Intracranial Space-occupying Lesions Research Articles

Canadian Association of Radiologists Central Nervous System Diagnostic Imaging Referral Guideline.

The Canadian Association of Radiologists (CAR) Central Nervous System Expert Panel is made up of physicians from the disciplines of radiology, emergency medicine, neurosurgery, and neurology, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 24 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 55 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 51 recommendation statements across the 24 scenarios. This guideline presents the methods of development and the referral recommendations for congenital disorders of the brain, cerebrovascular disease, multiple sclerosis and demyelinating disease, headache, concussion, pituitary and juxtasellar lesions, cranial neuropathy, brain stem symptoms, altered intracranial pressure (hypertension, hypotension, hydrocephalus suspected shunt malfunction, normal pressure hydrocephalus), vestibular and cochlear symptoms (hearing loss, vertigo), mental status change (acute, dementia/memory loss), visual loss, epilepsy and seizure, CNS infection, intracranial space-occupying lesions, suspected cerebral venous sinus thrombosis, vasculitis, movement disorders/Parkinsonism, metabolic and toxic encephalopathies, and aneurysm screening.

Cognitive and cortical network alterations in pediatric temporal lobe space-occupying lesions: an fMRI study

BackgroundTemporal lobe mass lesions are the most common intracranial space-occupying lesions in children, among various brain lobes. The temporal lobe is critically involved in higher cognitive functions, and surgical interventions often risk causing damage to these functions. If necessary interventions and prehabilitation can be conducted preoperatively, it might be possible to achieve a larger extent of lesion resection with minimal cognitive impairment. However, research in this area has been relatively limited in the past. Our study aims to fill this gap.MethodsWe enrolled 15 children with temporal lobe mass lesions and 15 age- and gender-matched healthy children as controls. All participants underwent cognitive assessments and functional MRI scans. The cognitive testing data and functional MRI data were then analyzed and compared between the two groups.ResultsOur findings suggest that children with temporal lobe mass lesions primarily exhibit impairments in working memory and sustained attention. Multiple brain network indices were altered in the affected children, with the most prominent change being hyperactivation of the default mode network (DMN). This hyperactivation was correlated with cognitive impairments, indicating that the overactivation of the DMN might represent an inefficient compensatory mechanism within the brain’s networks.ConclusionCompared to healthy children, those with temporal lobe mass lesions experience deficits in working memory and sustained attention, and the hyperactivation of the DMN may be the underlying network mechanism driving these cognitive impairments. Our research offers a unique and clinically valuable reference for future studies on preoperative interventions and prehabilitation in this population.

Horner Syndrome in a Pediatric Patient: A Case Report of Lymphatic Malformation Induced Presentation in a 7-year-old Boy

Lymphatic malformations are low-flow vascular anomalies that predominantly affect the cervicofacial region in the pediatric population. We describe a case of a 7-year-old healthy boy who presented to the emergency department with the classic triad of miosis, ptosis, and anhidrosis. Initial evaluation, including a cervicocranial computed tomography scan, revealed no intracranial space-occupying lesion. Subsequent diagnostic work-up, involving ultrasound and cervicothoracic magnetic resonance imaging, identified a cystic lesion in the upper mediastinum, consistent with the diagnosis of lymphatic malformations. The integration of a multidisciplinary team proved essential in reaching a definitive diagnosis and selecting the optimal treatment (ultrasound-guided sclerotherapy) mitigating the risk of life-threatening and cosmetic complications.

Paediatric brain lesions: a study of space-occupying conditions

Background: Intracranial space-occupying lesions (ICSOL) in children, encompassing neoplastic and inflammatory origins, pose significant diagnostic and therapeutic challenges. Modern imaging techniques like CT and MRI have revolutionized the understanding and management of ICSOL, altering their clinical presentation. This study aimed to investigate the epidemiology, clinical presentation, etiology, treatment modalities and outcomes of ICSOL in pediatric patients. Methods: A prospective analysis was conducted on pediatric patients diagnosed with ICSOL, utilizing medical records from a tertiary care hospital. Data regarding demographics, clinical symptoms, imaging findings, treatment modalities, and outcomes were collected and analyzed. Results: In this study on space-occupying lesions (SOL) in pediatric patients, revealing a diverse distribution across different age groups. Arachnoid cysts were the most prevalent, followed by hydrocephalus, hematomas, and tuberculomas. Clinical presentations varied widely, with Headache, Seizures and altered sensorium in limbs being the most common symptoms. Treatment approaches ranged from surgical resection or fenestration for arachnoid cysts to specific therapies such as ventriculoperitoneal shunt placement for hydrocephalus and antitubercular therapy for tuberculomas. Outcomes varied by lesion type, with some cases showing improvement, stability or worsening post-treatment. Conclusions: The study provides valuable insights into the epidemiology, clinical presentation, treatment, and outcomes of space-occupying lesions in children. Arachnoid cysts emerged as the predominant lesion type, while hydrocephalus, hematomas and tuberculomas were also notable. Understanding these factors is crucial for early diagnosis, effective management and improved outcomes in pediatric patients with brain lesions.

