CT 定位扫描在伽玛刀治疗三叉神经痛中的应用

目的：探讨伽玛刀治疗三叉神经痛应用 CT 定位扫描的可行性。方法回顾性分析成都军区机关医院肿瘤科从2010年10月-2013年6月收治的因核磁扫描禁忌证而行 CT 定位的三叉神经痛患者12例,局麻下在前额隆突和枕骨粗隆以上水平安装定位框架,基环低于外耳孔下﹥1 cm,在 CT 定位扫描图像上寻找三叉神经根出桥脑处,行伽玛刀治疗：等剂量曲线50％,最高剂量84-90 Gy。术后电话随访,行疼痛缓解评级和面部麻木评级。结果按以上方法安装立体定位框架,很好地躲避金属伪影,CT 扫描图像中可显示三叉神经根。术后随访平均14（6-38）个月,11例（91.67％）疼痛分级从Ⅳ、Ⅴ级降低至Ⅲ级以下,其中6例（50.00％）疼痛完全缓解,平均起效时间6（3-10）个月。3例（25.00％）患者出现Ⅲ级以下面部麻木。结论在前额隆突和枕骨粗隆水平,基环低于外耳孔下﹥1 cm 的位置安装立体定位框架,可避免金属伪影,显示三叉神经根,满足伽马刀治疗定位的需要。CT 定位扫描可作为有核磁扫描禁忌证患者伽玛刀治疗的定位方式。     

Association between neurovascular contact on MRI and response to gamma knife radiosurgery in trigeminal neuralgia

Treatment with gamma knife radiosurgery (GKRS) provides adequate short-term pain control in about 70% of the patients with intractable trigeminal neuralgia (TN). The purpose of our study was to evaluate whether the presence of neurovascular contact (NVC) at the root entry zone of the trigeminal nerve on pre-gamma knife MR imaging predicts an increased likelihood of an adequate response to GKRS.We studied 40 consecutive patients who underwent GKRS for treatment of intractable TN. Two neuroradiologists blinded to the side of symptoms analyzed pre-treatment constructive interference in steady state (CISS) images to determine the presence of NVC by consensus. An adequate response was defined as freedom from pain with or without reduced need for medical therapy. Adequate short-term response to GKRS was seen in 29 (72.5%) of 40 patients. NVC was seen in 30 of the 40 patients. Twenty-five (83.3%) of 30 patients with NVC had adequate short-term response to GKRS. Only four (40%) of the 10 patients without NVC had adequate response to GKRS (X²=7.06; P<0.01). Patients with NVC were seven times more likely to have an adequate response to GKRS than those without NVC (odds ratio =7.5).The presence of NVC on pre-treatment MR imaging predicts an increased likelihood of an adequate response to GKRS.     

Transoval trigeminal cisternography and glycerol injection in trigeminal neuralgia

In a series of 25 consecutive patients suffering from essential trigeminal neuralgia, transoval glycerol injection following H?kanson was performed in order to alleviate the pain attacks. This treatment proved to be successful in 76% of the patients. No major side-effects were reported. Authors stress the importance of a precise cisternography of Meckel's cave to ascertain the correct position of the needle, before injecting the glycerol. They discuss their mode of conducting the examination in using a conventional radiologic set-up. Transoval glycerol injection is a valuable interventional radiologic procedure and has to be taken into account as an alternative treatment of essential trigeminal neuralgia, especially when current therapeutic measures have failed.     

Angiographic observations in idiopathic trigeminal neuralgia

Twenty-four patients with idiopathic trigeminal neuralgia were treated by neurovascular decompression surgery. All patients underwent preoperative vertebral angiography. After surgery, the vertebral angiograms of these patients were retrospectively reviewed. In 23 of the 24 patients, the superior cerebellar artery (SCA) and/or the anterior inferior cerebellar artery (AICA) compressed the trigeminal nerve. In the remaining case, no such compression by vessels was observed. On review of the angiograms, most of the compressing arteries, and the sites and numbers of compression points could be identified. Most of the caudal points of the SCAs which did not compress the trigeminal nerve were located higher than the compression points of the SCAs. It was therefore concluded that vertebral angiography is useful in the preoperative evaluation of compressing arteries. Since superimposition of arteries could be avoided, the straight AP projection was the most valuable of the three projections employed.     

