Diagnosis Of Trigeminal Neuralgia Research Articles

Trigeminal neuralgia: drug therapy : The new German guideline

Trigeminal neuralgia is characterized by severe, lightning-like attacks of pain, which are mandatory for the diagnosis. The pain typically occurs on one side and is often triggered by simply touching the face, chewing or talking. In acute exacerbations, this can also hinder food and fluid intake, resulting in alife-threatening clinical picture. Adistinction is made between classical, secondary and idiopathic trigeminal neuralgia. For the diagnosis of trigeminal neuralgia, the medical history and imaging procedures are key for classification. The only active substances approved for the treatment of trigeminal neuralgia in Germany are carbamazepine and phenytoin, which is why off-label drugs often need to be used if there is no or insufficient effect or inacceptable side effects. Cooperation between research and clinical practice to improve the care of affected patients is therefore essential.

356 Nervus Intermedius Sectioning for the Treatment of Geniculate Neuralgia: A Single-Surgeon Case Series

INTRODUCTION: Geniculate neuralgia (GN) is a rare pain condition involving the nervus intermedius (NI), a branch of the facial nerve. The current standard for surgical intervention consists of a retrosigmoid craniotomy with sectioning of the NI. However, few case reports/series exist detailing the outcomes of GN surgical treatment. METHODS: We reviewed patient charts involving craniotomies for GN performed by a single surgeon between November 2020 and December 2022. RESULTS: Three patients underwent two craniotomies for GN. GN patients were largely female (91.30%) and White, non-Hispanic/Latino (78.26%). Nearly all GN patients had a concurrent diagnosis of trigeminal neuralgia (n = 22, 95.65%) and some also had a concurrent diagnosis of glossopharyngeal neuralgia (n = 9, 39.13%). Vascular contact with cranial nerves VII and VIII was reported in four procedures. 22 procedures (84.62%) resulted in profound pain relief, with BNI pain score decreasing from 5 to 1 between pre-op and latest follow-up. No patients experienced unexpected hearing loss compared to baseline at latest follow-up. One patient experienced facial paralysis on the side of surgery and two patients experienced some form of vestibular dysfunction at latest follow-up. Of 26 total procedures, 20 included NI sectioning. Initial craniotomies in which the NI was sectioned (n = 18) resolved GN pain 88.89% of the time whereas craniotomies without NI sectioning (n = 5) resolved GN pain 60% of the time. CONCLUSIONS: NI sectioning is an effective means of achieving GN pain relief. Post-operative complications including unexpected hearing loss, facial paralysis, and vestibular dysfunction were infrequently observed in our series.

Use Of Laser Phototherapy In The Treatment Of Trigeminal Neuralgia

Responsible for the sensory stimuli of the viscerocranium, the 5th pair of cranial nerves, called the trigeminal nerve due to its 3 branches, is a mixed-function nerve. The diagnosis of Trigeminal Neuralgia is directly related to the symptoms reported by the patient during the anamnesis. The right treatment depends on the correct diagnosis. The exact etiology of TN is still unknown. It affects around 4 to 13 individuals per 100,000 and although it seems to be a neuropathy with a low incidence, it is the most common among facial pain syndromes. A retrospective cross-sectional observational study was carried out. We used data on laser therapy treatment for Trigeminal Neuralgia, received and treated at the Laser Clinic of the Faculty of Dentistry of the Federal University of Bahia, from 2003 to 2022. A total of 119 patients with a diagnosis of Trigeminal Neuralgia were treated, most of them with unilateral pain (89%). After diagnosis, the initial irradiation protocol was determined individually. The laser frequency applied was 808 nm (infrared) due to its greater ability to penetrate and activate chromophores in nerve and bone structures. The amount of energy applied varies from case to case, usually starting with 2 or 3 J per point, which is indicated for cases of regeneration and analgesia. The final status of the treatment is based on the patient’s score according to the visual analog scale, where 10 is the highest pain threshold and 0 is no pain. 65% of the patients related no pain or ate at least under 3 grades before the first degree Laser phototherapy is an effective means of recovery, reducing pain symptoms and improving the quality of life of patients with Trigeminal Neuralgia, and the infrared wave spectrum is the most suitable for this treatment.

