磁共振血管成像对舌咽神经痛的的诊断价值(13例临床分析)

目的 分析舌咽神经痛的三维时间飞跃法磁共振血管成像(3D-TOF MRA)的影像学表现,探讨其诊断价值.方法 回顾性分析13例临床诊断舌咽神经痛患者的3D-TOF MRA表现,两名神经影像医生共同阅片达成共识,判断神经血管关系,并与手术结果对比.结果 3D-TOF MRA发现13例舌咽神经痛患者中共14侧舌咽神经出/入延髓区存在血管压迫或接触,其中症状侧舌咽神经有血管压迫或接触12例,无症状侧舌咽神经有血管压迫或接触2 例,本组病例统计学分析表明,舌咽神经痛患者症状的出现与舌咽神经出/入延髓区是否存在血管压迫或接触存在显著相关关系(P＜0.01) ,3D-TOF MRA对舌咽神经痛诊断的敏感性为84.62%,特异性为92.31%.13例有血管压迫或接触引起的舌咽神经痛患者手术证实责任血管9例为小脑后下动脉,1例为小脑前下动脉,1例为椎动脉,1例为未知的静脉,1例为未知的小动脉,而3D-TOF MRA 1例未发现责任血管,2例对责任血管判断不符.结论 3D-TOF MRA对诊断舌咽神经痛具有较高的敏感度及特异度,但对小血管的检出和责任血管的判断上仍存在不足.     

三叉神经痛病因诊断的影像学研究

目的 研究ＭＲＩ加三维体积扫描习时法磁共振血管成像（３Ｄ－ＴＯＦ－ＭＲＡ）对三叉神经痛（ＴＮ）病因诊断的临床价值。方法 常规ＭＲＩ加３Ｄ－ＴＯＦ－ＭＲＡ脑干溥层扫描３２例ＴＮ患者和３２名对照,盲法诊断三叉神经根部解剖改变,两组对照分析。结果 （１）ＴＮ患者症状侧三叉神经根部受压迫２９侧（９０．６％）,其中血管压迫２５侧（７８．１％）,肿瘤压迫４侧（１２．５％）;无症状侧受血管压迫２侧（６．３％）;对照组共６４侧,受血管压迫３侧（４．７％）。（２）常见压迫血管分别为小脑上动脉１７侧（６８．０％）,小脑前下动脉２侧,椎动脉１侧,不明起源动脉２侧,静脉２侧,血管畸形１侧。（３）三叉神经根部压迫侧发生ＴＮ相对危险度的估计值为３６．７。（４）三叉神经根部血管压迫形式可分为真正的压迫或包绕及紧密接触,ＴＮ症状侧以真正的压迫     

高分辨率强化3D - SPGR序列评价三叉神经痛患者神经血管的关系

目的 探讨强化三维损毁梯度回波( 3D - SPGR)序列检出三叉神经痛(TN)患者神经血管压迫(NVC)的能力.方法 对37例TN患者行强化3D- SPGR序列扫描,由高年资神经影像学医师评价三叉神经根进入区(REZ)神经与血管的关系,并与显微血管减压术(MVD)术中观察的结果对比.结果 37例患者中,MVD证实36例存在NVC,强化3D-SPGR显示了35例,其敏感性为97.2％,特异性为100％,且MRI所显示的责任血管位置与MVD之间有高度的一致性(K=0.81).在14例三叉神经上颌支疼痛的患者中,12例(85.7％)的NVC位于REZ的内侧,而在16例下颌支疼痛的患者中,13例(81.3％)的NVC位于REZ的外侧,两者之间的差异有统计学意义(P＜0.001).结论 强化3D - SPGR序列是检出TN患者NVC有效的检查方法,将为MVD术前制定治疗方案提供有价值的信息.     

Association between trigeminal neuralgia and multiple sclerosis: role of magnetic resonance imaging.