Magnetic resonance in trigeminal neuralgia]

One of the possible causes of the so-called "essential" trigeminal neuralgia is a neurovascular compression of the fifth cranial nerve root at the pons. The demonstration of this hypothesis could orientate the surgical treatment to microvascular decompression. In order to evaluate the role of MRI in the diagnosis of trigeminal neuralgia due to neurovascular compression, the authors present the results of a prospective evaluation of the cranial MR studies of 18 neuralgic patients in comparison with a retrospective evaluation of the cranial MR studies of 50 healthy control subjects. The results show that neurovascular compression can be demonstrated in 83.3% of the neurological patients. In all cases a good correlation between the clinical symptoms, the side of positive MR findings and the surgical findings, when available, was demonstrated. On the other hand, neurovascular compression was demonstrated in 28% of the healthy control subjects. The authors conclude that neurovascular compression can be demonstrated in a high percentage of patients with the so-called "essential" trigeminal neuralgia. Compared with the other imaging modalities (angiography, Computed Tomography) MRI is the best technique in the diagnosis of this disease. In fact, MRI is not only able to differentiate the symptomatic from the essential type of neuralgia, but is also very sensitive in the identification of trigeminal neuralgia due to neurovascular compression. This diagnosis could direct the surgical treatment to microvascular decompression.     

MRI volumetry for the preoperative diagnosis of trigeminal neuralgia

To assess whether quantitative measuring methods can help improve the reliability of MRI-based evaluations of the pathological role of a neurovascular conflict between an artery and the trigeminal nerve. In a prospective study, magnetic resonance images were obtained from 62 patients with unilateral facial pain and 50 healthy test subjects. In coronal T1- and T2-weighted sequences volume measurements were performed by regions of interest and compared intraindividually (healthy versus affected side in the patient populations and right versus left side in the group of test subjects) and on the basis of the different clinical pictures (t test for dependent and independent samples, p<0.05). In patients with trigeminal neuralgia, the affected nerve showed a smaller volume than the trigeminal nerve on the healthy side (p<0.001). Such a volume difference was noted neither in the other patients nor in the healthy test subjects. Quantitative MRI measurements allow a pathological neurovascular conflict to be distinguished from a nonpathological condition where an artery is in close proximity to the trigeminal nerve. The measured volume difference between the healthy and the affected nerve in patients with neuralgia is indicative of trigeminal nerve atrophy resulting from damage to the nerve.     

无损伤性治疗原发性三叉神经痛的临床观察

目的评价局部封闭联合卡马西平治疗原发性三叉神经痛的临床效果。方法选择2005年9月—2011年6月本院口腔科收治的60例原发性三叉神经痛患者,其中男26例,女34例,年龄30～70岁。采取随机数字表方法分为试验组和对照组1(局部封闭)、对照组2。试验组采用地塞米松1 mg、维生素B1100 mg、维生素B121 mg和2%利多卡因1 ml混合液行局部封闭,2次/周,共4周,同时口服卡马西平;对照组1单纯局部封闭,对照组2单纯口服卡马西平。采用疼痛视觉模拟评分法(VAS)对疼痛进行评估,并比较治疗前后的疗效。结果治疗后1个月和6个月时试验组的优良率(95.00%和80.00%)与对照组1(50%和45%)、对照组2(50%和45%)比较,差异均有统计学意义(P<0.05)。治疗后1个月试验组和对照组VAS值均显著下降,且组间差异有统计学意义(P<0.05);6个月后三组VAS值均增高,且差异仍有统计学意义(P<0.05)。结论局部封闭联合卡马西平治疗原发性三叉神经痛是一种有效和安全的方法。     

血管压迫性三叉神经痛的MRI研究

目的 采用MR断层血管成像术对血管压迫性三叉神经痛的责任血管作深入研究。方法 235侧正常三叉神经及147侧有三叉神经痛症状的三叉神经MR三维时间飞跃（3D-TOF）扫描图像由2名医师以盲法读片，评判所见三叉神经周围有无血管及其与血管的关系，并记录所见血管的直径、血管至脑干的距离及血管的走行方向。分别进行团体t检验和卡方检验以明确有无统计学意义。结果 共有242侧三叉神经周围可以见到关系密切的血管，其中111侧为无症状组，131侧为有症状组，经统计表明有症状组三又神经所见责任血管距脑干的距离中位数为2mm，明显较无症状组（中位数为4mm）短（P〈0．01），有症状组三叉神经所见责任血管与血管夹角（89．3％，117／131）〉45。（P〈0．01）。无症状组中仅有1例（0．4％，1／235）发现三叉神经受血管推压移位，而在有症状组中有45例（30．6％，45／147），因此有症状组三叉神经受压推移率明显高于无症状组（P〈0．01）。结论 MRI对血管压迫性三叉神经痛的责任血管的评估非常有价值。责任血管距脑干的最短距离及走行与血管压迫性三叉神经痛的发病非常有关。     

