Left Trigeminal Neuralgia Research Articles

Slow-Chronic Progressive Hydrocephalus as Complication of Microvascular Decompression for Trigeminal Neuralgia: A Case Report

Microvascular decompression (MVD) is one of the well-established treatment options for trigeminal neuralgia that may include posterior fossa surgery. However, Several complications were noted as being part of posterior fossa surgery and hydrocephalus is very rare to occur, especially the slow-chronic onset type. The pathophysiology is still unclear, but surgeons and patients must be warned about this possible surgical adverse event. Here we report a case of slow-chronic hydrocephalus in a 66-years old male who has a history of MVD procedure due to left trigeminal neuralgia. A shunt procedure was performed, in which after the surgery the patient’s complaints were resolved, and discharged without any morbidity.

Twitchy Pain of Left Face: A Rare Case of Idiopathic Trigeminal Neuralgia after Tooth Extraction in a Young Child

Introduction: Idiopathic Trigeminal neuralgia in children is a rare case presentation that poses a challenge in dental practice. This case involved a sequence of multi-management by several departments including Paediatric Dentistry, Oral Maxillofacial Surgery (OMFS), Otorhinolaryngology (ORL) and Paediatric Neurology. Case description: A 10-year-old girl was referred initially to the Paediatric Dentistry Specialist Clinic, School of Dental Sciences, Universiti Sains Malaysia (USM), Malaysia with the complaint of left facial pain associated with muscle twitching, weakness and swelling for five days prior to this first visit. There was a history of tooth extraction of her lower left second primary molar on the day before the episode of left facial pain and twitching. Clinical examination showed left facial involuntary twitching with visual analogue scale (VAS) pain score of 8, some evidence of left facial weakness, numbness but no facial swelling. No significant finding on the intraoral examination, including good healing signs at the exodontia site. The investigations included orthopantomography, Cranial Nerves II-XII examination and tests, blood investigations, Blood Urea and Serum Electrolyte (BUSE), electromyography (EMG) and electroencephalogram (EEG). The final diagnosis was left Idiopathic Trigeminal Neuralgia that is associated with tooth extraction. After a period of a month, the symptoms and signs were gradually reduced and ceased by taking oral medications such as Baclofen, Neurobion and Gabapentin. Joint management from multi-departments with close follow ups help to provide the conservative and safe treatment for this patient.

Anesthesia-induced Takotsubo cardiomyopathy in trigeminal neuralgia: illustrative case

Takotsubo syndrome (TS) represents a form of nonischemic cardiomyopathy characterized by sudden and temporary weakening of the myocardium. Many data suggest a primary role for sympathetic overstimulation in its pathogenesis. Nevertheless, these correlates are less easily identified during anesthesia. A 50-year-old female patient with a 4-year history of drug-resistant left trigeminal neuralgia. She was scheduled for surgical microvascular decompression. In the operating room, after induction of general anesthesia and oral intubation, the electrocardiogram revealed a significant ST segment elevation along with a sudden decrease in systolic blood pressure and heart rate. Administration of atropine caused a conversion into ventricular tachycardia. The advanced cardiac life support protocols were applied with prompt defibrillation and rapid recovery at sinus rhythm. A transthoracic echocardiogram revealed apical akinesia with ballooning of the left ventricle with a reduction of systolic function. An emergency coronary arteriography was performed, showing normal epicardial coronary vessels. After 4 days, echocardiography revealed normalization of the left ventricular function with improvement of the ejection fraction. In patients affected by trigeminal neuralgia, chronic pain can lead to a state of adrenergic hyperactivation, which can promote TS during the induction of general anesthesia, probably through the trigeminocardiac reflex.