Seven consecutive patients with multiple sclerosis and trigeminal neuralgia were investigated with MRI to determine the occurrence of a lesion which would account for the patients' pain. Two patients had bilateral symptoms. In the patients with unilateral trigeminal neuralgia vascular compression of the nerve by an artery at the root entry zone on the symptomatic side was confirmed in three patients and an epidermoid tumour distorting the nerve on the symptomatic side was identified in one patient. A demyelinating plaque was identified in only one patient, affecting the trigeminal nerve at the root entry zone at the pons. In those with bilateral symptoms neurovascular compression was identified on both sides in one patient and on one side only in the remaining patient. Microvascular decompression cured the pain in two patients with neurovascular compression. The variable aetiology of trigeminal neuralgia is stressed even in patients with coexistent neurological conditions such as multiple sclerosis, which can cause trigeminal neuralgia independent of other causes.     

3D-TOF磁共振血管成像诊断偏侧面肌痉挛的病因

目的　研究 3D TOF磁共振血管成像对偏侧面肌痉挛 (HFS)病因诊断的临床价值。方法　 3D TOF磁共振血管成像脑干薄层扫描 3 4例HFS患者和 3 5例对照 ,盲法诊断面神经根部解剖改变 ,两组对照分析。结果　 ( 1)HFS患者症状侧面神经根部受压迫 3 2侧 ( 94 % ) ,其中血管压迫 3 1侧( 91% ) ,肿瘤压迫 1侧 ( 3 % ) ;无症状侧受血管压迫 6侧 ( 18% ) ;对照组双侧受压迫 3侧 ( 4 % ) ,其中血管 2侧 ,肿瘤 1侧。 ( 2 )常见压迫血管分别为小脑前下动脉 11侧 ( 3 8% ) ,椎动脉单独或与小脑后下动脉联合 9侧 ( 2 9% ) ,小脑后下动脉 8侧 ( 2 5 % )。 ( 3 )面神经根部血管压迫发生HFS相对危险度的估计值为 3 7.2 8。 ( 4 )面肌痉挛侧面神经根部受血管压迫或包绕有 14侧 ( 4 5 % )。结论　研究提示 ,3D TOF磁共振血管成像为目前面肌痉挛病因诊断的最佳影像检查方法 ,HFS的主要病因为患侧面神经根部受血管压迫、包绕或与其紧密接触。     

三叉神经根入脑干区MRI形态学研究

目的研究原发性三叉神经痛(TN)患者三叉神经根入脑干区(REZ)的形态结构及其临床应用价值。方法 36例TN患者和20例非TN患者作为健康对照纳入研究。所有受试对象采用3.0TMRI扫描,采用可变翻转角的三维快速自旋回波序列(3D-SPACE)分别扫描两侧REZ区的形态学结构。采取图像分析软件测量分析三叉神经脑池段长度、三叉神经脑桥角、桥小脑角池面积和三叉神经脑池段面积。结果患侧三叉神经脑池段长度的均值、三叉神经脑桥角的均值、桥小脑角池面积的均值以及三叉神经脑池段面积的均值均小于健侧。对照组的三叉神经脑池段长度、三叉神经脑桥角、桥小脑角池面积及三叉神经脑池段面积的均值均大于疾病组。结论三叉神经脑池段较短,三叉神经脑桥角锐利,易发生神经血管冲突,临床上易导致TN;三叉神经脑池段面积缩小提示三叉神经根的萎缩性改变。MRI形态学信息有利于疾病的诊断及手术决策的选择。     

左侧延髓血管减压术治疗原发性高血压病的疗效研究

目的 探索左侧延髓微血管减压术(MVD)对颅神经疾病、脑出血病人的原发性高血压病的手术疗效.方法 26例左侧幕上脑内血肿、2例小脑血肿病人在血肿清除后,再行同侧枕下乙状窦后开颅,并对延髓进行MVD,其中15例病人是急诊手术;4例三叉神经痛、2例听神经瘤、1例三叉神经鞘瘤、1例舌咽神经痛的高血压病人,在完成肿瘤切除、颅神经MVD手术后再行MVD.观察病人的血压以及降血压药物用量和种类的变化.结果 术中发现压迫延髓和迷走神经根入脑区(REZ)的责任血管为小脑后下动脉20例,椎动脉主干11例,小脑前下动脉5例;其中接触型14例、压迫型10例、粘连型9例、贯穿型3例.24例高血压病得到治愈、好转10例、2例无效.结论 左侧延髓MVD可以有效治疗原发性高血压病.术中仔细探查远离REZ区的血管袢,并解除它们对迷走神经及延髓腹外侧的"琴弦式"牵拉刺激可以提高延髓MVD治疗原发性高血压病的疗效.     