Magnetic resonance imaging of idiopathic trigeminal neuralgia

Seventeen patients with idiopathic trigeminal neuralgia (ITN) and seven subjects of control group were evaluated with magnetic resonance imaging (MRI). Vascular contact at the proximal portion of the preganglionic segment (PGS) of the trigeminal nerve was observed in 100% of ITN on the affected side, 76% of ITN on the non-affected side, and 21% of control group. Deformity of the PGS was observed in 65% of ITN on the affected side, and in none of ITN on the non-affected side or control group. Non-surgical treatments were effective in all of the 6 patients without deformed PGS, but they failed to control trigeminal neuralgia in 4 of 11 patients with deformed PGS. This preliminary study suggests that MRI could be used for the clinical assessment of trigeminal neuralgia before treatment.     

Persistent trigeminal artery associated with trigeminal neuralgia: hypothesis of neurovascular compression

Introduction The aim of this study was to determine the prevalence of persistent trigeminal artery (PTA) associated with trigeminal neuralgia (TN). Methods From January 1998 to January 2004, 288 MRI scans of patients examined for trigeminal deficits were retrospectively evaluated. MRI was performed at 1.5 T. Scan protocols included cerebral TSE T2-weighted imaging, contrast enhanced SE T1-weighted imaging and thin-section 3D T2-weighted imaging of the temporal bones, 3D TOF pre- and postcontrast MR angiography. TN was defined as episodes of intense stabbing, electric shock-like pain in areas of the face supplied by the trigeminal branches. Neurovascular compression (NVC) was assumed to be present if the patient showed clinical features of TN, if there was contact between an artery and the trigeminal nerve on the affected side, and if other pathology had been excluded. The prevalence and confidence intervals were calculated (95% CI of the prevalence was based on the exact binomial distribution). Results Of 288 patients, 136 matched the criteria for TN. In this series a PTA was detected in three patients, which in all patients was on the same side as the TN. The prevalence of a PTA in patients presenting with TN was 2.2% (CI 0.005–0.06). Conclusion Previous studies have shown PTA as an incidental finding in 0.1–0.6% of cerebral angiograms. The prevalence of a PTA in patients with TN was 2.2%. With respect to the clinical significance, a PTA has to be considered in TN and the diagnosis of a PTA can easily be made using MR imaging/angiography.     

双侧原发性三叉神经痛的微球囊压迫治疗

目的 评价采用经皮穿刺微球囊压迫(PMC)技术治疗双侧原发性三叉神经痛的临床效果,探讨一侧行PMC术后对侧PMC术的手术时机.方法 对从2000年12月至2009年8月采用PMC技术治疗的74例双侧原发性三叉神经痛患者的临床资料进行回顾性分析.根据患者术后疼痛完全消失判定手术成功率,根据患者一侧手术后咀嚼肌运动功能的恢复情况选择对侧手术时机.结果 对74例患者共行145次手术(包括3例患者术后单侧疼痛症状复发行第2次手术治疗).术后即刻成功率为96.5%.随访1 ～ 7年,平均2.9年,疼痛复发率为2.1%.74例患者中行双侧手术者68例,其中57例在单侧进行PMC治疗后1 ～ 3个月内行对侧PMC术.结论 PMC技术是治疗双侧原发性三叉神经痛的有效方法,其中单侧进行PMC治疗后,可在术后1 ～ 3个月进行对侧的PMC手术.     

