Recurrence of trigeminal neuralgia due to an acquired arachnoid cyst

We present the case of a 55-year-old female with pain recurrence after microvascular decompression for trigeminal neuralgia due to development of an arachnoid cyst. Radioimaging studies were inconclusive for vascular compression but showed evidence of fifth nerve distortion. The patient underwent surgical re-exploration, and a cystic lesion of thickened arachnoid containing cerebrospinal fluid was identified and excised. Postoperatively, the patient obtained pain relief. Arachnoid cyst formation may be a possible reason for pain recurrence after microvascular decompression for trigeminal neuralgia, especially when repeat neuroimaging does not show clear evidence of fifth nerve vascular compression. Direct compression from the cyst or arterial pulsation transmission through the cyst to the nerve may be the cause of recurrence.     

Trigeminal neuralgia as unusual isolated symptom of fungal paranasal sinusitis in patients with haematological malignancies

A sinonasal infection is a frequent complication in patients with haematological malignancies, and may represent a challenge in terms of differential diagnosis between a bacterial or fungal infective process and tumour localization. A timely and correct diagnosis in these patients is critical and, therefore, may require consultation of specialists outside of haematology; an incorrect diagnosis which underestimates the seriousness of the infection can be fatal. Symptomatic trigeminal neuralgia resulting from direct compression or perineural invasion from malignancy is not uncommon in the literature. However, trigeminal neuralgia as an isolated symptom at the onset of a bacterial or invasive fungal sinusitis is rare and risks going unnoticed. The authors herein describe three cases of patients affected by acute myeloid leukaemia or lymphoma in which an invasive fungal sinusitis appeared at the onset as an isolated trigeminal neuralgia, with pain located along the distribution area of the second branch of the trigeminal nerve. Only after referring these patients to a neurologist for a host of neurological exams it was possible to confirm a diagnosis of secondary maxillary sinus fungal involvement.     

Trigeminal neuralgia in a patient with Dandy-Walker malformation.

BACKGROUND: Trigeminal neuralgia may be idiopathic or secondary to a number of cranial pathologies. We report a novel case of trigeminal neuralgia associated with Dandy-Walker malformation, which may be an etiologic factor. CASE DESCRIPTION: A 32-year-old male presented with shock-like pain in the somatosensory distribution of the right trigeminal nerve, which was refractory to all medication. MRI revealed a cystic lesion in the posterior fossa and a hypoplastic vermis. The pain was diagnosed as trigeminal neuralgia and was thought to be secondary to the Dandy-Walker malformation. The trigeminal neuralgia was treated successfully with radiofrequency thermocoagulation rhizotomy (RF-TR). CONCLUSION: Trigeminal neuralgia may be associated with Dandy-Walker malformation, however an etiological relationship is not proven. We suggest that traction on the trigeminal nerve may be significant. The posterior fossa cyst of Dandy-Walker malformation may be a complicating factor when considering microvascular decompression to treat the trigeminal neuralgia. Collapse of the cyst at surgery may destabilize the posterior fossa and further deform the trigeminal nerve. We suggest that RF-TR, which is minimally invasive and reliable, may be preferable.     

Idiopathic bilateral trigeminal neuralgia treated by bilateral microvascular decompression

Idiopathic trigeminal neuralgia is the most common type of cranial neuralgia. Trigeminal neuralgia is a form of facial pain characterized by proximal lancinating pain confined to the somatosensory distribution of the trigeminal nerve. Bilateral trigeminal neuralgia is a rare situation with an incidence of 1% to 6% in large trigeminal neuralgia series. There is no single or standard method for the treatment of bilateral trigeminal neuralgia. Microvascular decompression for treatment trigeminal neuralgia is an effective and relatively safe method in older patients. We report a rare case of bilateral trigeminal neuralgia treated by bilateral microvascular decompression.     

Trigeminal neuralgia due to multiple sclerosis: ultrastructural findings in trigeminal rhizotomy specimens

Trigeminal neuralgia is a well-recognized complication of multiple sclerosis. In patients with neuralgia not responding to medical treatment or transcutaneous ablative procedures, the pain can often be treated successfully by partial rhizotomy of the trigeminal sensory root. We have examined partial trigeminal rhizotomy specimens from six multiple sclerosis patients, aged between 34 and 77 years, with intractable trigeminal neuralgia lasting between 18 months and 11 years. The rhizotomy specimens were placed in buffered glutaraldehyde immediately after resection, and subsequently processed for electron microscopy. In all cases, this revealed demyelination in the proximal (CNS) part of the nerve root, with associated gliosis and variable inflammation. A consistent feature was the presence of clusters of juxtaposed axons without intervening glial processes. Similar juxtaposition of axons was previously observed in trigeminal neuralgia due to vascular compression of the nerve root. Experimental studies indicate that this arrangement of demyelinated axons is conducive to both spontaneous impulse activity and ephaptic spread of excitation. The demyelination and associated juxtaposition of axons may therefore account for key aspects of the pathogenesis of trigeminal neuralgia.     