PERPLEXING IMPACTED THIRD MOLARS IN A CASE OF TRIGEMINAL NEURALGIA AND ARACHNOID CYST (CASE REPORT)

Introduction: Trigeminal neuralgia (TN) is the most frequent form of craniofacial neuropathic pain, with a wide range of severity. Trigeminal neuralgia classically has been associated with neurovascular compression in the prepontine cistern at the nerve root entry zone or in Meckel’s cave due to an abnormal vessel, tumor, or cyst. Arachnoid cysts of the posterior cranial fossa are still less commonly compared to those superior to the constituent part of the posterior cranial fossa meninges. However, the arachnoid cyst in conjunction with the impacted third molar may cause compression of the trigeminal ganglion with similar clinical symptoms. The aim of this report is to explain the management of the first division of trigeminal neuralgia with an arachnoid cyst perplexed by impacted third molars. Case report: A case of a 27-year-old female with throbbing pain on top of her head, forehead, temple, and eyes several times. Extensive clinical and radiologic examinations were performed and revealed an arachnoid cyst and impacted third molars. Impacted third molars were removed. The patient declined the surgery for the arachnoid cyst and was treated symptomatically with amitriptyline 25 mg once daily until recently. The definitive diagnosis was the first division of trigeminal neuralgia and an arachnoid cyst. Conclusions A fundamental aspect of the diagnosis of trigeminal neuralgia is to examine and exclude all possible underlying etiologies and structural pathologies, which can refer the pain to a location remote from the stimulus.

The Comparison of General Characteristics and Early and Late Post-intervention Results in Patients With Trigeminal Neuralgia Secondary to Multiple Sclerosis and Idiopathic Trigeminal Neuralgia Treated With Radiofrequency Thermocoagulation.

Aim The aim of this study was to investigate possible differences (in terms of demographic structure, disease history, complaints, clinical findings, early and late treatment outcomes, and complications) between patients with idiopathic trigeminal neuralgia (ITN) and trigeminal neuralgia (TN) secondary to multiple sclerosis (MS) who were admitted to our clinic and underwent radiofrequency (RF) thermocoagulation procedure. Materials and methods Patients who underwent percutaneous radiofrequency thermocoagulation with a diagnosis of trigeminal neuralgia by a single neurosurgeon in a single neurosurgery clinic between January 2005 and January 2020 were included in this study. Patients were divided into two groups: idiopathic trigeminal neuralgia and trigeminal neuralgia secondary to multiple sclerosis (MSTN) according to their diagnosis. In our study, 215 TN patients who underwent 286 procedures were included. These patients were categorized according to age, sex, involved side, pain localization, and pain history. Postoperative complications were determined after each intervention. The early and late results of all interventions were evaluated, and the results were compared between both groups. All results were statistically analyzed. Results Considering the age of the patients, the mean age of the idiopathic group was higher than the multiple sclerosis group (58.18>49.46). In terms of the side of pain, bilateral involvement was significantly more common in the MS secondary group (1.48%<30.77%). There was no significant difference between the early results of both groups. In terms of remission periods, the pain-free period in the MS secondary group was significantly shorter than in the idiopathic group (mean value in months, 30.87>23.81). Conclusion The radiofrequency thermocoagulation of the trigeminal nerve is a highly effective, low-complication, reproducible procedure for trigeminal neuralgia, but the search for ways to improve the efficacy of treatment in MS patients should continue.