Quadruple vessel involvement at root entry zone in trigeminal neuralgia

The author describes a rare case of trigeminal neuralgia where four major named vessels of the posterior circulation were detected to be in close approximation to the trigeminal nerve. The quadruple vessel compression included a tortuous dilated basilar trunk, ipsilateral anterior inferior cerebellar artery, a superior cerebellar artery and superior petrosal vein. All vessels were related to the root entry zone of the nerve. Significance of such a multiple vessel neuovascular conflict at the root entry zone is discussed, highlighting technical implications during surgical management and its prognostic relevance.     

Trigeminal Neuralgia Caused by an Anomalous Posterior Inferior Cerebellar Artery from the Primitive Trigeminal Artery: Case Report

A 61-year-old woman presented with typical trigeminal neuralgia (TN), caused by an aberrant posterior inferior cerebellar artery (PICA) associated with the primitive trigeminal artery (PTA). Magnetic resonance angiography and digital subtraction angiography clearly showed an anomalous artery directly originating from the PTA and coursing into the PICA territory at the cerebellum. During microvascular decompression (MVD), we confirmed and decompressed vascular compression of the trigeminal nerve by this anomalous, PICA-variant type of PTA. The PTA did not conflict with the trigeminal nerve, and the anomalous PICA only compressed the caudolateral part of the trigeminal nerve, without the more common compression at its root entry zone. This case is informative due not only to its very unusual angioanatomical variation but also to its helpfulness for surgeons preparing a MVD for a TN associated with such a rare vascular anomaly.     

The significance of three-dimensional MR-defined neurovascular compression for the pathogenesis of trigeminal neuralgia

Three-dimensional MR tomography was used to examine the relationship between symptoms of trigeminal neuralgia and neurovascular compression of the nerve in 18 patients. The intensity of neurovascular interaction was classified according to neuroradiological criteria. We found that a radiologically defined compression or dislocation of the nerve by an artery was always associated with symptoms of trigeminal neuralgia. A simple contanct between vessel and nerve, however, was also observed on the asymptomatic sides of 10 out of 18 patients. In 6 of 18 patients, in contrast, trigeminal neuralgia was present in spite of the absence of neurovascular contact. In accordance with a cited study based on autopsy and intraoperative findings, our findings indicate that, in a certain proportion of cases, trigeminal neuralgia may be caused by neurovascular compression alone, whereas in other cases, other pathogenetic factors may be involved to a varying degree or be even exclusively responsible for the development of trigeminal neuralgia. The possible significance of the method for a preoperative estimation of the success of microvascular decompression of the trigeminal nerve is discussed.     

小脑动脉的临床解剖探讨

目的：为神经外科临床提供解剖学资料。方法：手术显微镜下观察５０例成人脑标本小脑动脉的起始、行径、主要分支、穿动脉及大致分布，检查各小脑动脉与出入脑干的颅神经的接触关系。结果：５０例人脑有小脑下后动脉（ＰＩＣＡ）９４支，小脑下前动脉（ＡＩＣＡ）９７支和小脑上动脉（ＳＣＡ）１１２支。２侧ＰＩＣＡ和１２侧ＳＣＡ接触三叉神经根，２侧ＡＩＣＡ接触面神经根，动脉与神经根接触多形成压迹。结论：小脑动脉的局部解剖有助于神经外科医生在颅后窝手术时，对这些动脉尤其是行程可能有变异的动脉及穿支要特别谨慎，避免损伤，并保护与小脑动脉关系密切的脑神经根；对某些脑干血管综合征患者及某些三叉神经痛、面肌痉挛患者采取相应的治疗。     

Operative findings in cases of trigeminal neuralgia without vascular compression: proposal of a different mechanism.