Intracranial arachnoid cyst complicated with subdural hygroma in a 10-year-old child: A case report and literature review

Arachnoid cysts are abnormal collections of fluids within the arachnoid membrane after a doubling of the structure. These benign lesions represent only 1% of all intracranial space-occupying lesions. The affected patient can remain asymptomatic for several years, which is an incidental finding in most cases. Cysts have been reported to rupture after a minor head trauma, causing subdural hygroma or hematoma; however, spontaneous rupture complicated with subdural hygroma has been rarely reported. Herein, we report a rare case of a 10-year-old boy whose pregnancy follow-up, delivery, and parent’s medical history were unremarkable. The patient was admitted for a temporal arachnoid cyst complicated with subdural hygroma, which was determined to be caused by intracranial hypertensive syndrome. He was successfully treated through endoscopic arachnoid cyst fenestration, wherein a pathway was created for the cyst to communicate with the subarachnoid space through the basal cisterns. The choice of treatment for arachnoid cysts remains controversial. Endoscopic treatment is considered when an ipsilateral subdural hygroma is present. Intracranial hypertensive syndrome subsided immediately after surgery. No post-operative complications occurred. The child recovered uneventfully in the post-operative period and was discharged 5 days after surgery. He underwent a follow-up computed tomography 1 month later, confirming a progressive regression of the hygroma as well as arachnoid cyst.

Intracranial arachnoid cyst in a 28-year-old man. A clinical case with a fatal outcome

Most intracranial arachnoid cysts are thought to be non-tumorous, congenital, intra-arachnoid cerebrospinal fluid collections that account for about 1% of all intracranial space-occupying lesions. In children, the prevalence of this pathology is 2.6%; in adults, it reaches 1.4%. The disease is more often registered in men. Most often arachnoid cysts are supratentorial. Their most common locations are in the middle cranial fossa and the retrocerebellar cistern. Less often they can be detected on the convexity of the brain hemispheres; however, cases of arachnoid cysts at more unusual sites have also been described, including in newborns. The pathology is often characterized by an asymptomatic course, while certain symptoms may have an acute onset, which is due to compression of brain structures caused by the large cyst size.This article describes a clinical case of a large intracranial arachnoid cyst in a 28-year-old man. It was not verified in the antemortem diagnosis, but was revealed according to the autopsy findings (macroscopic features of the cyst, histologic presentation with specific morphological changes, and findings of computed tomography of the cerebral hemispheres).

Changes on Cognition and Brain Network Temporal Variability After Pediatric Neurosurgery.

Pediatric intracranial space-occupying lesions are common, with prognoses improving markedly in recent years, significantly extending survival. As such, there is an imperative to pay increased attention to the postoperative cognitive functions and brain network alterations in these children because these factors significantly influence their quality of life. Temporal variability (TV) analysis of brain networks captures the full extent of resting-state activities, reflecting cognitive functions and rehabilitation potential. However, previous research rarely uses TV analyses and most focus on adults or children after multidisciplinary treatments, not reflecting the combined effect caused by neurosurgery only and self-repair. This study gives our insights into this field from a holistic perspective. We studied 35 children with intracranial space-occupying lesions, analyzing pre- and postsurgery MRI and cognitive tests. We used TV analysis to assess changes and correlated imaging indicators with cognitive performance. We observed a tendency for cognitive recovery after about 3 months postsurgery, primarily in the domains of social cognition and nonverbal reasoning. TV analysis of brain networks indicated increased nodal variability within systems such as the visual and sensorimotor networks, which are integral to external interactions. Correlative analysis showed that alterations in certain occipital regions were associated with changes in social cognition and nonverbal reasoning. These findings suggest significant intrinsic repair in cognitive functions and brain networks at around 3 months postneurosurgery in children. This study not only enriches our comprehension of postoperative cognitive and brain network self-repair processes in children but also furnishes potential therapeutic targets for rehabilitation interventions and establishes a theoretical foundation for proactive surgical interventions.