Behandeling van trigeminusneuralgie bij patiënten met multiple sclerose met behulp van radiofrequente thermocoagulatie van het ganglion van Gasser: een gevallenreeks

Treatment of trigeminal neuralgia in patients with multiple sclerosis using radiofrequency thermocoagulation of Gasser’s ganglion: a case series Patients with trigeminal neuralgia and multiple sclerosis (TNMS) are difficult to treat. Often, medication treatment does not provide sufficient pain relief. In these patients, radiofrequency thermocoagulation of Gasser’s ganglion can be performed. This case series looked at the results of patients with TNMS who underwent this procedure between January 2005 and March 2021. A total of 14 patients were included, most of whom underwent multiple procedures over the years. There was an average of 4 years between the diagnosis of trigeminal neuralgia and the first procedure. Adequate analgesia was obtained in 71% (1st procedure), 89% (2nd procedure), 100% (3rd procedure) and 50% (4th procedure) of the patients respectively. In 5 cases, hypoesthesia occurred in the denervated area, which was transient in 4 cases. There were no other complications. Based on these data, the authors come to the conclusion that radiofrequent thermocoagulation has a place in this difficult-to-treat condition thanks to the safe and substantial pain reduction in TNMS.

Diagnosis and treatment of trigeminal neuralgia

Background: Trigeminal neuralgia is a sudden and painful facial condition that is triggered by activities of daily living. The pain is debilitating and patients are often unable to perform routine daily tasks such as washing their face, shaving, and brushing their teeth, which in turn has an impact on their social life and mental well-being as they are often anxious and fearful of not knowing when the pain may occur.Current Concepts: Treatment for trigeminal neuralgia involves local nerve destruction surgeries, including neuroblocking, percutaneous ethanol injection therapy, percutaneous radio-frequency rhizotomy, and gamma knife surgery. Although these types of surgeries reduce pain, the side effects are unpleasant and include decreased facial sensation, which originates from the damage to the trigeminal nerve. Furthermore, these surgeries provide insufficient long-term outcomes and symptoms often recur. Microvascular decompression is a radical surgical approach that separates the blood vessels that cause pain from the nerves. In a large-scale study, microvascular decompression significantly reduced the pain in 80–96% of the patients who underwent initial treatment. Of these, 85% experienced significant pain reduction 38 months post-surgery, and 72–85% reported that they were able to manage their pain 5 years post-surgery. Currently, microvascular decompression is the most appropriate surgical approach to control pain in patients with trigeminal neuralgia, as it exhibits the highest rate of pain control and lowest rate of recurrence.Discussion and Conclusion: The accurate diagnosis of trigeminal neuralgia, through clinical symptoms and imaging, is important to obtain good treatment outcomes. Microvascular decompression should be considered when a patient responds poorly to initial treatment approaches, cannot receive surgical treatment due to side effects, or experiences pain recurrence following local nerve destruction.

SUNCT/SUNA: frequently misdiagnosed as trigeminal neuralgia?

Identify the number of cases with a possible diagnosis of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) in patients with a previous diagnosis of Trigeminal Neuralgia (TN) at the Neurology Service of the National Medical Center 20 de Noviembre. This will confirm that these trigeminal-autonomic cephalalgias should be ruled out and considered as differential diagnoses of trigeminal neuralgia. Cross-sectional and retrospective study. The complete electronic medical records of 100 patients with a diagnosis of TN were evaluated during the period from April 2010 to May 2020. Autonomic symptoms were intentionally searched for in these patients and compared with the diagnostic criteria of SUNCT and SUNA of the 3rd edition of the International Classification of Headache Disorders. Chi-square tests and subsequent bivariate regression were performed to determine the association between variables. One hundred patients with a diagnosis of TN were included. After reviewing the clinical manifestations, 12 patients with autonomic symptoms were found and compared with the diagnostic criteria of SUNCT and SUNA. However, they did not meet the absolute criteria to be diagnosed with the previously mentioned diseases, nor to be ruled out. TN is a painful and frequent entity that can present with autonomic symptoms, therefore making it important to identify SUNCT and SUNA as differential diagnoses, to recognize them and treat them appropriately.