面肌抽搐与三叉神经痛的MRI诊断

目的　探讨面肌抽搐及三叉神经痛患者血管压迫病因的MR表现及其诊断价值。方法　回顾性分析了 12 0例面肌抽搐及三叉神经痛患者MR表现及手术结果。结果　 (1) 6 3例面肌抽搐患者MR显示 12 6侧面听神经共发现 5 8侧存在神经血管压迫或接触 ,17侧可疑接触 ;5 7例三叉神经痛患者MR显示 114侧三叉神经共发现 4 5侧存在神经血管压迫或接触 ,12侧可疑接触。 (2 )统计学分析结果 :面肌抽搐患者症状侧和无症状侧差异有非常显著性意义 (χ2 =31 6 6 ,P <0 0 0 1) ;三叉神经痛患者症状侧和无症状侧差异有非常显著性意义 (χ2 =4 2 98,P <0 0 0 1)。 (3)根据手术结果 ,MR诊断面肌抽搐及三叉神经痛患者神经血管压迫或接触的敏感度为 94 % ,准确度为 83% ,阳性似然比为1 88。结论　MRI能清晰显示三叉神经脑池段与毗邻血管之间的关系 ,对面听神经及三叉神经血管压迫或接触的正确诊断具有较高的敏感度和准确度 ,为临床医师提供术前评估和指导治疗有极其重要的意义。     

高危原发性三叉神经痛的介入治疗

目的 评价经皮穿刺微球囊压迫三叉神经节(PMC)治疗高危原发性三叉神经痛方法的临床效果.方法 回顾性分析从2001年1月至2007年12月采用Mullan方法治疗3053例原发性三叉神经痛患者中804例高危患者采用PMC技术治疗的临床资料.结果 对804例患者行833次手术.术后即刻成功率为97.3%.平均随访36个月,疼痛复发率为6.8%.感觉异常的发生率为3.8%,无角膜溃疡,咀嚼肌无力约占2/3,复视占0.2%.结论 PMC方法是高危原发性三叉神经痛的首选且十分有效的治疗方法之一,尤其对于疼痛累及第一支且高危的患者更有优势.     

桥小脑角区显微手术治疗三叉神经痛101例

目的　介绍１０１ 例三叉神经痛经桥小脑角显微手术治疗经验。方法　分析１０１ 例三叉神经痛的病因、术式选择及复发率,并就减少并发症进行探讨。结果　３ 例胆质瘤切除术后三叉神经痛症状均消失。余９８ 例术后疼痛即刻消失者８８ 例;１０ 例仍疼痛但程度减轻,均存在于６２ 例行微血管减压术式者中,其中５ 例于术后１０ ｄ 内疼痛消失,另５ 例口服药物可控制。近期有效率１００ ％ ,近期治愈率８９８ ％ 。无死亡病例。共随访成功６５ 例,随访时间０５ ～７ ａ ,复发６例。结论　治疗三叉神经痛的桥小脑角区显微是最接近其病因的治疗,并视术中情况进一步实施微血管减压术或感觉根部分切断术,是治疗三叉神经痛较理想的手术。     

微球囊压迫半月节治疗三叉神经痛临床疗效分析

【摘要】　目的?总结分析经皮穿刺微球囊压迫术治疗原发性三叉神经痛的技术要点和临床效果。方法?回顾性分析自2016 年4月至 2019 年1月接受经皮穿刺微球囊压迫术治疗的53例三叉神经痛患者的临床资料。采用VRS、VAS-4和PPI疼痛量化表评估术后疗效和出院后的随访疗效。VAS≤10、VRS 0级或PPI 0级为疼痛完全缓解,VAS 10～40、VRS 1～2级或PPI 1～2级为疼痛满意缓解。 结果?本组患者疼痛受累最广泛的是上颌支,45例,术前疼痛病史20 d～32年,平均2.24年。7例曾接受过微球囊压迫术,2例曾接受过微血管减压术;术中球囊平均充盈容积0.702 mL,平均压迫时间125 s,3例术中发生球囊破裂。43例（81.1%）术后疼痛完全缓解,8例疼痛满意缓解,2例疼痛缓解不满意,总有效率为96.2%;术后患侧面部有麻木感50例（94.3%）,咬肌乏力12例（22.6%）,口周疱疹5例（9.4％）,复视1例（1.9%）,头痛5例（9.4%）。平均随访时间19.9个月;术后1年仍保持疼痛完全缓解者有30例（83.3%）;至末次随访,本组整体的疼痛完全缓解率为71.7%（33例）,疼痛满意缓解率24%（12例）,总有效率95.7%;27例（57.4%）患者存在持续性的面部麻木感,其中6例麻木感严重影响日常生活并伴有同侧咬肌萎缩或面瘫。期间1例患者复发,之后又接受了2次球囊压迫术。结论?经皮穿刺微球囊压迫术是治疗原发性三叉神经痛有效的微创手术方法,对于高龄体弱、不能耐受全麻手术或畏惧手术者更具有治疗优势,但也不能忽视伴发的严重的面部麻木感。     