Diagnostic Algorithm for Intracranial Lesions in the Emergency Department: Effectiveness of the Relative Brain Volume and Hounsfield Unit Value Measured by Perfusion Tomography.

Background Early treatment of intracranial lesions in the emergency department is crucial, but it can be challenging to differentiate between them. This differentiation is essential because the treatment of each type of lesion is different. Cerebral computed tomography perfusion (CTP) imaging can help visualize the vascularity of brain lesions and provide absolute quantification of physiological parameters. Compared to magnetic resonance imaging, CTP has several advantages, such as simplicity, wide availability, and reproducibility. Purpose This study aimed to assess the effectiveness of Hounsfield units (HU) in measuring the density of hypercellular lesions and the ability of CTP to quantify hemodynamics in distinguishing intracranial space-occupying lesions. Methods A retrospective study was conducted from March 2016 to March 2022. All patients underwent CTP and CT scans, and relative cerebral blood volume (rCBV) and HU were obtained for intracranial lesions. Results We included a total of 244 patients in our study. This group consisted of 87 (35.7%) individuals with glioblastomas (GBs), 48 (19.7%) with primary central nervous systemlymphoma (PCNSL), 45 (18.4%) with metastases (METs), and 64 (26.2) with abscesses. Our study showed that the HUs for METs were higher than those for GB (S 57.4% and E 88.5%). In addition, rCBV values for PCNSL and abscesses were lower than those for GB and METs. The HU in PCNSL was higher than those in abscesses (S 94.1% and E 96.6%). Conclusion PCT parameters provide valuable information for diagnosing brain lesions. A comprehensive assessment improves accuracy. Combining rCBV and HU enhances diagnostic accuracy, making it a valuable tool for distinguishing between lesions. PCT's widespread availability allows for the use of both anatomical and functional information with high spatial resolution for diagnosing and managing brain tumor patients.

Sample strategies for the assessment of the apparent diffusion coefficient in single large intracranial space-occupying lesions of dogs and cats.

Diffusion-weighted imaging is increasingly available for brain investigation. Image interpretation of intracranial space-occupying lesions often includes the derived apparent diffusion coefficient (ADC) analysis. In human medicine, ADC can help discriminate between benign and malignant lesions in intracranial tumors. This study investigates the difference in ADC values depending on the sample strategies of image analysis. MRI examination, including diffusion-weighted images of canine and feline patients presented between 2015 and 2020, were reviewed retrospectively. Patients with single, large intracranial space-occupying lesions were included. Lesions homogeneity was subjectively scored. ADC values were calculated using six different methods of sampling (M1-M6) on the ADC map. M1 included as much as possible of the lesion on a maximum of five consecutive slices; M2 included five central and five peripheral ROIs; M3 included a single ROI on the solid part of the lesion; M4 included three central ROIs on one slice; M5 included three central ROIs on different slices; and M6 included one large ROI on the entire lesion. A total of 201 animals of various breeds, genders, and ages were analyzed. ADC values differed significantly between M5 against M2 (peripheral) (p < 0.001), M5 against M6 (p = 0.009), and M4 against M2 (peripheral) (p = 0.005). When lesions scored as homogeneous in all sequences were excluded, an additional significant difference in three further sampling methods was present (p < 0.005). ADC of single, large, intracranial space-occupying lesions differed significantly in half of the tested methods of sampling. Excluding homogeneous lesions, additional significant differences among the sampling methods were present. The obtained results should increase awareness of the variability of the ADC, depending on the sample strategies used.

Neurocysticercosis in a Nigerian woman -missed diagnosis of a neglected disease and surgical management

Neurocysticercosis is a rarely diagnosed but significant clinical problem from infestation with taenia solium. It occurs as a result of ingestion of infested pork and the mode of transmission is usually feco-oral. It is commonly associated with non-specific neurologic manifestations expected of intracranial space-occupying lesions with its most common neurological presentation being seizures. However, its diagnosis without seizure is rarely reported. We report a recent experience in this regard and outcome of this disease which was inadvertently managed surgically. A good history and high index of suspicion especially in developing and low socioeconomic region is helpful for diagnosis in the presence of appropriate radiological findings. Prognosis is good when treatment is tailored to well selected cases. Treatment options include medical with or without surgical removal of encapsulated cyst. A high index of suspicion will be helpful in making appropriate diagnosis and proper management of this disease.

