Bilateral Trigeminal Neuralgia Research Articles

Acute Lyme Disease Presenting as Bilateral Trigeminal Neuralgia (P3-13.003)

Acute Lyme Disease Presenting as Bilateral Trigeminal Neuralgia (P3-13.003)

Efficacy andsafety ofpercutaneous balloon compression forbilateral trigeminal neuralgia: a retrospective study.

Percutaneous balloon compression (PBC) of the Gasserian ganglion is steadily gaining traction within the trigeminal neuralgia (TN) community. Bilateral trigeminal neuralgia (BTN) is a rare condition, and its treatment remains challenging. As far as we know, there are currently no research reports on the treatment outcomes of PBC for BTN.The purpose of this study is to meticulously evaluate the efficacy and safety of PBC for BTN in our medical institution. In this retrospective study, we collected and analyzed the medical records of all patients with BTN who underwent the PBC procedure at the Department of Neurosurgery at Hebei General Hospital from July 2017 to July 2023. After undergoing PBC therapy, all patients were promptly assessed for treatment efficacy based on the modified Barrow Neurological Institute (BNI) pain intensity grading scale. All 37 patients with BTN experienced significant pain relief (BNI I-IIIb) immediately following unilateral PBC treatment. Among these patients, 25 reported relief from pain on the non-operative side, which was effectively managed with medication. Out of the 12 patients who did not experience improvement in contralateral symptoms, 11 received contralateral PBC. Out of the 48 treated sides, 47 sides (97.9%) achieved excellent pain control following a single PBC procedure. The follow-up times ranged from 2 to 62months. At the 1-year follow-up, 94.6% of the patients maintained excellent therapeutic outcomes.Three recurrent patients underwent repeated unilateral PBC, and all of them maintained excellent pain control postoperatively. At the last follow-up, satisfaction was at 91.7% (measured using the Likert scale), with no severe complications occurring. The results indicate that PBC is an effective and relatively safe method for treating BTN, offering a valuable option for pain control in these rare cases of TN.

Sequential onset of bilateral trigeminal neuralgia: clinical presentation and outcomes

PurposeSequential onset of bilateral trigeminal neuralgia (TN) is rare and not well-described in the literature. The objective of this study was to characterize demographic, clinical, and procedural characteristics of patients with sequential onset bilateral TN. MethodsWe retrospectively reviewed patients presenting with sequential onset bilateral TN at our institution from 2007 to 2020. Patient demographics, clinical diagnoses, pain outcomes, and procedural characteristics were recorded and compared. Factors associated with pain recurrence were assessed using survival analyses and multivariate regressions. ResultsWe identified 34 patients who presented with sequential onset bilateral TN. The average age of onset for the index case was 49.9 ± 15.5 years, and 58.0 ± 16.8 years for the contralateral case. In total for our cohort, 91 surgical procedures were performed for the index case, and 70 for the contralateral case. With each additional surgical intervention, pain-free survival was more likely to decrease, p = 0.05. When controlled for order of intervention, glycerin rhizotomy (p = 0.01) and glycerin-radiofrequency rhizotomy (p = 0.05) were more likely associated with pain recurrence compared to microvascular decompression. While pain outcomes were significantly decreased in our cohort at final follow-up, 82.4% of patients were still dependent on medication for pain management after an average of 5.03 ± 7.74 years. ConclusionOur results represent one of the largest series of sequential onset bilateral TN in North America. Our study demonstrates the high treatment burden and chronicity of pain encountered in this population.