Clinical Profile and Treatment Outcome of Patients with Trigeminal Neuralgia: A Retrospective study in a Tertiary Hospital of Eastern Nepal

Introduction: Neuropathic orofacial pain is common non-dontogenic pain. Diagnosis relies primarily on history taking with less of pathologic change visible. Trigeminal neuralgia (TGN) is a common neuropathic pain affecting the maxillofacial region of fifth cranial nerve (V). Objective: To assess clinical characteristics, effective therapeutic regimen, side effect, radiographic and laboratory investigation inTrigeminal neuralgia patients. Methods: Retrospective study included all patients visiting the department with records from 2014 to 2021. After ethical approval forstudy, eighty patients were diagnosed based on ICHD3 criteria. Patient with atypical feature with sensory deficit underwent CT OR MRI to rule of mass or lesion along the cerebello-pontine angle recess and other organic cause. The data were analysed using SPSS version 11.5 and Microsoft Excel 2017. Results: A total of 80 patients were retrieved. The common side affected were right 46 (57.5%) followed by left 28 (35%), bilateral four(5%) and anterior region two (2.5%). The most common branch involved was mandibular followed by maxillary branch and combination. Management was primarily done by carbamazepine (CBZ) or in combination. Common side effects were drowsiness, dizziness, nausea and diplopia. CT scan and MRI showed space occupying lesion in three cases. Refractory cases underwent neurolysis and symptomatic and few classical TGN cases were sent for surgical management. Conclusions: Diagnosis of Trigeminal neuralgia is primarily based on clinical characteristic due to high cost and unavailability of imaging and nerve testing. Treatment is by single or multiple drugs with adjunct therapy.

Gamma Knife Radiosurgery for Trigeminal Neuralgia : Review and Update.

Accurate diagnosis of trigeminal neuralgia (TN) is the starting point for optimal treatment. Gamma knife radiosurgery (GKRS) is currently regarded as one of the first-line treatment options for medically refractory TN. GKRS is a less invasive treatment with a low risk of complications than other surgical procedures that provides a favorable pain control (BNI I–IIIb) rate of >75% at short-term follow-up. Drawbacks of GKRS include the latency period before pain relief and higher recurrence rate compared with microvascular decompression. Therefore, repeat treatment is necessary if the initial GKRS was effective but followed by recurrence. The concept of dose rate and the biologically effective dose of radiation has been actively studied in radiation oncology and is also applied in GKRS for TN to achieve high safety and efficacy by prescribing the optimal dose. Recent progress in functional imaging, such as diffusion tensor imaging, enables us to understand the pathophysiology of TN and predict the clinical outcome after GKRS. Here, we review TN, GKRS, and recent updates, especially in the concepts of radiation dose, diffusion tensor imaging studies, and repeat treatment in GKRS for TN.

361 Prevalence and Trends of Surgical Intervention for Trigeminal Neuralgia in the Inpatient Setting in the United States: Analyses from a National Database from 2002-2015

INTRODUCTION: Trigeminal neuralgia is a debilitating neurological condition characterized by sharp, stabbing pain in the distribution of the trigeminal nerve and its branches. For trigeminal neuralgia that is refractory to medical therapy, surgery is generally indicated. Herein, we sought to assess the prevalence of trigeminal neuralgia among inpatient admissions, utilization of surgical intervention, and trends of utilization of common surgical approaches for TN using a national database. METHODS: The National Inpatient Sample (NIS) was queried for all patients with trigeminal neuralgia using international classification of disease 9th revision clinical modification (ICD-9-CM) diagnosis code (350.1) between the 1st quarter of 2002 and the 3rd quarter of 2015. Cases were also classified into surgical groups using ICD-9 procedure codes which included MVD, percutaneous procedures and stereotactic radiosurgery. Using weighted discharge methodology, national estimates for prevalence, primary admissions, and utilization of each surgery type were computed. RESULTS: A total of 405,445 patients with trigeminal neuralgia were identified between the 1st quarter of 2002 and the 3rd quarter of 2015. The inpatient prevalence of trigeminal neuralgia in this 14 year cohort was found to be 63.8 per 100,000, and was found to increase from 54.9 per 100,000 in 2002 to 76 per 100,00 in 2015. A total of 67,768 patients had a primary diagnosis of trigeminal neuralgia. Of these, 41,473 (61.2%) underwent a surgical procedure; surgical utilization increased from 59.7% cases in 2002 to 69.1% in 2015. Of the cases undergoing a surgical intervention for trigeminal neuralgia, an MVD was performed for the majority of patients (87%, n=36,083) followed by percutaneous procedures (7.3%, n=3,036) and stereotactic radiosurgery (7.1%, n=2,940). Furthermore, the percent-utilization of MVD among patients undergoing surgical intervention increased form 67.3% in 2002 to 98% in 2015, the percent utilization of percutaneous procedures fell from 17.9% to 2%, and the percent utilization of stereotactic radiosurgery fell from 15.5% to 0.4%. CONCLUSION: The trends within surgical management of trigeminal neuralgia have been rapidly evolving over the past two decades with a steady trend towards MVD.