Tumefactive Multiple Sclerosis: A Mimicker of Intracranial Space-Occupying Lesions

Abstract: A chronic disease of CNS, Multiple sclerosis is characterized by inflammation and demyelination with axonal injury affecting upper motor neurons of brain or spinal cord. Tumefactive multiple sclerosis is a rare form of MS which mimics intracranial tumor-like space-occupying lesions on radiography. A 25-year old gentleman presented 2-month history of gradual onset difficulty in walking, slurring of speech and double vision. The patient had an ataxic gait accentuated by tandem walking with tendency to fall towards right and a negative Romberg’s sign. There was dysarthria and signs of cerebellar lesion present on the right side. Muscle tone was normal in upper limbs but increased (spasticity) in lower limbs bilaterally. Power was normal but deep tendon reflexes were exaggerated in all 4 limbs with bilateral up-going plantar reflex. MRI scan of the brain demonstrated tumour-like tumefactive lesions in the right cerebellum, right pons and the left subcortical region with no post-contrast enhancement of these lesions. MRI of whole spine demonstrated subtle hyperintense signals in the cervical spine. He had a past history of transverse myelitis 2 years ago with full clinical recovery with oral steroids. He was diagnosed with Tumefactive Multiple Sclerosis and started on corticosteroid therapy resulting in dramatic improvement.

Intracranial Space-Occupying Lesion Presenting as Catatonia in a Patient of Affective Disorder with a History of Recurrent Catatonic Episodes: A Case Report

Intracranial Space-Occupying Lesion Presenting as Catatonia in a Patient of Affective Disorder with a History of Recurrent Catatonic Episodes: A Case Report

Structural and functional changes following brain surgery in pediatric patients with intracranial space-occupying lesions.

We explored the structural and functional changes of the healthy hemisphere of the brain after surgery in children with intracranial space-occupying lesions. We enrolled 32 patients with unilateral intracranial space-occupying lesions for brain imaging and cognitive assessment. Voxel-based morphometry and surface-based morphometry analyses were used to investigate the structural images of the healthy hemisphere. Functional images were analyzed using regional homogeneity, amplitude of low-frequency fluctuations, and fractional-amplitude of low-frequency fluctuations. Voxel-based morphometry and surface-based morphometry analysis used the statistical model built into the CAT 12 toolbox. Paired t-tests were used for functional image and cognitive test scores. For structural image analysis, we used family-wise error correction of peak level (p < 0.05), and for functional image analysis, we use Gaussian random-field theory correction (voxel p < 0.001, cluster p < 0.05). We found an increase in gray matter volume in the healthy hemisphere within six months postoperatively, mainly in the frontal lobe. Regional homogeneity and fractional-amplitude of low-frequency fluctuations also showed greater functional activity in the frontal lobe. The results of cognitive tests showed that psychomotor speed and motor speed decreased significantly after surgery, and reasoning increased significantly after surgery. We concluded that in children with intracranial space-occupying lesions, the healthy hemisphere exhibits compensatory structural and functional effects within six months after surgery. This effect occurs mainly in the frontal lobe and is responsible for some higher cognitive compensation. This may provide some guidance for the rehabilitation of children after brain surgery.

Diagnostic evaluation of optic nerve sheath diameter in predicting elevated intracranial pressure among neurocritically ill patients: A prospective observational study.