443 Bilateral Facial Pain With Simultaneous Onset in Trigeminal Neuralgia

INTRODUCTION: Bilateral TN (BTN) represents a non-negligible disease burden. BTN is often sequential in nature, meaning pain develops on one side before developing on the contralateral side. The few cases of simultaneous onset BTN are often indiscriminately considered or not specified from sequential onset BTN cases. METHODS: A retrospective analysis was conducted to identify patients with simultaneous onset of bilateral TN. Demographic characteristics and comorbidities were assessed. Treatment plans and modalities were recorded, and procedural outcomes and treatment durability was assessed by determining median time pain recurrence in patients with at least 30 days of follow-up. Pharmacotherapy treatment and Barrow Neurological Institute pain intensity scores were compared at last follow-up with index treatment. RESULTS: Between 1996 and 2021, 17 out of 1723 patients with trigeminal neuralgia presented with simultaneous onset of bilateral trigeminal orofacial pain which underwent bilateral surgical intervention. Patients were followed for 3 to 148 months, during which 63 procedures were performed: 20 glycerin rhizotomies, 25 glycerin-radiofrequency rhizotomies, and 18 microvascular decompressions. 16 of 17 patients experienced pain recurrence after undergoing treatment: 12 with bilateral pain and 4 with unilateral recurrence. Glycerin-radiofrequency rhizotomy provided the greatest recurrence free interval (median = 15.4 months) compared to glycerin rhizotomy (median = 0.9 months; p = 0.02) and microvascular decompression (median = 7.8 months; p = 0.25). Over the course of treatment, the number of pharmacotherapy agents increased from 2 to 3 (p = 0.05). Overall facial pain scores improved from a median of 6 to 4 bilaterally. CONCLUSIONS: Patients with simultaneous bilateral trigeminal neuralgia represent a rare disease population who tend to have early pain recurrence after surgical treatment. Nevertheless, many experience overall pain improvement with re-treatment.

Can fifth nerve mapping guide rhizotomy for recurrent trigeminal neuralgia? Case report

IntroductionMicrovascular decompression (MVD) is usually considered the first-line treatment for trigeminal neuralgia (TN) when medical treatments fail. Recurrence is rare and best treatment option is controversial. MVD was proposed as a feasible and effective technique for recurrent TN by many authors. Nevertheless, in a substantial number of cases, not any impingement or deterioration are found intraoperatively and partial selective rhizotomy is then advised. The rhizotomy site is mostly guided by anatomical landmarks, but variations due to scarring and adhesions are common pitfalls in these second surgeries. Intraoperative monitoring is infrequently used during MVD for trigeminal neuralgia. We describe the use of nerve mapping in a case of recurrence, revealing an unexpected rootlet distribution and thus safely guiding partial rhizotomy. Clinical presentationA 53-year-old woman had suffered from bilateral trigeminal neuralgia for 10 years. Symptoms began on the right side. MVD resolved her symptoms but, after a few months, she developed left TN which persisted after left MVD, radiofrequency and radiosurgery. She was referred to our center for a second MVD on the left side. Intraoperative inspection detected no relevant findings, and nerve mapping followed by partial selective rhizotomy was performed. Complete pain relief was achieved. There were no complications. ConclusionRhizotomy is seldom employed for refractory trigeminal neuralgia. The effects of previous treatments can jeopardize anatomical landmarks. Nerve mapping seems a promising tool to improve results.

Unilateral Approach to Primary Bilateral Trigeminal Neuralgia Via Bilateral Microvascular Decompression.

Background:Primary bilateral trigeminal neuralgia is a rare disease characterized by paroxysmal bilateral facial pain confined to the somatosensory distribution of the trigeminal nerve. Nonetheless, while treatment of bilateral trigeminal neuralgia with microvascular decompression (MVD) has been reported, there have been no trials of a unilateral approach for bilateral MVD.Methods:The authors retrospectively analyzed the outcomes and complications of 2 cases of bilateral trigeminal neuralgia treated with MVD by unilateral craniotomy. The 2 patients were followed up for 27 and 32 months, with satisfactory results. One patient developed facial numbness on 1 side postoperatively, which disappeared 3 months later.Conclusions:Microvascular decompression is an effective and safe opinion for primary bilateral trigeminal neuralgia that fails to respond adequately to medical therapy. The authors suggest that the initial surgery be performed on the more seriously affected side. Unilateral craniotomy for bilateral MVD represents a new therapeutic approach in patients with an enlarged superior trigeminal nerve space.

Levetiracetam in management of bilateral trigeminal neuralgia due to large glomus tumor case report

Background: Trigeminal neuralgia can be classical or idiopathic. While trigeminal neuralgia (TN) due to space-occupying lesions is atypical, such lesions rarely cause severe TN secondary to trigeminal nerve irritation. Mass effect from these lesions has been shown to correlate with symptom burden, due to direct or indirect compressive effects. A tethering effect, provoked by an abnormal root-stretching force, theoretically plays a role in trigeminal nerve hyperexcitability. Case: The likely etiology in this case presentation is a large glomus tumor invading the middle and posterior cranial fossa. Glomus tumors are uncommon benign tumors of the head and neck derived from neural crest cells. Even more strikingly, a large glomus tumor causes bilateral TN due to direct compression on one side and indirect compression on the contralateral side. Conclusion: Although the gold standard in TN management is carbamazepine, other anti-epileptic drugs (AEDs) have been used in the treatment of patients unable to take carbamazepine. A few studies suggest levetiracetam alleviates central and neuropathic pain, supporting the hypothesis that it may be effective in management of TN.