Polymorphisms of Nav1.6 sodium channel, Brain-derived Neurotrophic Factor, Catechol-O-methyltransferase and Guanosine Triphosphate Cyclohydrolase 1 genes in trigeminal neuralgia

SubjectsTrigeminal neuralgia is a neuropathic pain characterized by episodes of severe shock-like pain within the distribution of one or more divisions of the trigeminal nerve. Pain can be influenced by ethnicity, environment, gender, psychological traits, and genetics. Molecules Nav1.6 sodium channel, Brain-derived Neurotrophic Factor, Catechol-O-methyltransferase and Guanosine Triphosphate Cyclohydrolase 1 have been involved in mechanisms that underlie pain and neurological conditions. ObjectiveThe aim of this case-control study was to investigate the occurrence of genetic polymorphisms in Nav1.6 sodium channel (SCN8A/rs303810), Brain-derived Neurotrophic Factor (BDNF/rs6265/Val66Met), Catechol-O-methyltransferase (COMT/rs4680/Val158Met), and Guanosine Triphosphate Cyclohydrolase 1 (GCH1/rs8007267) genes in trigeminal neuralgia patients. MethodsNinety-six subjects were divided into two groups: 48 with trigeminal neuralgia diagnosis and 48 controls. Pain was evaluated by visual analog scale and genomic DNA was obtained from oral swabs and analyzed by real-time polymerase chain reaction. ResultsNo association was observed among SCN8A, BDNF, COMT or GCH1 polymorphisms and the presence of trigeminal neuralgia. Genotype distribution and allele frequencies did not correlate to pain severity. ConclusionsAlthough no association of evaluated polymorphisms and trigeminal neuralgia or pain was observed, our data contributes to the knowledge of genetic susceptibility to trigeminal neuralgia, which is very scarce. Further studies may focus on other polymorphisms and mutations, as well as on epigenetics and transcriptional regulation of these genes, in order to clarify or definitively exclude the role of Nav1.6, BDNF, COMT or GCH1 in trigeminal neuralgia susceptibility and pathophysiology.

Is this really trigeminal neuralgia? Diagnostic re-evaluation of patients referred for neurosurgery

Patients with facial pain are sometimes referred for neurosurgical treatment with a poorly documented diagnosis of trigeminal neuralgia. In such cases, neurosurgery will usually not be helpful. We conducted a re-evaluation of the diagnosis in patients referred for neurosurgical treatment of presumed trigeminal neuralgia. Our objective was to find out why and how often misdiagnosis occurred. A retrospective study was done in consecutive first-time patients referred for trigeminal neuralgia to our outpatient clinic in 2019. We used five ICHD-3-based clinical criteria to verify or exclude the diagnosis. In patients where trigeminal neuralgia was excluded, we established a diagnosis for their facial pain based upon medical history and a physical examination by a neurosurgeon- often supplemented with examination by an oral surgeon. Thirty-eight patients were referred for presumed trigeminal neuralgia. Only 17 of them fulfilled the five criteria and were diagnosed with trigeminal neuralgia. In20 of the remaining 21 patients trigeminal neuralgia could be clearly excluded, while one of the patients had a periodontitis closely mimicking trigeminal neuralgia. In 14of the 21 patients we diagnosed temporomandibular dysfunction or dental conditions. MRI scans had detected low-grade neurovascular contacts in 13 of the 21 patients, a finding that was clearly overestimated by the referring neurologists in seven patients. Overdiagnosis of trigeminal neuralgia was common in patients referred for neurosurgery, mostly due to insufficient clinical evaluation combined with an overestimation of MRI-detected NVCs. The clinical diagnosis should be critically re-evaluated before recommending neurosurgery to patients referred for presumed trigeminal neuralgia.