Optic nerve sheath diameter (ONSD) is used as a surrogate for intracranial pressure (ICP) with a marked variation in its optimal cutoff in various subgroups of neurocritical illnesses. Real-world data on ultrasound (US)-ONSD performance among a diverse population and its trend corresponding with clinical deterioration are scarce. We aim to determine the diagnostic performance of ONSD compared to computed tomography (CT) in predicting elevated ICP in a mixed population of neurocritical patients. Baseline ONSD measurements (T1) using B-mode US were recorded among eligible patients. Follow-up ONSD (T2) was recorded during clinical deterioration defined by ≥2 drops in Glasgow Coma Scale/Full Outline of UnResponsiveness (GCS/FOUR) scores. Its diagnostic performance in predicting elevated ICP was assessed by comparing it with the concurrently taken CT findings as a reference standard. The difference between the two ONSD measurements was termed delta ONSD. In the final analysis, 129 participants were included. The population comprised traumatic brain injury, stroke (hemorrhagic and ischemic), intracranial space-occupying lesions, and other medical conditions. The optimal ONSD (T2) cutoff of 5.23 mm had a diagnostic accuracy of 80.73% to predict elevated ICP (sensitivity: 82%; specificity: 78%; area under the curve: 0.88; and 95% confidence interval [CI]: 0.819-0.941). Each unit increase in delta ONSD was associated with increased odds of need for surgical intervention (odds ratio [OR]: 3.91; 95% CI: 1.31-12.6, P = 0.017) and death at intensive care unit discharge (OR: 8.24; 95% CI: 1.78-41.15, P = 0.007). ONSD cutoff of 5.23 mm has a good diagnostic accuracy in predicting elevated ICP compared to CT during clinical deterioration. ONSD measurements correlate well with corresponding GCS/FOUR scores.

An Observational Comparative Study to Evaluate the Use of Image-Guided Surgery in the Management and Outcome of Supratentorial Intracranial Space-Occupying Lesions.

The objective of this article is to study the effect of neuronavigation on the outcome of surgery for supratentorial tumors, such as the extent of resection, size of craniotomy, and overall morbidity and mortality by comparing with conventional excision. A total of 50 patients undergoing intracranial surgery for supratentorial space-occupying lesions from 2020 to 2022 were included in the study. One intervention group consisted of patients undergoing surgical resection of supratentorial tumors utilizing image guidance versus the control group, which consisted of patients undergoing surgical excision of supratentorial tumor excision without image guidance. Parameters used to compare the outcome were the extent of resection of the lesions, craniotomy size, and overall morbidity and mortality. There was no significant reduction in craniotomy size or prolongation of operative duration with the use of neuronavigation. There was no significant difference in postoperative hospital stay between the two groups. Neuronavigation-assisted cases did not show any significant reduction in the occurrence of postoperative neurological deficits or any reduction of overall morbidity and mortality.

Role of perfusion weighted imaging in the differential diagnosis of intracranial space occupying lesions

Introduction. Magnetic Resonance Imaging (MRI) is a well-established modality for identifying intracranial space-occupying lesions (ICSOLs). However, conventional MRI has limitations in the cerebral glioma accurate grading. Advanced techniques, like Diffusion-Weighted Imaging (DWI), Perfusion MRI, and Magnetic Resonance Spectroscopic Imaging (MRS), have been introduced to address these limitations. Aims and objective. The primary objective of this research is to assess the significance of perfusion-weighted imaging (PWI) in distinguishing intracranial space-occupying lesions (ICSOLs), with a specific emphasis on its capacity to refine diagnostic accuracy and advance the classification of cerebral gliomas. Materials and methods. A prospective observational research involving 38 patients having ICSOLs used a Philips Multiva 1.5 Tesla MRI system. The protocol included DWI, ADC (Apparent Diffusion Coefficient) analysis, and perfusion imaging. Results. The study population (n=38) had a diverse age range (22-70 years), with a majority in the 30-40 age group. High-grade gliomas constituted 43.2% of all the cases. Significant differences in rCBF, rCBV, and MTT have been observed among HGGs &amp; LGGs. Specific cut-off values were used to predict glioma grades. Discussion. Comparisons with existing studies validated these findings, emphasizing the utility of advanced physiological techniques in enhancing diagnostic precision. Discrepancies with certain studies have highlighted the need for a comprehensive approach to lesion characterization. Conclusion. Intracranial lesion diagnosis, especially for meningiomas, demonstrated comparable efficacy between conventional and advanced techniques. While conventional MRI can differentiate lower-grade from higher-grade gliomas to a limited extent, the combination of advanced physiological approaches significantly improves specificity in tumor categorization.