Small Posterior Cranial Fossa and Cerebellopontine Cistern Volumes Are Associated With Bilateral Trigeminal Neuralgia.

Objective: To investigate whether small volumes of the posterior cranial fossa and cerebellopontine cisterns are associated with bilateral trigeminal neuralgia (BTN) and to provide further knowledge regarding the etiology and treatment of this rare disease.Methods: We retrospectively analyzed clinical data and imaging examination results for 30 BTN patients between January 2009 and December 2019. Thirty age- and sex-matched healthy individuals and 30 patients with unilateral trigeminal neuralgia (UTN) were selected as two control groups. The volume of the posterior cranial fossa (VPCF) and volumes of the cerebellopontine cisterns were measured using ITK-SNAP 3.0, which considers the cerebrospinal fluid (CSF) volume based on the region of interest (ROI). Preoperative and postoperative statuses were based on visual analog scale (VAS) pain scores and Barrow Neurological Institute (BNI) scores.Results: A total of 30 patients (11 males; 19 females) were included, and the age of the BTN participants ranged from 41 to 77 (59.93 ± 9.89) years. The duration of TN ranged from 1 to 20 (5.36 ± 3.92) years, and the interval between the two sides ranged from 0 to 3 (1.10 ± 0.79) years. Three patients (10%) in the BTN group had familial trigeminal neuralgia, with no other hereditary history of neurological disorders. In BTN patients, with 25 (83.3%) cases on the left side and 26 (86.7%) on the right side, veins were identified in the operative field and regarded as the individual or offending vessel. The mean VPCF was significantly lower in the patients with BTN than in the healthy controls (4,813 ± 1,155 mm3 vs. 5,127 ± 1,129 mm3, p = 0.008). The volumes of the cerebellopontine cisterns on both sides were significantly smaller in the BTN patients than in the healthy controls (477 ± 115 mm3 vs. 515 ± 112 mm3 on the left side, p = 0.001; and 481 ± 114 mm3 vs. 515 ± 110 mm3 on the right side, p = 0.007). There was no significant difference between the BTN group and the UTN group in terms of the VPCF (4,843 ± 1,184 mm3 vs. 4,813 ± 1,155 mm3, p = 0.402), and there was also no significant difference between the two groups in terms of preoperative VAS pain scores or BNI scores.Conclusion: Overcrowding in the posterior fossa will lead to closer neurovascular relations and, a higher incidence of NVC, and ultimately may be more likely to lead to TN. Veins are the common offending vessels that cause BTN; they might be associated with abnormal vascular development leading to NVC. Microsurgical vascular decompression (MVD) is a safe and effective method for the treatment of BTN, similar to UTN.

Gamma Knife radiosurgery for bilateral trigeminal neuralgia

OBJECTIVEA small subset of patients with trigeminal neuralgia (TN) will experience bilateral symptoms. Treatment in these patients is controversial because the population is heterogeneous and patients may have nonvascular etiologies of their pain. This study reports treatment outcomes in the largest cohort of patients with bilateral TN who have undergone Gamma Knife radiosurgery (GKRS) to date.METHODSA retrospective chart review identified 51 individual nerves in 34 patients with bilateral TN who were treated with GKRS at the authors’ institution between 2001 and 2015, with 12 nerves in 11 patients undergoing repeat GKRS for recurrent or persistent symptoms. Long-term follow-up was obtained by telephone interview. Pain outcomes were measured using the Barrow Neurological Institute (BNI) pain scale, with BNI IIIb or better considered a successful treatment.RESULTSThere was sufficient follow-up to determine treatment outcomes for 48 individual nerves in 33 patients. Of these nerves, 42 (88%) achieved at least BNI IIIb pain relief. The median duration of pain relief was 1.9 years, and 1-, 3-, and 5-year pain relief rates were 64%, 44%, and 44%, respectively. No patients experienced bothersome facial numbness, and 1 case of anesthesia dolorosa and 2 cases of corneal dryness were reported. Patients with a history of definite or possible multiple sclerosis were significantly more likely to experience BNI IV–V relapse. There was no statistically significant difference in treatment outcomes between patients in this series versus a large cohort of patients with unilateral TN treated at the authors’ institution. There was sufficient follow-up to determine treatment outcomes for 11 individual nerves in 10 patients treated with repeat GKRS. Ten nerves (91%) improved to at least BNI IIIb after treatment. The median duration of pain relief was 2.8 years, with 1-, 3-, and 5-year rates of pain relief of 79%, 53%, and 53%, respectively. There was no statistically significant difference in outcomes between initial and repeat GKRS. One case of bothersome facial numbness and 1 case of corneal dryness were reported, with no patients developing anesthesia dolorosa with retreatment.CONCLUSIONSGKRS is a safe, well-tolerated treatment for patients with medically refractory bilateral TN. Efficacy of treatment appears similar to that in patients with unilateral TN. GKRS can be safely repeated in this population if necessary.