An age-dependent outcome analysis of microvascular decompression and percutaneous thermocoagulation in trigeminal neuralgia

BackgroundTrigeminal neuralgia (TN) is a severe pain condition and the most common facial neuralgia. While microvascular decompression (MVD) presents an excellent treatment in neurovascular compression cases, percutaneous thermocoagulation (PT) of the ganglion Gasseri is an alternative option. This study aimed to evaluate post-operative complication rate and outcome of both treatment strategies related to the patient’s age.MethodsThe medical records of all patients with the diagnosis of trigeminal neuralgia undergoing an MVD or PT of the ganglion Gasseri (between January 2007 and September 2017) were reviewed to determine the efficacy and the complication rate of both methods in regard to the patient’s age.ResultsSeventy-nine patients underwent MVD surgery and 39 a PT. The mean age of patients in the MVD group was 61 years and 73 years in the PT group. There were 59 (50%) female patients. Nerve-vessel conflict could be identified in 78 (98.7%) MVD and 17 (43.6%) PT patients on preoperative MRI. Charlson comorbidity index was significantly higher in PT group (2.4 (1.8) versus 3.8 (1.8) p < 0.001). The Barrow pain score (BPS) at the last follow-up demonstrated higher scores after PT (p = 0.007). The complication rate was markedly higher in PT group, mostly due to the facial hypesthesia (84.6% versus 27.8%; p < 0.001). Mean symptom-free survival was significantly shorter in the PT group (9 vs. 26 months, p < 0.001). It remained statistically significant when stratified into age groups: (65 years and older: 9 vs. 18 months, p = 0.001).Duration of symptoms (OR 1.005, 95% CI 1.000–1.010), primary procedure (OR 6.198, 95% CI 2.650–14.496), patient age (OR 1.033, 95% CI 1.002–1.066), and postoperative complication rate (OR 2.777, 95% CI 1.309–5.890) were associated with treatment failure.ConclusionIn this patient series, the MVD is confirmed to be an excellent treatment option independent of patient’s age. However, while PT is an effective procedure, time to pain recurrence is shorter, and the favorable outcome (BPS 1 and 2) rate is lower compared to MVD. Hence MVD should be the preferred treatment and PT should remain an alternative in very selected cases when latter is not possible but not in the elderly patient per se.

Please spare my teeth! Dental procedures and trigeminal neuralgia.

Background: The correct diagnosis of trigeminal neuralgia (TN) is still a far cry and the patients suffer from unnecessary dental procedures before getting the definite treatment. In this study, we evaluated, if the patients have undergone dental procedures for their misdiagnosed TN before receiving definite treatment for the same.Methods: A total of 187 patients received GKRS for their TN (excluding secondary TN) in two institutes from 2010 to 2019. We did a retrospective analysis of these patients’ primary complaints on a standard questionnaire.Results: One hundred and seventeen of the 187 patients responded. About 55.5% of patients had a toothache and 65.8% did visit a dentist for the pain. About 41.8% of patients underwent one dental procedure; 18.8% suffered from worsening of the pain while 8.5% received some partial improvement. About 19.6% also underwent root canal treatment while 6.8% had a nerve block. Mean of 1.6 teeth was extracted per person. About 71% of patients were satisfied with their Gamma Knife radiosurgery for TN at a median follow-up of 49 months.Conclusion: There is a need for a better understanding of the disease among the dentists and the patients for the timely and correct treatment, without losing their teeth. The onus lies on neurosurgeons/neurologists disseminate knowledge regarding proper diagnosis and treatment modalities.