Trigeminal Ganglioneuroma: A rare case of trigeminal neuralgia caused by Meckel’s cavum tumor: a case report and review of the literature

Background: Ganglioneuroma (GN) is a rare benign tumor originating from the sympathetic nerves, and its origination from the trigeminal nerves is even rarer. Only six cases of GN originating from the trigeminal nerve have previously been reported. Aim: To report a very rare case of GN arising in Mikel's cave revealed by atypical trigeminal neuralgia. Case report: A 24-Year-old Moroccan man presented left trigeminal neuralgia. Intracranial MRI showed a 4.4 x 2.5 x 3 cm well-circumscribed multilobular mass in the posterior middle fossa and the petroclival area with compression to the medial temporal lobe. The tumor appeared homogeneously hypointense on T1WI, and hyperintense on T2WI and T2WI-Flair, and showed heterogeneous moderate enhancement. Bone window petrous CT scan showed thinning and remodeling bone on the left petrous apex. The preoperative diagnosis was cystic schwannoma. The patient underwent a subtemporal extradural approach with total removal of the lesion. The histological and immunohistochemically study confirmed the diagnosis of GN. Postoperative was marked by left keratitis for two months. No recurrence was documented on 3 years follow-up. Conclusion: we described a benign and extremely rare trigeminal ganglioneuroma. This case is the seven-reported case in the literature. The subtemporal interdural approach must be considered in the surgical approach of trigeminal Meckel's GN. Trigeminal GN should be considered in the differential diagnosis of the tumor found in Mickel's cavum.

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.

Endoscopic-assisted microvascular decompression for trigeminal neuralgia secondary to vertebrobasilar dolichoectasia: Case reports and literature review

Abstract Introduction: Trigeminal neuralgia (TN) secondary to vertebrobasilar dolichoectasia (VBD) was a rare condition with limited cases reported in the medical literature. This paper reported two successful cases of endoscopic-assisted microvascular decompression (MVD) for TN secondary to VBD. Case presentation no. 1: A 53-year-old male with a history of myocardial infarction and heart failure was diagnosed of left trigeminal neuralgia V2 and V3 for three years. The pain did not respond to medical therapy with Tegretol at the dose of 800mg per day. Brain magnetic resonance imaging (MRI) revealed a neurovascular conflict between VBD and the left trigeminal nerve. The endoscopic-assisted MVD was indicated and we used keyhole retrosigmoid craniotomy. The shredded neurosurgical sponges were interposed between VBD and trigeminal nerve. The 0o and 30o rigid rod-lens endoscope was used to explore and confirm the complete decompression. Postoperatively, TN was disappeared entirely. At one-year postoperative, no facial pain and paraesthesia were found. Case presentation no. 2: A 71-year-old male with healthy history was diagnosed of right trigeminal neuralgia V2 for four years. The pain did not respond to medical therapy with Tegretol at the dose of 800mg per day. Brain MRI demonstrated a neurovascular conflict between VBD and the right trigeminal nerve. He was received endoscopic-assisted MVD via keyhole retrosigmoid craniotomy. After the operation, his facial pain disappeared permanently and he has paraesthesia at right upper lip. He was discharged after a week. At 6 months postoperative, no facial pain were found. Conclusion: Endoscope-assisted MVD allowed better visualization of REZ and neurovascular conflicts behind neural structures and least cerebellar retraction in management of trigeminal neuralgia secondary to VBD. Keywords: Trigeminal neuralgia, vertebrobasilar dolichoectasia, microvascular decompression, endoscope-assisted.

Refractory Trigeminal Neuralgia: Successful Treatment with LINAC Based Stereotactic Radiosurgery (SRS): First Case in Bangladesh

Purpose: To present first case of refractory trigeminal Neuralgia treated with SRS in Bangladesh, procedural technique, and outcomes in terms of pain relief. Background: Trigeminal neuralgia (TN), classically known as tic doloureaux is a chronic and recurrent disabling pain syndrome, which described as episodes of lancinating pain over the face along the sensory distribution of trigeminal nerve. First line management of TN is medical with different permutation & combination to control the pain. After the failure of medical management, non-invasive SRS is an established modality to achieve long term pain control. Here, we are reporting a case of TN treated with LINAC based SRS. Case Presentation: A 61 years old, gentleman who developed piercing pain inside his left eye for a duration 1-1.5 sec, precipitated while shaving, brushing teeth in year 2015, occurred 4-5 time a day. He was diagnosed as left TN of V1, started on Carbamazepine, Pregabalin. In 3 years, pain progressed to involve all 3 branches. Even combination Carbamazepine, Gabapentin, Tramadol, Amitriptyline, Clonazepam, & Morphine could not control the pain. Pain was persisting all over the day and he also developed suicidal tendency. Later he has been referred to us for SRS. SRS was done in April-2019, a dose of 90Gy was delivered to the Distal Retrogasserian (RG) also called Marseille point of trigeminal nerve root. Eight months after the SRS patient is almost free of pain without any Medicine. Conclusions: LINAC based SRS is a non-invasive, frameless, and safe procedure with excellent pain control for refractory Trigeminal neuralgia. Bang. J Neurosurgery 2020; 10(1): 123-129

