Dosimetric impact of rotational errors in trigeminal neuralgia radiosurgery using CyberKnife

Purpose: Trigeminal neuralgia (TN) can be treated on the CyberKnife system using two different treatment delivery paths: the general-purpose full path corrects small rotations, while the dedicated trigeminal path improves dose fall-off but does not allow rotational corrections. The study evaluates the impact of uncorrected rotations on brainstem dose and the length of CN5 (denoted as L-eff) covered by the prescription dose.Methods and materials: A proposed model estimates the delivered dose considering translational and rotational delivery errors for TN treatments on the CyberKnife system. The model is validated using radiochromic film measurements with and without rotational setup error for both paths. L-eff and the brainstem dose is retrospectively assessed for 24 cases planned using the trigeminal path. For 15 cases, plans generated using both paths are compared for the target coverage and toxicity to the brainstem.Results: In experimental validations, measured and estimated doses agree at 1%/1 mm level. For 24 cases, the treated L-eff is 5.3 +/- 1.7 mm, reduced from 5.9 +/- 1.8 mm in the planned dose. Constraints for the brainstem are met in 23 cases for the treated dose but require frequent treatment interruption to maintain rotational corrections <0.5(degrees) using the trigeminal path. The treated length of CN5, and plan quality metrics are similar for the two paths, favoring the full path where rotations are corrected.Conclusions: We validated an analytical model that can provide patient-specific tolerances on rotations to meet plan objectives. Treatment using the full path can reduce treatment time and allow for rotational corrections.