent GKRS from May 2012 until December 2022&#46; Among these patients&#44; 45 patients who were follow-up for at least 12 months were included in the study&#46; A mean dose of 87&#46;5&#160;Gy &#40;range&#44; 80&#8211;90&#41; was administered to the trigeminal nerve&#46; Postoperatively&#44; outcome was considered excellent if the patient was pain- and medication-free&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The mean symtpom duration was 9&#46;53 years&#44; and the mean patient age was 59&#46;8 years &#40;range&#44; 34&#8211;85&#41;&#46; The mean follow-up period was 46&#46;8 months &#40;range&#44; 12&#8211;127 months&#41;&#46; 46&#46;7&#37; of patients had a history of previous surgical interventions&#46; A single nerve division was affected in 14 patients &#40;31&#46;1&#37;&#41;&#44; and multiple divisions were affected in 31 patients &#40;68&#46;9&#37;&#41;&#46; The rate of initial pain relief was 80&#37;&#46; Hypoesthesia in the area of trigeminal nerve developed in 30 &#40;66&#46;7&#37;&#41;&#46; Twenty patients &#40;44&#46;4&#37;&#41; exhibited excellent results within 72&#46;4 months&#46; Recurrence occurred in 11 patients &#40;24&#46;4&#37;&#41; with 27&#46;6 months&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Our results suggest that GKRS is a safe and effective procedure&#46; Thus&#44; it is an attractive first- and second-line treatment choice for TGN&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo fue evaluar los resultados de los pacientes con neuralgia del trig&#233;mino &#40;TGN&#41; que se sometieron a radiocirug&#237;a con Gamma Knife &#40;GKRS&#41;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y M&#233;todos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cincuenta y tres pacientes con TGN tipica se sometieron a GKRS entre mayo de 2012 y diciembre de 2022&#46; Entre estos pacientes&#44; se incluyeron al estudio 45 pacientes que fueron seguidos durante al menos 12 meses&#46; Se administr&#243; una dosis media de 87&#44;5 Gy &#40;rango&#44; 80-90&#41; al nervio trig&#233;mino&#46; El resultado postoperatorio se consider&#243; excelente si el paciente no padec&#237;a dolor ni medicaci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La duraci&#243;n media de los s&#237;ntomas fue de 9&#44;53 a&#241;os y la edad media de los pacientes fue de 59&#44;8 &#40;rango&#44; 34 a 85&#41;&#46; El per&#237;odo medio de seguimiento fue de 46&#44;8 meses &#40;rango&#44; 12-127 meses&#41;&#46; El 46&#44;7&#37; de los pacientes ten&#237;a antecedentes de intervenciones quir&#250;rgicas previas&#46; Una sola divisi&#243;n nerviosa se vio afectada en 14 pacientes &#40;31&#44;1&#37;&#41; y multiples divisiones en 31 pacientes &#40;68&#44;9&#37;&#41;&#46; La tasa de alivio del dolor inicial fue del 80&#37;&#46; La hipoestesia en el &#225;rea de distribuci&#243;n del nervio trig&#233;mino se desaroll&#243; en 30 pacientes &#40;66&#44;7&#37;&#41;&#46;Viente pacientes &#40;44&#44;4&#37;&#41; mostraron excelentes resultados en 72&#44;4 meses&#46; La recurrencia se desaroll&#243; en 11 pacientes &#40;24&#44;4&#37;&#41; con 27&#44;6 meses&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados sugieren que GKRS es un procedimiento seguro y eficaz&#46; Por tant&#305;&#44; es una opci&#243;n atractiva de primera y segunda l&#237;nea para la TGN&#46;</p></span>"
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CISS MRI shows proximal target selection to REZ of TGN&#46; Inner circle &#40;yellow&#41; represents 50&#37; isodose line and outer circle &#40;green&#41; represents 20&#37; isodose line&#46; Note that 50&#37; isodose line stays tangential to brainstem surface&#46;</p>"
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      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr2.jpeg"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">T1 weigthed MRI shows distal target selection to anterior cisternal portion of TGN&#46; Inner circle represent 50&#37; isodose line whereas outer circle represents 20&#37; isodose line&#46; Note that 20&#37; isodose line stays tangential to brainstem surface&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Age &#40;year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">59&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">62&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">59&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of symptoms &#40;year&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">33&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">58&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total <span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&#47;<span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Previous Surgery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Radiofrequency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Balloon compression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Glycerol injection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#46;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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Microvascular decompression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">91&#46;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="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Gamma Knife&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">BNI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">I</th><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">II</th><th class="td-with-role" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IIIa</th><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IV</th><th class="td-with-role" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">V</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
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Journal Information
Vol. 35. Issue 5.
Pages 225-232 (September - October 2024)
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Vol. 35. Issue 5.
Pages 225-232 (September - October 2024)
Clinical Research
Gamma Knife radiosurgery for the treatment of trigeminal neuralgia: A single center-experience
Radiocirugía Gamma-Knife para el tratamiento de la neuralgia del trigémino: una experiencia en un solo centro
Mehmet Osman Akcakayaa