Idiopathic Intracranial Hypertension With Transcribriform Plate Intranasal Meningocele Without Cerebrospinal Fluid Rhinorrhea: A Case Report

Idiopathic intracranial hypertension (IIH) is a rare disorder of unclear pathogenesis occurring commonly in obese women of childbearing age and characterized by increased intracranial pressure in the absence of intracranial space-occupying lesion or cerebrospinal fluid outflow obstruction. We report a rare case of a middle-aged obese female with intractable headache referred to the department of radiology for neuroimaging on account of suspected dural sinus thrombosis and brain Magnetic Resonance Imaging (MRI) which revealed signs of IIH with asymptomatic transcribriform plate intranasal meningocele with a view to underscore the quiddity of IIH in middleaged obese females and also emphasize the need for radiologists to diligently review previous patient’s images where available for possible finding that could contribute to a suspected diagnosis.

Profiling of circulating glial cells for accurate blood-based diagnosis of glial malignancies.

Here, we describe a blood test for the detection of glial malignancies (GLI-M) based on the identification of circulating glial cells (CGCs). The test is highly specific for GLI-M and can detect multiple grades (II-IV) and subtypes including gliomas, astrocytomas, oligodendrogliomas, oligoastrocytomas and glioblastomas, irrespective of gender and age. Analytical validation of the test was performed as per Clinical and Laboratory Standards Institute (CLSI) guidelines. Real-world performance characteristics of the test were evaluated in four clinical (observational) studies. The test has high analytical sensitivity (95%), specificity (100%) and precision (coefficient of variation [CV] = 13.7% for repeatability and CV = 23.5% for within laboratory precision, both at the detection threshold) and is not prone to interference from common drugs and serum factors. The ability of the test to detect and differentiate GLI-M from non-malignant brain tumours (NBT), brain metastases from primary epithelial malignancies (EPI-M) and healthy individual donors (HD) was evaluated in four clinical cohorts. Across these clinical studies, the test showed 99.35% sensitivity (95% confidence interval [CI]: 96.44%-99.98%) and 100% specificity (95% CI: 99.37%-100%). The performance characteristics of this test support its clinical utility for diagnostic triaging of individuals presenting with intracranial space-occupying lesions (ICSOL).

Chronic subdural hematoma associated with type II and type III Galassi arachnoid cysts: illustrative cases.

Arachnoid cysts (ACs) are congenital abnormalities that can be located anywhere within the subarachnoid space along the cerebrospinal axis, although they are most often found on the left side in the temporal fossa and sylvian fissure. ACs comprise approximately 1% of all intracranial space-occupying lesions and are considered potential risk factors for subdural hematoma (SDH) in individuals of all age groups who have experienced traumatic brain injury. Although it is uncommon for an intracystic hemorrhage of an AC to occur without evidence of head trauma, it may be more common among children and young adults. Here, the authors present three cases of spontaneous AC intracystic hemorrhage with chronic SDH. Additionally, they provide a thorough review of the existing literature. All three patients with AC were adolescent males. In all cases, AC was identified using the Galassi classification (type II or III) and associated with spontaneous intracystic hemorrhage and chronic SDH as seen on imaging. Spontaneous intracystic hemorrhage is a rare complication and occurs most commonly on the left side. Surgery is the definitive treatment, requiring either craniotomy or burr hole for hematoma evacuation and microsurgical fenestration to drain the cyst into the subarachnoid cisterns.

Acute on Chronic Presentation of Trigeminal Neuralgia

Trigeminal neuralgia (TN) is characterized by sudden, severe, brief, stabbing, usually unilateral, and recurrent pain within one or more branches of the trigeminal nerve. It is divided into three types: (1) primary or classical TN, which requires demonstration of morphologic changes in the trigeminal nerve root from vascular compression, (2) secondary to other identifiable neurologic causes such as multiple sclerosis and intracranial space-occupying lesion, and (3) idiopathic, in which the etiology is unknown. Treatment and prognosis depend on the type. We present this case of an elderly woman with an unusual presentation of TN in a previously diagnosed case. The episodes were increasing in severity and duration, not responding to medical management, allodynia and constant pain was present, and they were accompanied by uncontrolled hypertension. These features strongly suggested other likely causes such as intracranial space-occupying lesions, multiple sclerosis, and central pain. Expert consultations from physicians and neurologists were sought for control of hypertension and reaching a diagnosis. Magnetic resonance angiogram of the brain was done and a diagnosis of classical TN with persistent background facial pain was established. The treatment was successfully done by radiofrequency ablation of the Gasserian ganglion. The pain and blood pressure responded to the treatment.