Clinical outcomes of 114 patients who underwent Gamma-knife radiosurgery for medically refractory idiopathic trigeminal neuralgia

The optimal radiation dose and target of Gamma-knife radiosurgery (GKRS) for medically refractory idiopathic trigeminal neuralgia (TN) are contentious. We investigated the effects and trigeminal nerve deficits of GKRS using two isocenters to treat a great length of the trigeminal nerve. Between January 2005 and March 2010, 129 patients with idiopathic TN underwent GKRS at the West China Hospital of Sichuan University. A maximum central dose of 80-90 Gy was delivered to the trigeminal nerve root with two isocenters via a 4 mm collimator helmet. One hundred and fourteen patients were followed-up periodically by telephone interview to determine the effects, trigeminal nerve deficits and time to the onset of pain relief. The mean follow-up duration was 29.6 months. One hundred and nine patients had complete or partial pain relief and the treatment failed in five patients. Nine patients experienced a recurrence after a mean time of 12.7 months, following an initial interval of pain relief. There were no significant differences between patients with different grades of pain relief with respect to central doses. The mean time to the onset of pain relief was 3.6 weeks. The time to the onset of complete pain relief was significantly shorter than that for partial pain relief. Forty-nine patients reported mild-to-moderate facial numbness and one patient experienced paroxysmal temporalis muscle spasms two weeks after the treatment. GKRS treatment for medically refractory idiopathic TN with two isocenters resulted in an initial pain improvement in 95.6% of patients. The early response to the treatment might suggest a good outcome but, given the high incidence of nerve deficits, GKRS for TN with two isocenters is not recommended as a routine treatment protocol.     

显微血管减压及神经松解手术治疗颅神经疾病1956例

目的 探讨显微血管减压及神经松解手术治疗颅神经疾病的方法及经验。方法 总结自1986至2005年12月以来局麻下共实施显微血管减压及神经松解手术治疗颅神经疾病1956例，其中三叉神经痛1465例，面肌痉挛428例，舌咽神经痛63例。患者平均年龄62．5岁，病史3至37年不等。介绍了显微血管减压及神经松解手术技巧及术中寻找责任血管及部分神经根切断的注意事项。结果 手术确定了1462例三叉神经痛、428例面肌痉挛和51例舌咽神经痛患者的压迫责任血管，并以teflon垫棉置于其间；对1876例局部蛛网膜和颅神经间的粘连行神经松解手术；对45例行神经根部分切断。手术效果满意。术后总有效率100％。31例复发，其中23例行二次手术治疗后病愈。结论 显微血管减压及神经松解手术是治疗颅神经疾病的有效手段，疗效确切。     

A case with trigeminal herpes zoster manifesting a long lesion of the spinal trigeminal nucleus and tract on MR T2-weighted image]

We reported a 53-year-old man with the right trigeminal herpes zoster with preceding neuralgia (preherpetic neuralgia) in the right upper cervical nerve area. He developed dysesthesia and scapular pain in the right second cervical nerve area. 5 days later, herpes zoster emerged in the area of the right maxillary division of trigeminal nerve. Furthermore, he developed paralysis on the right facial muscle on the 12th day after the onset of scapular pain. Neurological examination revealed decrease in superficial sensation accompanied by pain and dysesthesia in the areas innervated by the right maxillary division of trigeminal nerve and the right second cervical nerve, and the right peripheral facial nerve palsy. Any rash was not observed in the right second cervical nerve area throughout the course. The cerebrospinal fluid showed a mild mononuclear pleocytosis. The antibody titer for varicella zoster virus (VZV) was elevated in both cerebrospinal fluid and blood serum. T2-weighted magnetic resonance (MR) image revealed a continuously long high-signal lesion corresponding to the right spinal trigeminal nucleus and tract, extending from the lower pons to the second cervical segment of the spinal cord. This lesion could have resulted from a centripetal migration of VZV from the Gasser ganglion to the spinal trigeminal nucleus and tract, which was probably related to the preherpetic neuralgia in the upper cervical nerve area without rash.     

Trigeminal neuralgia caused by contralateral supratentorial meningioma

Most trigeminal neuralgia is attributable to vascular compression of the root entry zone of the trigeminal nerve at the pons. Only about 5-10% of trigeminal neuralgia cases are caused by direct compression by ipsilateral cerebellopontine angle tumors. Trigeminal neuralgia caused by contralateral posterior fossa tumors are extremely rare. Cases in which neuralgia is caused by a contralateral supratentorial tumor have been seldom reported. This report describes a case of large meningioma in the left occipital region. The patient's right facial pain subsided gradually after tumor excision. This neuralgia is likely due to a displaced adjacent vessel that developed following brainstem distortion by the tumor.     