Microvascular decompression for the treatment of neurogenic hypertension with trigeminal neuralgia

BackgroundTo evaluate the efficacy of microvascular decompression (MVD) in reducing hypertension (HTN) in hypertensive patients with trigeminal neuralgia (TN).MethodsThe clinical data of 58 cases of neurogenic HTN with TN treated in our hospital were retrospectively reviewed. Preoperative MR revealed abnormal blood pressure in the left rostral ventrolateral medulla (RVLM) and the posterior cranial nerve root entry zone (REZ). The patients were divided into control group: only trigeminal nerve was treated with MVD; experimental group: trigeminal nerve, RVLM and REZ were treated with MVD at the same time. The patients were followed up for 6 months to 1 year to observe the changes of blood pressure.ResultsThere was no significant difference in gender, age, course of TN, course of HTN, grade of HTN and preoperative blood pressure between the two groups. After operation, the effective rate of HTN improvement with MVD was 32.1% in the control group. There was no significant difference in the preoperative and post operative blood pressure. (P△SBP = 0.131; P△BDP = 0.078). In the experimental group, the effective rate was 83.3%. The postoperative blood pressure was significantly lower than preoperative values. (P△SBP < 0.001; P△DBP < 0.001).ConclusionsMVD is an effective treatment for neurogenic HTN. However, the criteria for selecting hypertensive patients who need MVD to control their HTN still needs to be further determined. Possible indications may include: left trigeminal neuralgia, neurogenic HTN; abnormal blood pressure compression in the left RVLM and REZ areas on MR; and blood pressure in these patients can not be effectively controlled by drugs.

Altered structure and functional connection in patients with classical trigeminal neuralgia.

Classical trigeminal neuralgia (TN) is a specific type of neuropathic orofacial pain of which the plasticity of brain structure and connectivity have remained largely unknown. A total of 62 TN patients were included and referred to MRI scans. Voxel-based morphometry was used to analyze the change of gray matter volume. Resting-state functional imaging was used to analyze the connectivity between brain regions. The results showed gray matter volume reduction in components of the prefrontal cortex, precentral gyrus, cerebellar tonsil, thalamus, hypothalamus, and nucleus accumbens among right TN patient and in the inferior frontal gyrus, precentral gyrus, cerebellum, thalamus, ventral striatum, and putamen among left TN patients. The connections between the right superior frontal gyrus and right middle frontal gyrus were lower in right TN patients. The connection between the left precentral gyrus and the left superior frontal gyrus was lower while the connection between bilateral thalamus was higher in left TN patients. The changes of volume in bilateral thalamus of right TN patients and left ventral striatum of left TN patients, and the connectivity between bilateral thalamus of left TN patients were moderately correlated with pain duration. These findings suggest that brain regions such as the thalamus may not only be involved in processing of pain stimuli but also be important for the development of TN. The left hemisphere may be dominant in processing and modulation of TN pain signal. Chronification of TN induces volume changes in brain regions which are associated with emotional or cognitive modulation of pain. Hum Brain Mapp 39:609-621, 2018. © 2017 Wiley Periodicals, Inc.

Surgical treatment of rare metastatic tumor in Meckel’s Cave: a case report

Abstract Objectives: Metastases in Meckel’s cave are a rare tumor entity, but they should be considered in patients with a known primary malignancy and who complain of trigeminal neuralgia. Methods: The case of a patient with a left trigeminal neuralgia caused by a metastatic tumor involving the Meckel’s cave and Gasserian ganglion is reported. Preoperative symptoms included headache, trigeminal hyperesthesia and facial pain. Results: The patient underwent microsurgical resection of the tumor, obtaining a histological diagnosis and a resolution of the pain. Trigeminal motor function was preserved. Conclusion: The best treatment for tumors of Meckel’s cave, including metastases, is complete microsurgical removal. Although good results have been reported with radiosurgery, this treatment should be reserved only for nonresectable and residual tumors.