血管压迫性三叉神经痛责任血管的3.0T MRI研究

目的 采用3.0 T MRI显示三叉神经及周围血管的解剖关系,分析产生原发性三叉神经痛(TN)的血管压迫特点.方法 选择50例TN患者(50支TN患侧和50支TN对侧三叉神经;其中23例行微血管解压术)和50名没有面部疼痛的志愿者(100支非TN三叉神经),在3.0TMR采用三维快速稳态梯度回波序列(3D TRU-FISP)及3D 三维时间飞跃(TOF-MRA)扫描.若判断TN患者为静脉病变,并行增强3D快速小角度反转序列(3DFLASH)扫描.以上图像融合重建成虚拟脑池图,评价神经血管压迫程度分级(1级无压迫,2级静脉性压迫,3级神经与动脉接触,4级有动脉压痕,5级动脉压迫导致神经明显移位),以及血管接触神经的方位(三叉神经的上侧或其他侧)、血管神经接触点的位置(近:位于三叉神经脑池段近脑干1/3长度区域,远:位于三叉神经脑池段远脑干2/3长度区域).3D TRU-FISP序列重建的冠、矢状面图像用于测量神经长度、神经横截面及脑池面积.采用卡方检验观察2组的三叉神经:血管压迫神经引起神经切迹或移位(4级和5级)、血管神经压迫点和神经出脑干处距离、血管压迫神经的位置位于神经上侧方的发生率.采用t检验观察测量数值的统计学意义,并用Logisac回归分析三叉神经痛的发病因素.结果 两序列及融合图像可以清晰显示神经血管的关系,与23例微血管解压术中所见吻合度高,术后症状消失或明显减轻21例.血管压迫或接触三叉神经的发生率在志愿者组(1级79支,2级5支,3级8支,4级8支)、TN对侧(1级27支,2级6支,3级9支,4级8支)及TN患侧(1级4支,2级t2支,3级12支,4级7支,5级15支)分别为21.0％(21/100)、46.0％ (23/50)、92.0％ (46/50).TN患侧三叉神经较志愿者三叉神经血管受压迫程度4、5级者差异有统计学意义(x2=27.0,P ＜0.01);血管接触点的位置在TN患侧近32支、远14支,在志愿者近4支、远17支(x2=14.8,p＜0.01);压迫血管位置中,TN患侧位于神经上侧36支、其他侧10支,志愿者中位于神经上侧5支、其他侧16支(x2=18.0,P＜0.01);所在层面脑桥池面积,TN患侧为(183.9+52.5) mm2、对侧为(217.8±58.8)mm2(t=-3.04,P＜0.01);脑池段神经中点截面积,TN患侧为(6.3±1.3)mm2、对侧为(7.7±1.6) mm2(t=-4.8,P＜0.01);脑池段神经长度,TN患侧为(8.0±1.9)mm、对侧为(9.0±2.0)mm(t=-2.64,P＜0.05),差异均有统计学意义.结论 MR可以清楚显示TN患者血管与三叉神经的关系,受压迫神经位置更靠神经近端及头侧、神经所在层面脑桥池面积较小者,均是较强的手术指征.     

CT引导下栅栏定位器在射频温控热凝术治疗三叉神经痛中的应用

目的 探讨CT引导下应用栅栏定位器射频温控热凝术(RFT)治疗三叉神经痛的疗效.方法 取仰卧位采用Hartel入路穿刺法,利用双栅栏定位器联合CT半冠位扫描,进行卵圆孔及半月神经节定位穿刺.结果 81例患者卵圆孔穿刺手术成功率为100％,80例(98.8％)疼痛即刻消失,1例无效.术后面部明显麻木80例(98.8％),咀嚼无力2例(2.5％),角膜反射减退3例(3.8％).均无严重并发症出现.随访时间1～4年,复发6例,复发率为7.5％.结论 CT引导下应用栅栏定位器使卯圆孔穿刺成功率达100％,治疗三叉神经痛复发率较低,取得了良好的止痛效果,并降低并发症发生率.定位简单易行,值得推广应用.