Left-sided Trigeminal Neuralgia Research Articles

Atypical refractory occipital neuralgia treated with a unilateral dual-lead occipital nerve stimulator: a case report.

Aim: To describe the successful treatment of atypical occipital neuralgia (ON) using a unilateral dual-lead occipital nerve stimulator. Setting: Outpatient clinic/operating room. Patient: A 53-year-old male with atypical ON. Case description: Patient was previously diagnosed with treatment-refractory left-sided trigeminal neuralgia with atypical occipital distribution. On presentation, his symptoms were consistent with ON with distribution to the left fronto-orbital area. He received a left-sided nerve stimulator implant targeting both the greater and lesser occipital nerves. Results: Patient reported pain relief from a numerical rating scale 10/10 to 3-4/10. Conclusion: ON with referred ipsilateral trigeminal distribution should be considered when patients present with simultaneous facial and occipital pain. Further, a dual-lead unilateral stimulator approach may be a viable treatment.

The effect of microvascular decompression of the CN IX-X root entry/exit zone and the ventrolateral medulla in neurogenic hypertension involving the vertebral/basilar artery.

Neurogenic hypertension (HTN) is a type of HTN characterized by increased activity of the sympathetic nervous system. Vascular compression is one of the pathogenic mechanisms of neurogenic HTN. Despite Jannetta's solid anatomical and physiological arguments in favor of neurogenic HTN in the 1970's, the treatment for essential HTN by microvascular decompression (MVD) still lacks established selection criteria. Therefore, the subjects selected for our center were limited to patients with primary trigeminal neuralgia (TN) and primary hemifacial spasm (HFS) of the vertebral/basilar artery (VA/BA) responsible vessel type coexisting with neurogenic HTN who underwent MVD of the brainstem to further explore possible indications for MVD in the treatment of neurogenic HTN. A retrospective analysis of 63 patients who were diagnosed with neurogenic HTN had symptoms of HFS and TN cranial nerve disease. Patients were treated at our neurosurgery department from January 2018 to January 2023. A preoperative magnetic resonance examination of the patients revealed the presence of abnormally located vascular compression in the rostral ventrolateral medulla (RVLM) and the root entry zone (REZ) of the IX and X cranial nerves (CN IX- X). There was no significant difference between the two groups in terms of gender, age, course of HFS, course of TN, course of HTN, degree of HTN, or preoperative blood pressure. Based on the postoperative blood pressure levels, nine out of 63 patients were cured (14.28%), eight cases (12.70%) showed a marked effect, 16 cases (25.40%) were effective, and 30 cases were invalid (47.62%). The overall efficacy was 52.38%. However, 39 cases of combined cranial nerve disease were on the left side of the efficacy rate (66.67%) and 24 cases of combined cranial nerve disease were on the right side of the efficacy rate (29.16%). Over the last few decades, many scholars have made pioneering progress in the clinical retrospective study of MVD for neurogenic hypertension, and our study confirms the efficacy of MVD in treating vertebral/basilar artery-type neurogenic hypertension by relieving the vascular pressure of RVLM. In the future, with the development and deepening of pathological mechanisms and clinical observational studies, MVD may become an important treatment for neurogenic hypertension by strictly grasping the surgical indications. MVD is an effective treatment for neurogenic HTN. Indications may include the following: left-sided TN or HFS combined with neurogenic HTN; VA/BA compression in the left RVLM and REZ areas on MRI; and blood pressure in these patients cannot be effectively controlled by drugs.

Expect the Unexpected!! – Transient Cranial Nerve Palsies after Radiofrequency Ablation of Gasserian Ganglion for Trigeminal Neuralgia