Presentación inusual de un tic convulsivo doloroso

The term 'painful tic convulsive' is used to describe the syndrome involving concomitant hemifacial spasm and ipsilateral trigeminal neuralgia. Vascular compression of the fifth and seventh cranial nerves is the most common cause, involving the entry and exit zone of rootlets coming from the brainstem; nevertheless, different etiologies of this syndrome has been previously reported. Treatment for this disease is based on surgical microvascular decompression of the nerve rootlets, but still a topic of debate.A 63-year-old woman with history of 14 years presenting left trigeminal neuralgia, associated with ipsilateral hemifacial spasm for more than ten years. Medical treatment was installed without adequate symptom control. Patient was subjected to surgical treatment via a microasterional approach, with dissection of arachnoid fibrous tissue surrounding fifth and seventh nerves during the first surgery. A second surgery was performed with insertion of a teflon fragment aside of each exit nerve root (V and VII-VIII complex). Symptoms resolved immediately after the surgery and has persisted during the 1-year follow-up. Painful tic convulsive etiology could be multifactorial.This report is the first clinical case describing basal arachnoiditis as a primary cause of painful tic convulsive.Presentacion inusual de un tic convulsivo doloroso.Introduccion. La presentacion clinica de un espasmo hemifacial asociado a neuralgia trigeminal ipsilateral se conoce como tic convulsivo doloroso. La causa mas comun de esta patologia es la compresion vascular de los nervios craneales V y complejo VII-VIII en la zona de entrada y salida de las raices en el tronco del encefalo, pero existen informes de diversas etiologias. Su tratamiento, aunque aun esta en discusion, se basa en la descompresion microvascular quirurgica. Caso clinico. Mujer de 63 años, con un cuadro de evolucion de 14 años de neuralgia trigeminal, con predominio en distribucion de la rama maxilar (V2) izquierda, asociado durante mas de 10 años a espasmo hemifacial ipsilateral. Tras fallar el tratamiento medico, se sometio a cirugia por abordaje microasterional, y en un primer momento se realizo una diseccion de adherencias aracnoideas firmes rodeando complejos nerviosos. En un segundo tiempo quirurgico se insertaron fragmentos de teflon en los sitios de entrada de los nervios V y complejo VII-VIII, y se logro una resolucion completa de la sintomatologia durante mas de un año. Conclusion. La etiologia del tic convulsivo doloroso en esta paciente fue aracnoiditis basal, lo cual la convierte en el unico caso comunicado hasta el momento con dicha etiologia.

Brain white matter plasticity and functional reorganization underlying the central pathogenesis of trigeminal neuralgia.

Peripheral nerve damage does not fully explain the pathogenesis of trigeminal neuralgia (TN). Central nervous system changes can follow trigeminal nerve dysfunction. We hypothesized that brain white matter and functional connectivity changes in TN patients were involved in pain perception, modulation, the cognitive-affective system, and motor function; moreover, changes in functional reorganization were correlated with white matter alterations. Twenty left TN patients and twenty-two healthy controls were studied. Diffusion kurtosis imaging was analyzed to extract diffusion and kurtosis parameters, and functional connectivity density (FCD) mapping was used to explore the functional reorganization in the brain. In the patient group, we found lower axial kurtosis and higher axial diffusivity in tracts participated in sensory, cognitive-affective, and modulatory aspects of pain, such as the corticospinal tract, superior longitudinal fasciculus, anterior thalamic radiation, inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, cingulated gyrus, forceps major and uncinate fasciculus. Patients exhibited complex FCD reorganization of hippocampus, striatum, thalamus, precentral gyrus, precuneus, prefrontal cortex and inferior parietal lobule in multiple modulatory networks that played crucial roles in pain perception, modulation, cognitive-affective system, and motor function. Further, the correlated structural-functional changes may be responsible for the persistence of long-term recurrent pain and sensory-related dysfunction in TN.

The Continuous Assessment of Cranial Motion in Thermoplastic Masks During CyberKnife Radiosurgery for Trigeminal Neuralgia.