Characteristics and treatment of Multiple Sclerosis-related trigeminal neuralgia: An Italian multi-centre study

BackgroundThe prevalence of trigeminal neuralgia (TN) in Multiple Sclerosis (MS) patients is higher than in the general population and its management can be particularly challenging. Our aim is to describe the characteristics, treatment and prognostic factors of MS-related TN in a retrospective multicentre study. MethodsNeurologists members of the RIREMS group (Rising Researchers in MS) enrolled MS patients with a TN diagnosis and filled out a spreadsheet comprising their clinical data. ResultsPopulation consisted of 298 patients. First-choice preventive treatments were carbamazepine and oxcarbazepine. A surgical procedure was performed in 81 (30%) patients, most commonly gamma knife stereotactic radiosurgery (37%), followed by microvascular decompression (22%) and radiofrequency thermocoagulation (21%); one third of patients underwent at least two procedures. Surgery was associated with higher disability, male sex and longer interval between MS and TN onset. Patients (77%) who stayed on at least one preventive medication at most recent follow-up, after a mean period of 8 years, had a higher disability compared to the untreated group. Furthermore, patients with higher disability at TN onset were less likely to discontinue their first preventive medication due to pain remission, had bilateral TN more frequently and underwent surgical interventions earlier. ConclusionMS patients with a higher disability at TN onset and with a longer interval between MS and TN onset had differing clinical features and outcomes: pain was more frequently bilateral, surgery was more frequent and anticipated, and preventive medication discontinuation due to pain remission was less common.

Combined Hyperactive Dysfunction Syndrome of the Cranial Nerves: Analysis of 37 Cases and Literature Review

Hyperactive dysfunction syndrome (HDS) of the cranial nerves, such as trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN), is commonly managed by microsurgical treatment. However, certain patients may present a combination of these syndromes in the neurosurgery department. Here, we aimed to retrospectively assess patients with combined HDS from a single center. Of 1275 consecutive patients with HDS treated at our center between 2007 and 2017, 37 patients with combined HDS were enrolled, and their medical and surgical records were analyzed. The patients with combined HDS, accounting for 2.9% of all patients with HDS, included 22 patients with bilateral TN, 5 patients with TN-HFS, 8 patients with TN-GPN, and 2 patients with GPN-HFS. A comparison of patients with single and combined HDS indicated a significant difference in the mean age at initial diagnosis (63.57 vs. 56.18 years, P= 0.000) but no such difference in the sex ratio (0.54 vs. 0.59, P= 0.865) or incidence of hypertension (32.43% vs. 24.56%, P= 0.274). In total, 32 microvascular decompression (MVD) procedures were performed in the 27 patients with combined HDS, and repeated MVD was required in 5 patients with bilateral TN. Of the 27 patients who underwent MVD, 25 (92.6%) experienced clinical cure or obvious alleviation. Combined HDS involves a group of functional disturbance disorders affecting specific cranial nerves, and it may include TN, HFS, and GPN. In addition to gender and incidence of hypertension, age appeared to be a vital indicator for the development of combined HDS, although this finding was inconsistent in previous studies. MVD appears to be a safe and effective treatment for combined HDS, with a high rate of long-term success.