A method for intraoperative microneurographic recording of unitary activity in the trigeminal ganglion of patients with trigeminal neuralgia

The etiology of trigeminal neuralgia appears to be vascular compression of the nerve at the root entry zone. However, the physiologic mechanism of trigeminal neuralgia remains uncertain. To gain insight into the pathophysiology of the disorder, we developed a method for intraoperative microneurographic recordings from the trigeminal ganglion of patients with trigeminal neuralgia. The recordings are performed immediately prior to standard percutaneous trigeminal gangliolysis for pain relief. Spontaneous or evoked single- and multi-unit action potential activity can be recorded and the location of receptive fields determined. The method should facilitate the testing of hypotheses concerning the origin of this unique pain disorder.     

The pathology of shingles: Head and Campbell's 1900 monograph.

Shingles (herpes zoster) and postherpetic neuralgia, a chronic neuropathic pain syndrome that can persist after the shingles lesions heal, were studied by eminent neurologists of the 19th century. Autopsy studies were used to establish sensory neural pathways in the peripheral and central nervous systems. More recently, zoster and postherpetic neuralgia have served as models for the study of the pathogenesis and treatment of neuropathic pain. Postherpetic neuralgia has the cardinal clinical features of all neuropathic pain syndromes, including sensory abnormalities, ongoing pain, and allodynia (touch-induced pain). Unlike most other neuropathic pain syndromes, such as trigeminal neuralgia or nerve root compressions, shingles has a well-defined pathogenesis and onset, as well as visible lesions, and is therefore uniquely suitable for study.     

脑干三叉神经诱发电位对三叉神经痛微血管减压术的应用研究

目的 评价三叉神经痛微血管减压术前、后三叉神经的传导功能变化，探讨脑干三叉神经诱发电位对三叉神经痛微血管减压术的指导及其对手术预后的评估，探讨微血管减压术的可能机制。方法 14例经术前核磁共振斜矢状位成像证实有神经血管压迫的三叉神经痛的病人，在微血管减压过程中，通过术前、中、后记录早期头皮诱发电位监测三叉神经传导功能。结果 所有病例的术前头皮诱发电位均呈潜伏期延长与波幅降低的改变，显示三叉神经根部的传导功能损害。脑干三叉神经诱发电位证实微血管减压术后，14例病人三叉神经传导功能迅速恢复，术后疼痛均缓解。结论 微血管减压术后三叉神经痛的改善，常与神经生理学数值恢复正常有关，提示神经传导功能的恢复。微血管减压术后电生理参数值的迅速恢复及疼痛缓解，证明这两种现象与髓鞘再生无关。脑干三叉神经诱发电位预测微血管减压术的效果是可靠的。     

Clinical presentation of trigeminal neuralgia and the rationale of microvascular decompression

Among the facial pain syndromes, trigeminal neuralgia has a special position for many reasons. Already described in the Romans age, the specific features of its severe symptoms, the therapeutic debate and the recent curative possibilities, make this complex pain syndrome a unique entity. The clinical onset is predominantly unilateral and is described as an electric, lancinating, focal and sharp pain. It can last seconds to minutes initially, and sometimes can last as long as 1 hour. Usually the patient is symptom-free between attacks. Later in the course of the disease, patients report dull, aching, constant pain in the same distribution as the paroxysms. The pain can be triggered by non-noxious stimuli like chewing, talking, swallowing, wind on the face, cold and light touch. Thought to be attributable to fifth cranial nerve dysfunction, the first surgical attempts aimed to interrupt nerve continuity by means of a rizothomy, with disappearance of both pain and sensory disturbances. Further investigations claimed nerve compression by vascular structures as responsible of nervous dysfunction. Hence the attempt to perform a decompression in order to relieve the symptoms and maintain physiologic nerve function. From the successful attempts of first microvascular decompression descends the now standardised and widespread technique that is commonly used today to treat trigeminal neuralgia.

     

Surgical treatment of parapontine epidermoid cysts presenting with trigeminal neuralgia

We retrospectively reviewed the management of 49 patients with parapontine epidermoid cyst presenting with trigeminal neuralgia, emphasizing the importance of fully removing the tumor to relieve the trigeminal neuralgia. Clinical symptoms, MRI, the operative approach, and post-operative results were examined. Trigeminal neuralgia was noted in all patients. The mean duration from onset of symptoms to surgery was 18 months. Total removal was achieved in 23 patients, near-total removal in 21, and subtotal removal in five patients. However, all tumor capsule that adhered to the trigeminal nerve was completely removed. After the operation, 33 patients developed facial hypoesthesia, three complained of double vision, and two developed acute hydrocephalus. At six months of follow-up, all patients had recovered and returned to their normal lives. At 2 years of follow-up, one patient experienced pain recurrence and underwent another operation. Parapontine epidermoid cysts either encase cranial nerve (CN) V but with intact arachnoid between the capsule and the nerve, or compress and distort the nerve with tumor capsule adherent or attached to the nerve surface. Resecting the tumor capsule’s attachment to CN V is critical in relieving pain, even though this method may damage the nerve.     