Trigeminal neuralgia is the most common type of craniofacial neuralgia, characterized by paroxysmal lancinating electric shock-like pain confined to the somatosensory distribution of the trigeminal nerve. Fluoroscopy-guided Radiofrequency Ablation of Gasserian Ganglion (RFA-GG) is the commonly performed minimally invasive pain intervention in these patients. Various complications such as masseter weakness, corneal anesthesia, dysesthesia, anesthesia dolorosa, keratitis, and cranial nerve deficits have been reported during the procedure. We present the case of a 58-year-old male diagnosed with left-sided trigeminal neuralgia involving mandibular division of trigeminal nerve (V3 division) with a Numerical Rating Scale of 9/10 at the time of presentation. As the patient was unresponsive to medical management, RFA of the V3 division of GG was performed with acceptable sensory and motor stimulation. Postablation, 1 ml of 1.0% Lidocaine injection with 2 mg injection dexamethasone was given. After the procedure, the patient complained of dizziness, left-sided hearing loss, and double vision on looking toward the left side. On examination, deviation of the angle of the mouth toward the right side, reduced blink reflex on the left side, and incomplete closure of the left eyelid were observed. Vitals were stable and there was no respiratory discomfort. The patient was reassured and monitored in the recovery room. Signs and symptoms were transient and the patient recovered completely after 45 min. Clinical findings were suggestive of the involvement of three cranial nerves: the abducens nerve, the facial nerve, and the vestibulocochlear nerve. Spillage of local anesthetic solution into adjacent cranial nerves surrounding the GG might be the causative mechanism for transient cranial nerve palsies in this case.

Teaching Video Neuro Images : Trigeminal neuralgia due to compression by the superior cerebellar artery

A man in his 50s had longstanding left-sided trigeminal neuralgia triggered by eating and brushing his teeth, which was refractory to maximal medical management. MRI fast imaging employing steady-state acquisition demonstrated left trigeminal nerve compression by the left superior cerebellar artery (figure). Therefore, the patient underwent a craniotomy for microvascular decompression (MVD). In select patients, MVD can be an effective treatment for trigeminal neuralgia.1,2 Prognostic indicators of long-term relief include male sex, immediate postoperative relief, and duration of symptoms for less than 8 years.1 The patient's adhered nerve was freed from the artery (video 1 at [Neurology.org][1]). Facial pain improved substantially in the immediate postoperative period. [1]: http://neurology.org/lookup/doi/10.1212/WNL.0000000000004746

Reader response: Teaching NeuroImages: Amlodipine-responsive trigeminal neuralgia: An alibi for vascular compression theory.

We read with interest the report by Uniyal et al.,1 which described a 55-year-old woman exhibiting hypertension with recurrent short-lasting episodes of left-sided trigeminal neuralgia. The patient noted pain relief after consumption of the antihypertensive drug amlodipine. Moreover, the pain recurred if the drug was discontinued. A brain MRI revealed tortuous blood vessels compressing the left rostral anterolateral medulla and the left trigeminal nerve root. This case reminded us of a patient with similar symptoms who we encountered years ago.2 A 59-year-old man with hypertension had a long history of left-sided refractory trigeminal neuralgia. The patient noted that the painful exacerbations occurred in parallel with hypertensive crises and was relieved only by clonidine administration. At the bedside, with continuous monitoring of systemic blood pressure, we demonstrated that the pain reliably resolved as soon as his systolic pressure dropped below 140 mm Hg. Continuous blood pressure monitoring also confirmed the temporal relationship between hypertensive crises often shortly preceding the pain. Catheter angiography demonstrated a dolichoectatic basilar artery compressing the left side of the posterior fossa with a loop compressing the root entry zone of the trigeminal nerve. We agree with Uniyal et al. that, in these cases, the continuous pulsatile compression against the trigeminal nerve root reinforced by hypertensive spikes could have triggered the pain attacks.1 These cases may lend further support to the vascular compression theory of trigeminal neuralgia popularized by Peter Jannetta and other authors,3–5 not necessarily representing a simple alibi for it.

Affective Circuitry Alterations in Patients with Trigeminal Neuralgia.