A case report of bilateral trigeminal neuralgia combined with bilateral glossopharyngeal neuralgia

A case report of bilateral trigeminal neuralgia combined with bilateral glossopharyngeal neuralgia

Gamma Knife Radiosurgery for Bilateral Trigeminal Neuralgia

Bilateral trigeminal neuralgia (BTN) makes up a small subset of patients with trigeminal neuralgia. These patients have a higher incidence of familial TN and multiple sclerosis and their management is controversial. Here we report a large single institution retrospective cohort of patients with BTN treated with stereotactic radiosurgery (SRS). SRS database review identified 78 nerves in 52 patients with BTN who underwent at least one SRS between 1999 and 2017. Background history, demographics, treatment outcomes, complications, and dosimetric data were obtained by retrospective chart review. Long-term follow-up was obtained by a standardized telephone interview performed by a physician. Successful treatment was defined as BNI IIIb or better pain relief. Time-to-failure outcomes were estimated by the Kaplan-Meier method. Hazard ratios (HR) associated with patient and treatment-related variables for time-to-failure outcomes were estimated by Cox proportional hazards methods. Of the 78 individual nerves treated with a first SRS, 77 had sufficient follow up data to determine BNI pain score outcomes. Sixty-seven of the 77 nerves (87%) achieved ≥ BNI IIIb pain relief, with 34 (44%) achieving BNI I pain relief. The median time to BNI IIIb pain relief was 3.5 weeks. At a median follow-up of 3.4 years, the median duration of ≥ BNI IIIb pain relief was 2.5 years. The estimated 1, 3, and 5-year rates of ≥ BNI IIIb pain relief were 71%, 43%, and 32%. Post-SRS facial numbness was seen in 33 (43%) cases, with five (6.5%) being bothersome. Two (2.6%) cases of anesthesia dolorosa (AD) and five (6.4%) cases of corneal numbness were reported. SRS with a maximal post procedure BNI of IIIb were more likely to experience pain relapse than those who achieved BNI I relief (HR 2.55, p = 0.04), as were those who had a history of prior ipsilateral microvascular decompression (MVD) (HR 2.64, p = 0.03). Left sided pain was more likely to relapse than right sided (HR 2.22, p = 0.02). Twenty-two nerves underwent repeat SRS for recurrent pain, of which 20 had sufficient follow up to determine BNI pain score outcomes. Of these, 19 (95%) had ≥ BNI IIIb pain relief, with 8 (40%) reaching BNI I relief. The median time to BNI IIIb pain relief was 8 weeks. At a median follow-up of 4.1 years, the median duration of BNI IIIb or better pain relief was 8 years, with estimated 1, 3, and 5-year rates of pain relief of 89%, 62%, and 62% respectively. Eleven (55%) experienced facial numbness after repeat SRS with four (20%) being bothersome. One case (5.6%) of corneal numbness and zero cases of AD were reported after repeat SRS. SRS is an effective, well-tolerated treatment modality for patients with BTN. Patients with prior MVD or SRS that resulted in maximal pain relief of BNI IIIb are more likely to experience pain relapse than those who achieved BNI I relief. Repeat SRS appears to have greater efficacy and durability than initial SRS, and despite increased bothersome facial numbness remains well tolerated.

Radio-frequency ablation of trigeminal ganglion for refractory pain of bilateral trigeminal neuralgia in a patient with multiple sclerosis

Trigeminal neuralgia (TN) is one of the most excruciating variety of craniofacial neuralgias with 12% prevalence in general population. It can be either primary (idiopathic, 90% cases) or secondary (due to pathology such as tumor, multiple sclerosis [MS], and arteriovenous malformation, 10% of cases). TN has a 20 times higher risk of prevalence in patients with MS with an average incidence of 2%. Bilateral TN is significantly more common in patients with MS (18%) when compared to the normal population (5%). Pharmacotherapy is the first line and mainstay of management, but a small percentage of patients continue to have unremitting pain requiring other management modalities such as minimally invasive percutaneous techniques, microvascular decompression, or stereotactic radiosurgery. There is, however, no consensus at present regarding its selection for an individual patient. This case report highlights successful application of radio-frequency ablation in a patient with MS who had bilateral presentation with different timings.

Management of Primary Bilateral Trigeminal Neuralgia with Microvascular Decompression: 13-Case Series.