Surgical Management of Medically Refractory Trigeminal Neuralgia

The role of surgery for patients with medically refractory trigeminal neuralgia (TN) is well established. High-quality magnetic resonance imaging, including gadolinium-enhanced and volume acquisition sequences, should be performed to exclude intracranial tumors or demyelinating disease as the cause of the pain, as well as to clearly demonstrate the trigeminal nerve and adjacent blood vessels. For physiologically healthy patients with Type 1 TN, a microvascular decompression (MVD) is the preferred surgical approach because of its high rate of complete pain relief, the durability of the pain relief, and the fact that trigeminal injury is not required for pain relief. Patients with recurrent TN after a failed MVD, patients with significant medical comorbidities, and patients with multiple sclerosis–related TN are generally recommended to undergo less invasive, destructive surgical techniques aimed at providing pain relief by damaging the trigeminal nerve.     

Vertebrobasilar dolichoectasia as a cause of trigeminal neuralgia: the role of microvascular decompression. Case report

Our purpose is to report a case of trigeminal neuralgia caused by vertebrobasilar dolichoectasia treated with microvascular decompression. A 63-year-old man sought treatment for a recurrent lancinating left facial pain in V2 and V3 trigeminal territories. The computed tomography angiography revealed a mechanical compression of the left trigeminal nerve due to vertebrobasilar dolichoectasia. The patient was submitted to a left suboccipital craniotomy. Shredded Teflon was introduced in the conflicting neurovascular area, achieving a satisfactory decompression. The patients pain resolved immediately. Vertebrobasilar dolichoectasia is a rare cause of trigeminal neuralgia and a successful outcome can be achieved with microvascular decompression.     

微血管减压术治疗典型及非典型三叉神经痛的疗效对比研究

目的探讨微血管减压术治疗典型及非典型三叉神经痛的不同疗效及其可能机制。方法寸比分析2003～2004年间经微血管减压术治疗的45例典型三又神经痛患者及17例非典型三叉神经痛患者的临床特征、术中所见年口手术疗效。结果45例典型三叉神经痛患者中，平均痛程3．1年，平均发病年龄60．3岁。其中20例（44．4％）患者中疼痛累及三又神经的单一分支，其余25例（55．6％）疼痛均累及2或3个分支。术中见39例（86．7％）为动脉压迫，6例（13．3％）为动脉和静脉混合压迫。术后疼痛完全缓解44例（97．8％），明显减轻1例（2．2）。而在17例非典型三叉神经痛患者中，平均病程8．7年，平均发病年龄55.5岁，疼痛均累及三叉神经的2或3个分支。术中见10例（58．8％）为动脉压迫，7例（41．2％）为动脉年口静脉混合压迫。术后疼痛完全缓解5倒（29.4％），明显减轻10例（58．8％），无效2例（11．8％）。结论微血管减压术治疗典型三叉神经痛的疗效明显优于非典型患者，这可能与典型三叉神经痛患者的病程较短、发病年龄较晚、疼痛多呈单支分布、且以动脉压迫为主以及术中能够实现充分减压有关。     

Trigeminal neuralgia and treatment options

Trigeminal neuralgia is a painful condition of the face characterized by paroxysmal lancinating, shock-like pain confined to the somatosensory distribution of the trigeminal nerve. The etiology of most cases of trigeminal neuralgia has been suggested to be vascular compression of the central axons of the trigeminal nerve at the level of pontocerebellar region, so called hyperactive dysfunctional syndrome. Trigeminal neuralgia is the one of the most known pain syndromes. Several neurosurgical procedures have been developed for the treatment of idiopathic trigeminal neuralgia and in this review, idiopathic trigeminal neuralgia was discussed in aspect of different surgical modalities.     

Pre-trigeminal neuralgia

Eighteen patients who subsequently developed typical trigeminal neuralgia experienced a prodromal pain termed "pre-trigeminal neuralgia." These patients described their prodromal pain as a toothache or sinusitis-like pain lasting up to several hours, sometimes triggered by jaw movements or by drinking hot or cold liquids. Typical trigeminal neuralgia developed a few days to 12 years later, and in all cases affected the same division of the trigeminal nerve. Six additional patients experiencing what appeared to be pre-trigeminal neuralgia became pain-free when taking carbamazepine or baclofen. Recognition of pretrigeminal neuralgia makes it possible to relieve the pain with appropriate medications and avoid unnecessary irreversible dental procedures.