Trigeminal neuralgia (TN) is a severe chronic neuropathic facial pain disorder. Affect-related behavioral and structural brain changes have been noted across chronic pain disorders, but have not been well-studied in TN. We examined the potential impact of TN (37 patients: 23 with right-sided TN, 14 with left-sided TN), compared to age- and sex-matched healthy controls, on three major white matter tracts responsible for carrying affect-related signals—i.e., cingulum, fornix, and medial forebrain bundle. Diffusion magnetic resonance imaging (dMRI), deterministic multi-tensor tractography for tract modeling, and a model-driven region-of-interest approach was used. We also used volumetric gray matter analysis on key targets of these pathways (i.e., hippocampus, cingulate cortex subregions, nucleus accumbens, and ventral diencephalon). Hypotheses included: (1) successful modeling of tracts; (2) altered white matter microstructure of the cingulum and medial forebrain bundle (via changes in dMRI metrics such as fractional anisotropy, and mean, axial, and radial diffusivities) compared to controls; (3) no alterations in the control region of the fornix; (4) corresponding decreases in gray matter volumes. Results showed (1) all 325 tracts were successfully modeled, although 11 were partially complete; (2) The cingulum and medial forebrain bundle (MFB) were altered in those with TN, with dMRI metric changes in the middle (p = 0.001) and posterior cingulum (p < 0.0001), and the MFB near the ventral tegmental area (MFB-VTA) (p = 0.001). The posterior cingulum and MFB-VTA also showed unilateral differences between right- and left-sided TN patients; (3) No differences were noted at any fornix subdivision; (4) decreased volumes were noted for the hippocampus, posterior cingulate, nucleus accumbens, and ventral diencephalon. Together, these results support the notion of selectively altered affective circuits in patients with TN, which may be related to the experience of negative affect and the increased comorbidity of mood and anxiety disorders in this population.

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.

Resolution of trigeminal neuralgia following minimal coil embolization of a primitive trigeminal artery associated with a cerebellar arteriovenous malformation

Dear Editor, Trigeminal neuralgia (TN) is most often caused by the superior cerebellar artery (SCA), and microvascular decompression (MVD) is the first treatment option for uncontrollable TN by medication [2]. We report a case of TN caused by a primitive trigeminal artery (PTA) as a cerebellar arteriovenous malformation (AVM) feeder. Because the middle portion of the PTA involved perforating arteries, we occluded only the distal portion of the PTA with coils, and succeeded in relieving the pain. This minimal embolization of an offending artery with coils may be a treatment option for selected cases of TN. A 53-year-old man suffered from left-sided TN. Imagings showed a 6.3-cm AVM in the left hemispheric cerebellum associated with the left PTA (Fig. 1a, b). The Spetzler– Martin grade was V. We first treated the patient with antiTN medication. The pain became worse, and the patient had difficulty in eating. A diagnostic angiogram was performed. The PTAwas a feeder of the AVM (Fig. 1d). Detailed threedimensional analysis showed that the middle portion of the PTA (attached to the trigeminal nerve) was likely to be responsible for TN (Fig. 1c). We planned to perform endovascular treatment because MVD was technically difficult owing to the large AVM. We occluded only the distal portion of the PTA with coils expecting a collapse of the middle portion of the PTA and relief of the pain (Fig. 1e). Although we could not achieve occlusion or flow stagnation of the middle potion of the PTA, we finished the procedure because small branches at the middle portion appeared after occlusion of the distal portion of the PTA and they might have supplied normal brain parenchyma. There were no periprocedural complications. The pain was completely resolved in 1 month. Angiographic follow-up 10 months after the operation showed that the middle portion of the PTAwas narrowed and string-like, and that the distal portion of the PTAwas occluded (Fig. 1F). This narrowing suggested that contact of the PTA and the trigeminal nerve had been released. The patient remained pain-free for 12 months after the operation. Our patient had two rare conditions, which involved TN associated with both a PTA and a cerebellar AVM. To the best of our knowledge, this is the first report of these rare conditions. There are 21 cases previously reported to have TN associated with a PTA [3, 4, 7–9]. In 18 out of the 21 cases, MVD was performed, and the pain was relieved. In the remaining three cases, medication was sufficient. Considering these results, MVD would be the first option for TN associated with a PTAwhen medical treatment fails. However, in our patient, MVD was technically difficult because of the large cerebellar AVM. Lesley reviewed the literature and summarized 59 cases of TN associated with AVM [5]. Most of them were surgically treated. Only four cases of TN have been treated with endovascular surgery, and they were all associated with AVM, but not with a PTA [1, 5, 6, 10]. One of these patients [1] was treated with coils, and the other three [5, 6, 10] were treated with ethylene-vinyl alcohol copolymer (Onyx; eV3, Neurovascular, Irvine, CA, USA). In all of these four patients, the pain was relieved. Our treatment strategy was K. Kono (*) : T. Terada Department of Neurosurgery, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama 640-8505, Japan e-mail: vyr01450@gmail.com

Surgical treatment of trigeminal neuralgia. Results from the use of glycerol injection, microvascular decompression, and rhizotomia