Bilateral trigeminal neuralgia is a relatively rare disease. Microvascular decompression (MVD) is a safe and effective treatment for unilateral trigeminal neuralgia; however, its utility in bilateral trigeminal neuralgia is unclear. Here, we report our experience with MVD in 13 cases of primary bilateral trigeminal neuralgia. We retrospectively analyzed 13 cases of bilateral trigeminal neuralgia that were treated with MVD between January 2013 and January 2015. Surgical outcomes and complications were explored in each case. Postoperatively, 11 patients had excellent outcomes and 2 patients had good outcomes on the operative side. Three patients also reported the amelioration of contralateral symptoms after MVD. Of 10 cases indicating no contralateral improvement, 1 refused to undergo a second MVD procedure on the opposite side and 9 underwent a second MVD procedure and experienced symptom relief. The superior cerebellar artery was the most common offending vessel. There were no severe MVD-related complications. Vascular compression plays a causative role in bilateral and unilateral trigeminal neuralgia. MVD appears to be a safe and effective treatment option in patients who are refractory to pharmacotherapy.

206 Percutaneous Balloon Compression as Treatment to Trigeminal Neuralgia

Abstract INTRODUCTION Percutaneous balloon compression of the Gasserian ganglionic has been used to treat Trigeminal Neuralgia (TN) since 1983. METHODS We performed a retrospective study on 222 patient's records which have received 242 procedures of Percutaneous Balloon Compression (PBC) as treatment for TN. A 6 months follow-up period after surgery was needed to be included in the study. They were operated at Functional Neurosurgery Unit in Brazil from February 2002 to July 2016. RESULTS >The patient's age ranged from 29 to 91 years (mean, 62, 2 years), 43% were males and 57% were females. Rare cases of bilateral trigeminal neuralgia were seen in 5 patients. Immediately after surgery, 193 (79,7%) patients became pain-free and 34 (14%) patients became pain free during the following 4 days. Carbamazepine was suspended in 93.7% of cases. Out of the total, only 13 (5,37%) patients related residual pain on follow-up. Hypoesthesia was reported after 83,8% of procedures. In addition, bradycardia was seen in 58,1% of cases during foramen ovale puncture. Transitory complications such as diplopia (2,47%), otalgia (1,23%) and tinnitus (1,23%) were reported. Regarding to balloon appearance, pear and dumb-bell shapes were detected in 74,8% and 7,4% of procedures, respectively. Only 15 (6,19%) patients needed a reoperation due to pain persistence. CONCLUSION PBC showed to be an effective and safe technique which provides high rates of pain relief (93,7%) in the following 6 months after surgery. The Carbamazepine's use was markedly reduced (93,7%). In addition, relapse of pain occurred in few cases (5,37%). Complications were minor and transitory. Comparing statistically, we can stat that the balloon shapes (82,2%) and hypoesthesia (83,8%) findings had a positive influence on pain relief rate (93,7%). Our findings support that PBC should be considered as primary surgical treatment of trigeminal neuralgia.

Bilateral painful tic convulsif

‘Painful tic convulsif’ (PTC) describes the coexistence of hemifacial spasm and trigeminal neuralgia. In this report, we describe a unique presentation of bilateral PTC in a man with bilateral hemifacial...

Combined Hyperactive Dysfunction Syndrome of the Cranial Nerves: A Retrospective Systematic Study of Clinical Characteristics in 44 Patients.

Combined hyperactive dysfunction syndrome (HDS) is defined as the combination symptoms arising from overactivity in cranial nerves, specifically, trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN), without an obvious explanatory structural lesion. This study retrospectively analyzes the clinical characteristics of combined HDS treated with microvascular decompression (MVD) in a single institution. A total of 1450 patients with HDS were treated with MVD in our department during a 10-year period, among which 44 cases of combined HDS were identified. Clinical records and follow-ups were reviewed. Combined HDS comprised 3.03% (44/1450) of all HDS in our series, with female predominance compared with single HDS (P= 0.002), including combined TN-HFS (14 cases), combined TN-GPN (26 cases), bilateral TN (2 cases), and combined TN-HFS-GPN (2cases). The average age at diagnosis of patients with combined HDS (60.9 years) was significantly older than that of patients with single HDS (53.5 years) (P= 0.035). Hypertension was closely associated with the prevalence of combined HDS compared with single HDS (P= 0.009). The curative rate was 97.7% (43/44) after MVD, and therecurrence rate was 3.33%. The incidence rates of postoperative cardiac, pulmonary, thromboembolic, and delirium complications were higher in combined HDS than in single HDS (P < 0.05). Combined HDS is a rarely occurring syndrome usually observed in older females, and the most common types are combined TN-GPN and combined TN-HFS. Age and gender seemed to be causes for developing combined HDS, and MVD shows potential as a favorable treatment choice.