Trigeminal neuralgia is known to be caused by vascular compression at the trigeminal root entry zone (REZ) and microvascular decompression provides good outcome in most of cases. However, in some cases, no vascular compression was observed at the REZ. Over the last 2(1/2) years, the first author operated on 53 cases of trigeminal neuralgia with microvascular decompression and encountered nine cases where no offending vessels were noted at or near the REZ. They were divided into two groups: five cases involving an initial operation and four cases involving a second operation. In the former, arachnoid thickening, angulation or torsion of the root axis were common findings. Dissection of thick arachnoid around the root along the whole length reversed the root to be straight and flaccid. Complete pain relief was noted in four of five cases. In one case of atypical pain, constant facial pain remained. In the latter four cases, where the first operations were done more than 4 years before, thick granulation was noted around REZ without new offending vessels in two cases. In the remaining two cases, where no offending vessels were noted in the first operation, thick adhesion of a distal portion of the root with dura on the pyramidal bone was noted. Meticulous dissection of t he whole length of the root was done and complete pain relief was obtained. Delayed but complete pain relief in these nine cases was noted. Based on operative findings, arachnoid thickening or granulomatous adhesion between the root and surrounding structures can cause an abnormal course of the trigeminal nerve root, which causes root angulation and/or torsion. They can also cause pulsatile movement of the trigeminal nerve root. This tethering effect can promote abnormal root stretching force, especially at REZ, which might promote hyperexitability of the nerve.This speculative mechanism suggests that it is important to make the root free along the entire length, especially at its distal portion in cases with no offending vessels.     

三叉神经痛发病机理研究

目的 研究微血管压迫引起三叉神经痛(TN)的发病机制。方法 连续分析50例TN患的临床特征、术中所见和手术疗效，包括扳机点的位置、疼痛范围、病程、血管压迫三叉神经根的部位与程度、术后疼痛缓解的进程与最终结果。结果 扳机点均位于TN的分布范围之内。随着病程延长，疼痛有转化为不典型的趋势，可出现间歇期疼痛或面部麻木。压迫血管以小脑上动脉、小脑前下动脉和动静脉同时压迫多见。压迫血管与三叉神经根之间可为接触、粘连、成角和轴性移位，压迫部位以内侧、外侧及多点压迫多见，而且压迫部位与压迫程度与TN的临床表现和手术疗效密切相关。结论 血管压迫部位决定了扳机点的位置及疼痛范围，压迫程度决定了手术疗效。血管压迫引起的神经根脱髓鞘以及由此引起的神经纤维直接接触、传导扩散和负反馈调节可能是TN的发病机制。     

Differences in individual susceptibility affect the development of trigeminal neuralgia

Trigeminal neuralgia is a syndrome due to dysfunctional hyperactivity of the trigeminal nerve,and is characterized by a sudden,usually unilateral,recurrent lancinating pain arising from one or more divisions of the nerve.The most accepted pathogenetic mechanism for trigeminal neuralgia is compression of the nerve at its dorsal root entry zone or in its distal course.In this paper,we report four cases with trigeminal neuralgia due to an unknown mechanism after an intracranial intervention.The onset of trigeminal neuralgia after surgical interventions that are unrelated to the trigeminal nerve suggests that in patients with greater individual susceptibility,nerve contact with the vascular structure due to postoperative pressure and changes in cerebrospinal fluid flow may cause the onset of pain.     