Trigeminal neuralgia : Modern diagnostic workup and treatment

The present article gives an update of relevant aspects in the diagnosis and therapy of trigeminal neuralgia from the neurological, neuroradiological and neurosurgical point of view. The diagnosis of trigeminal neuralgia is clinical, but high-quality imaging is mandatory to identify secondary causes and aneurovascular contact. New methods such as DTI (diffusion tensor imaging) allow amore differentiated assessment of the consequences of avascular contact on the trigeminal nerve. Carbamazepine and oxcarbazepine continue to be first choice for the medical treatment, but have been supplemented by additional options such as pregabaline, lamotrigine, and onabotulinumtoxinA. In patients insufficiently responding to medical treatment, there are neurosurgical treatment options giving very good results. The best long-term results have been described for microvascular decompression, but percutaneous and radiosurgical treatments also are good options, especially in patients with an increased surgical risk profile, in secondary trigeminal neuralgia, and in case of recurrence after microvascular decompression.

Image diagnosis of Trigeminal Neuralgia caused by Vascular Compression

Trigeminal Neuralgia (TGN) is a disease frequently encountered by the neurologists and neurosurgeons. The typical pain of TGN is lancinating in nature in one side of face along the distribution of Trigeminal nerve. Pain is sharp shooting and periodic in nature, aggravated by various factors, like eating, talking, laughing. A typical trigeminal neuralgia is caused by compression to the Root exit zone (REZ) by superior cerebellar artery (SCA), aberrant loop of Antero inferior cerebellar artery (AICA), dolichobasilar artery or a large sized vein. However facial pain mimicking TGN may occur by a tumor, plaque of Multiple sclerosis or may be idiopathic. So this is very important to know the cause of TGN/ facial pain for planning of specific treatment. Most of the patients remain pain free by medical management by using Carbamazepine, oxycarbazepine, Pregabalin, Gabapentin, Clonazepam etc. But medically refractory TGN can be treated by Microvascular decompression (MVD) with significantly satisfactory results if the cause is by vascular compression. However during MVD no significant blood vessels are seen and surgery become failed. Clinical examination and evaluation is very important, however to become confirmed about the pathogenesis needs imaging of brain. MRI of brain can differentiate any tumor or Plaque of MS. But conventional MRI images can not show us clearly the blood vessel causing TGN. Conventional MRA could show the blood vessels, which might be causing compression to REZ but does not confirm the fact. Constructive interference in steady state (CISS) MR images were evaluated in our 15 cases to find neurovascular relationship at the REZ. In 11 cases CISS images showed excellent visualization of fifth nerve and blood vessels causing compression to REZ in all case of TGN who underwent Microvascular decompression (MVD) with excellent result. In 2 patients we depended on clinical findings and T2 MR Images. In one of them we could find Offending vessels who were also improved clinically. In one case we did not find any significant offending vessel except a small vein and this patient did not show any improvement. In rest two cases, in one patient CISS showed a tiny vessel and after MVD the patient did not improve. In one patient no significant vessels were not seen in CISS images. We did not go for MVD for this case. So the pre-operative CISS MR images are more precise to show the neurovascular relationship and determine the offending blood vessel causing TGN. Thus we can avoid an unnecessary MVD.&#x0D; Bang. J Neurosurgery 2020; 10(1): 3-8

Concomitant continuous pain in patients with trigeminal neuralgia is associated with trigeminal nerve root atrophy.