Granulomatosis With Polyangiitis Masquerading as Bilateral Trigeminal Neuralgia

A 32-year-old woman presented with symptoms of bilateral trigeminal neuralgia (TN) that has been refractory to empiric therapy. Imaging showed normal caliber trigeminal nerves with no evidence of nerve compression. Autoimmune etiology was considered due to unnatural presentation of symptoms. Workup revealed elevated perinuclear antineutrophil cytoplasmic antibody (P-ANCA) and elevated myeloperoxidase (MPO) antibodies suggestive of localized ANCA-related vasculitis. A literature review revealed one case, which illustrates granulomatosis with polyangiitis (GPA) causing the classical symptoms of TN in absence of its more common symptoms. Patient was started on methotrexate 15 mg weekly and low-dose prednisone daily with significant improvement in symptoms. Ear-nose-throat (ENT) manifestations of rheumatologic disorders represent a diagnostic challenge. ENT symptoms can often represent the initial sign of an otherwise asymptomatic and undiagnosed autoimmune disease process, which often calls for prompt and aggressive immunosuppressive treatment which leads to not only better control of TN symptoms but also we speculate that early immunosuppressive therapy will control the progression of the underlying autoimmune disease. J Med Cases. 2016;7(9):384-385 doi: http://dx.doi.org/10.14740/jmc2636e

New Clinical and Morphologic Aspects in Trigeminal Neuralgia

High-resolution magnetic resonance imaging can be used to delineate the morphology of neurovascular compression (NVC) in detail. This study focuses on essential morphologic parameters in relation to the clinical appearance of patients with trigeminal neuralgia (TN). A total of 180 patients with TN underwent magnetic resonance-constructive interference in steady state/time of flight. Parameters of the affected nerves (length) and causative vessels were examined: (1) the relationship between the NVC site (caudal/cranial/laterocaudal/mediocranial) and affected area (V1, V2, V3); (2) nerve deformity; (3) vascular loop; (4) existence of a "cerebrospinal fluid (CSF) sign" by a separation of trigeminal fascicles by a vessel; and (5) localization of the causative vessel. A total of 10 patients with V1 affection showed 6 caudal, 0 cranial and laterocaudal, and 4 mediocranial NVC; 26 patients with V2 affection showed 17 caudal, 0 cranial, 1 laterocaudal, and 8 mediocranial NVC; 29 patients with V3 affection showed 23 caudal, 1 cranial, 3 laterocaudal, and 2 mediocranial NVC; 25 patients with V1 and V2 affection showed 17 caudal, 1 cranial, 0 laterocaudal, and 7 mediocranial NVC; 36 patients with V2 and V3 affection showed 30 caudal, 3 cranial, 1 laterocaudal, and 2 mediocranial NVC; and 6 patients with V1, V2, and V3 affection showed 4 caudal, 1 cranial, 0 laterocaudal, and 1 mediocranial NVC. A total of 63 patients (35%) showed nerval deformity by distorsion of the trigeminal fascicles from compressing vessel; 37 of 39 patients (95%) with right-sided deformity showed right-sided TN; and 21 of 22 patients (95%) with left-sided TN showed left-sided nerve deformation. Two patients with bilateral nerve deformity showed bilateral TN. Rostral superior cerebellar artery (SCA) loop compression was seen in 24 patients (17%), caudal SCA loop compression was seen in 10 patients (7%), and double SCA loop compression was seen in 33 patients (23%). Sandwich compression was seen in 18 (12%), and a CSF sign was seen in 24 patients. All 24 patients (100%) with a CSF sign had V1 affection. The CSF sign is pathognomonic for V1 affection. Vascular loops from cranial on the nerve were the most frequent types of compression in all areas of pain, followed by mediocranial loops. This evaluation is reproducible and contributes to the role of magnetic resonance imaging and a classification of findings in the preoperative evaluation of NVC.