磁共振对因神经血管压迫致三叉神经痛的诊断价值

目的 分析原发性三叉神经痛患者的MR表现,探讨MRI对因神经血管压迫致原发性三叉神经痛的诊断价值。方法回顾性分析12例三叉神经痛患者的MRI表现,就三叉神经和周围血管的关系与手术结果进行对照分析。结果 12例三叉神经痛患者的MRI资料中,神经血管压迫、接触或可疑接触者11例,占91.7％;该12例患者均行手术,证实血管压迫或接触者12例;故与手术结果对照,MRI诊断三叉神经痛神经血管压迫或接触的敏感性为91.7％。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,对三叉神经血管压迫或接触的诊断具有较高的敏感性,对提供术前评估和指导治疗有极其重要的意义。     

Trigeminal neuralgia. Pathophysiology and treatment

Trigeminal neuralgia is a very peculiar disease. The pain, also known as "tic douloureux", is paroxystic and very severe. It can be triggered by a light cutaneous stimulus on a very localized spot on the face (the so-called "trigger zone"). The patient can sometimes benefit from long remissions without any treatment. With the exception of multiple sclerosis and of uncommon cases of posterior fossa tumours or other lesions impinging on the trigeminal nerve, ganglion or root, trigeminal neuralgia is considered as "idiopathic". Some benign abnormality had for long been suspected. The current opinion is now in favour of a "neurovascular conflict": an artery, most often a loop of the superior or anteroinferior cerebellar artery, has an offending contact with the trigeminal nerve root, which results in localized demyelination and ectopic triggering of neuronal discharges. This hypothesis is in agreement with the relief provided by antiepileptic drugs and is supported by recent neuroimaging data. Therapeutic options are reviewed: very efficient drugs are available but fail to provide a significant relief and/or have important side effects in many cases. Surgical alternatives are available, for which guidelines are proposed.     

伽玛刀双靶点与单靶点治疗原发性三叉神经痛的对比分析

目的对比分析伽玛刀双靶点与单靶点治疗原发性三叉神经痛的疗效。方法回顾性分析236例单靶点与12例双靶点治疗的经验。均使用Leksell—B型伽玛刀，准直器4mm。双靶点者靶点分别置于三叉神经根脑桥进入区和近三叉神经半月节处，单靶点者仅置于三叉神经根脑桥进入区。两组均为中心剂量70—90Gy，50％等剂量线限定靶点；将20％等剂量线限定在脑桥表面，使脑干表面剂量小于16Gy。结果随访12～114个月，平均66.4月。单靶点组有效223例（94．5％），无效13例（5．5％），复发14例（5．9％），发生并发症9例（3．8％）。双靶点组有效12例（100％），发生并发症4例（33.3％）。经统计学分析，两组治疗有效率差异无统计学意义（P〉0.05）．并发症发生率以双靶点者为高（P〈0.05）。结论双靶点治疗不能明显提高有效率，反而可使并发症发生率明显增加。当三叉神经根紧贴脑桥或受压变形时，为弥补单靶点可能引起的三叉神经受照不足，可使用双靶点治疗。     

Successful vascular decompression in an 11-year-old patient with trigeminal neuralgia

Case report We present the case of an 11-year-old boy who was suffering distinct trigeminal neuralgia. At the age of 3 years, the patient had contracted a severe Epstein–Barr virus infection and developed mild meningoencephalitis. Magnetic resonance imaging scans showed a slight enhancement in the pontomesencephalic cistern as well as a neurovascular conflict at the right trigeminal nerve. Intraoperatively, thickened fibrous tissue was found that was attached to both the trigeminal nerve and the superior cerebellar artery. Microvascular decompression using Gore Tex as tissue implant brought immediate relief. Discussion Trigeminal neuralgia in pediatric patients is very rare. We present a case of typical trigeminal neuralgia in a child, demonstrating the pathogenesis of the neurovascular conflict due to subarachnoidal adhesions after meningoencephalitis.     

Resolution of trigeminal neuralgia following pontine haemorrhage

Trigeminal neuralgia is characterized by paroxysms of pain in the sensory distribution of the trigeminal nerve usually caused by vascular compression of the trigeminal nerve at the root entry zone. We describe a 57-year-old woman who experienced complete resolution of trigeminal neuralgia following hypertensive pontine haemorrhage.