Trigeminal neuralgia is an exemplary neuropathic pain condition characterized by paroxysmal electric-shock-like pain. However, up to 50% of patients also experiences concomitant continuous pain. In this neuroimaging study, we aimed to identify the specific anatomical features of trigeminal nerve root in patients with concomitant continuous pain. We enrolled 73 patients with a definitive diagnosis of classical and idiopathic trigeminal neuralgia and 40 healthy participants. The diagnosis of trigeminal neuralgia was independently confirmed by two clinicians. Patients were grouped as patients with purely paroxysmal pain (45 patients) and patients also with concomitant continuous pain (28 patients). All participants underwent a structured clinical examination and a 3T MRI with sequences dedicated to the anatomical study of the trigeminal nerve root, including volumetric study. Images analysis was independently performed by two investigators, blinded to any clinical data. In most patients with concomitant continuous pain, this type of pain, described as burning, throbbing or aching, manifested at the disease onset. Demographic and clinical variables did not differ between the two groups of patients; the frequency of neurovascular compression and nerve dislocation were similar. Conversely, trigeminal nerve root atrophy was more severe in patients with concomitant continuous pain than in those with purely paroxysmal pain (p = 0.006). Our clinical and neuroimaging study found that in patients with trigeminal neuralgia, concomitant continuous pain was associated with trigeminal nerve root atrophy, therefore suggesting that this type of pain is likely related to axonal loss and abnormal activity in denervated trigeminal second-order neurons.

Corneal Confocal Microscopy Demonstrates Corneal Nerve Loss in Patients With Trigeminal Neuralgia.

Background: The diagnosis of trigeminal neuralgia (TN) is challenging due to the lack of objective diagnostics. Corneal confocal microscopy (CCM) is a non-invasive ophthalmic imaging technique, which allows quantification of corneal nerve fibers arising from the trigeminal ganglion and may allow the assessment of neurodegeneration in TN.Methods: CCM was undertaken in 11 patients with TN and 11 age-matched healthy controls. Corneal nerve fiber density (CNFD), corneal nerve branch density, corneal nerve fiber length (CNFL), corneal nerve fiber width, corneal nerve fiber area, and dendritic cell and non-dendritic cell density with or without nerve fiber contact were quantified.Results: Patients with TN had significantly lower CNFD and CNFL but no difference for any other corneal nerve or dendritic cell parameter in the ipsilateral and the contralateral cornea compared to the control group. There was no significant difference in corneal nerve and cell parameters between patients with TN with and without involvement of the ophthalmic nerve (V1) or with nerve vessel conflict.Conclusion: Corneal confocal microscopy is a rapid non-invasive imaging technique that identifies symmetrical corneal nerve loss in patients with TN.

Increased risk of tinnitus following a trigeminal neuralgia diagnosis: a one-year follow-up study

BackgroundTinnitus due to hyperactivity across neuronal ensembles along the auditory pathway is reported. We hypothesized that trigeminal neuralgia patients may subsequently suffer from tinnitus. Using nationwide, population-based data and a retrospective cohort study design, we investigated the risk of tinnitus within 1 year following trigeminal neuralgia.MethodsWe used the Taiwan National Health Insurance Research Dataset, a claims database, to identify all patients diagnosed with trigeminal neuralgia from January 2001 to December 2014, 12,587 patients. From the remaining patients, we identified 12,587 comparison patients without trigeminal neuralgia by propensity score matching, using sex, age, monthly income, geographic region, residential urbanization level, and tinnitus-relevant comorbidities (hyperlipidemia, diabetes, coronary heart disease, hypertension, cervical spondylosis, temporomandibular joint disorders and injury to head and neck and index year). All study patients (n = 25,174) were tracked for a one-year period to identify those with a subsequent diagnosis of tinnitus over 1-year follow-up.ResultsAmong total 25,174 sample patients, the incidence of tinnitus was 18.21 per 100 person-years (95% CI = 17.66 ~ 18.77), the rate being 23.57 (95% CI = 22.68 ~ 24.49) among patients with trigeminal neuralgia and 13.17 (95% CI = 12.53 ~ 13.84) among comparison patients. Furthermore, the adjusted Cox proportional hazard ratio for tinnitus in the trigeminal neuralgia group was 1.68 (95% CI = 1.58 ~ 1.80) relative to the comparison cohort.ConclusionsWe found a significantly increased risk of tinnitus within 1 year of trigeminal neuralgia diagnosis compared to those without the diagnosis. Further studies in other countries and ethnicities are needed to explore the relationship between trigeminal neuralgia and subsequent tinnitus.