The study aims to assess the efficacy and safety of surgical treatment of trigeminal neuralgia (TN) in our department and to identify prognostic factors. Seventy patients receiving surgical treatment for TN during the period 2003-2004 were included in this retrospective study. The surgical procedures used were glycerol injection (GI), microvascular decompression (MVD), or rhizotomia (RIZ). All patients were divided into spontaneous onset TN type1 (brief lancinating pain) or TN type 2 (continuous pain component). Two patients had bilateral TN; each side was regarded as a separate case. These 70 patients had a total of 160 interventions (110 GI, 40 MVD, and ten RIZ) performed in the period 1998-2007. Data were obtained by chart review and telephone interview. Patients provided information about pre- and postoperative pain characteristics including subtype, duration, intensity, and the use of antiepileptic drugs. Outcome was evaluated using a pain vector diagram. To quantify self-reported pain, we developed a new vector-based pain diagram. The subtype of TN was shown to be a very important prognostic factor. One year after MVD, 90% of patients with type 1 TN still had positive effect, whereas this was only true in 73% of patients with type 2 TN. After RIZ, the results were 71% and 33% for types 1 and 2, respectively. For comparison, GI had a significant lower effect but if the treatment led to hypoesthesia, 41% continued to have a positive effect 1 year after surgery, compared to only 24% if postoperative sensation was normal. Type 2 TN was found to be dominated by women with left-sided TN outside the V2 dermatome and with a lower probability of a neurovascular conflict. As expected, 1/5 of the cases developed postoperative hypoesthesia in the face following a nerve destructive procedure (RIZ and GI). Using MVD, the risk of serious side effects was about 4%. Complementary and alternative treatment had no general or permanent effect in the investigated population-quite the contrary. Regarding prognosis and outcome, we find that it is very important to classify TN in subgroups (types 1 and 2). Dealing with medically treatment-resistant type 1 TN, MVD and RIZ are reasonably safe and effective interventions. The surgical results dealing with type 2 TN are still very poor. All patients with medically treatment-resistant TN should be offered referral to a neurosurgical unit with experience in treating this painful disease. We recommend using a vector-based pain diagram when evaluating the outcome of multiple interventions.

Coexistent trigeminal neuralgia, hemifacial spasm, and hypertension: preoperative imaging of neurovascular compression

The case is reported of a 60-year-old woman with left-sided trigeminal neuralgia, hemifacial spasm, and hypertension. Compression of the left trigeminal, facial, and vagus nerves by the anterior and posterior inferior cerebellar arteries and a persistent trigeminal artery variant were demonstrated by magnetic resonance angiography using a novel sequence. At operation the angiographic appearances were confirmed, and decompression was performed with the placement of polyvinyl sponge at all three levels. Postoperatively, the patient had complete relief from the trigeminal neuralgia and hemifacial spasm and has sustained normotension without medication.

External carotid artery fistula due to microcompression of the gasserian ganglion for relief of trigeminal neuralgia

Vascular complications after percutaneous injection procedures for relief of trigeminal neuralgia are varied, ranging from puncture of arterial or venous structures to carotid-cavernous fistulas. The authors present a patient in whom an external carotid artery fistula occurred after a microcompression procedure for the treatment of a left-sided trigeminal neuralgia. This is believed to be the first case of this complication secondary to a percutaneous injection procedure for relief of facial pain.

MANHATTAN DERMATOLOGICAL SOCIETY

<h3>Fixed Drug Eruption Due to Penicillin. Presented by Dr. Orlando Canizares.</h3> S. M., a man aged 24, is presented from the Veterans Administration Hospital, Bronx, N. Y., with a recurrent eruption of the penis. The patient suffered frozen feet and hands in Bastogne and received shell fragments in the face in 1945, after which occurrence he had left-sided trigeminal neuralgia. While returning to the United States in 1945, aboard a hospital ship, he acquired a lesion on the shaft of the penis which was diagnosed as "ringworm." This cleared up with local treatment. On May 6, 1949 he underwent a Caldwell-Luc operation to remove splinters from the left maxillary sinus, after which he was given penicillin daily for four days. On May 8 he manifested an erythematous, vesicular eruption on the shaft of the penis. This cleared up on treatment with saline soaks. On October 4 he had a revision