Stereotactic radiosurgery (SRS) treatment is characterized by high doses per fraction and extremely steep dose gradients. This requires a great degree of accurate localization to the appropriate treatment position, and continuous immobilization during the treatment session. In the case of Trigeminal Neuralgia (TGN) treatment this is especially true as the very small target volume makes positional accuracy critical. In this study we carried out a quantitative analysis of patient motion during the full treatment fraction within a radiosurgery immobilization mask system. Patient cranial movement was assessed by using the image guidance stereo x-ray cameras on a CyberKnife (CK) M6 robotic radiosurgery system (Accuray, Sunnyvale, CA). A total of five patients received treatments for either right or left TGN. The duration of treatment varied from 24-64 minutes. Orthogonal images were taken every 15 seconds during the treatment to assess patient movement. Approximately 60 stereo images were taken per patient and a total of 560 images were analyzed in this study. The mean absolute movement in each of longitudinal, lateral or vertical directions was approximately 0.3 mm for the duration of the treatment; however, on occasion much greater movement was observed during a fraction. The maximum displacement was in the longitudinal direction and reached 2.4 mm compared to the initial setup. Images taken at the end of the treatment session showed that the patients typically return to a position closer to the original setup position than the maximum excursion that occurred. This data suggests that although this mask system appears stable during much of the treatment session; for some patients there may be momentary patient movements that take place. Frequent imaging and correction can help mitigate the effect of this movement. It is important to understand the limitations of non-invasive mask systems when used for very high precision treatment.

A very rare, petro-clival, neurothekeoma tumor. Case Report

Abstract Known as nerve sheath myxoma too, neurothekeoma are benign tumors, usually arise in the skin of the head, neck region and upper extremities, in young females. Cerebral neurothekeoma are very rare, a few cases were already described in the parasellar area, in the middle cranial and posterior fossa. We present a petro-clival neurotekoma. A 78-year-old male was admitted for two years left fronto-temporal headache completed in the last 6 months with left trigeminal V1 neuralgia, left facial hypoesthesia, diplopia, swallowing disorders for liquid foods, balance disorders. From his medical records we noticed: stage 2 chronic kidney disease, hypertension, prostate adenoma, dyslipidemia hypercholesterolemia. The MRI showed a macronodular petroclival mass in hiper T2, hipo T1, flair iso signal; normal cerebral angiography. The patient was operated on using a left retrosigmoid, retromastoidian approach. A 4/3/3 cm tumor, gray, encapsulated, soft consistency, partially cystic, less bleeding, attached to the dura, displacing the basilar artery and brain stem controlateral, encasing the trigeminal nerve. The tumor was totally removed with a good postop evolution. Six months follow up he had no more facial pain, but only persistant left facial hypoesthesia. Histologically the tumor had lobular appearance with spindle or stellate cells embedded in abundant myxoid background. The tumor cells were diffusely positive for S100, PGP9.5’, CD 34” positive in vessels, Ki67’positive in 5%. Cranial MRI performed one month after surgery did not show any residual tumor. Also known as nerve sheath myxomas, neurothekoma are rare benign tumors. For intracranial neurothekoma surgical indication is mandatory

Clinical features of bilateral trigeminal neuralgia

Among 238 patients with bilateral trigeminal neuralgia(TN)who visited our hospital between April 2007 and June 2014, 5(2%)were surgically treated by microvascular decompression(MVD). The initial symptom was on the right side in four and on both sides in one patient. Intervals between the initial and second onset on the other side(left)were two months, and four, six, and eight years. None of the patients showed involvement of the first branch of the trigeminal nerve. The patients with bilateral TN were younger than the 154 patients with unilateral TN who were treated surgically by MVD in this period(45 vs. 65 years), and the bilateral TN patients predominantly were women(4/5 vs. 99/154). In the surgical field, the trigeminal nerve and root entry zone were compressed more by veins in the bi lateral TN patients than in the unilateral TN(4/5 vs. 60/154, respectively)patients. We could not identify any differences in MRI CISS before versus after the onset of left trigeminal neuralgia, suggesting that compression is not the sole cause of the symptom.

Intracranial Aspergillosis Mimicking a Middle Cranial Fossa Tumor Involving the Cavernous Sinus in an Immunocompetent Patient: Case Report and Literature Review

Intracranial aspergillosis is rare in immunocompetent patients. Extension to the cranial base via the sphenoid sinus is exceptional. Authors report a case of middle cranial fossa aspergillosis involving the cavernous sinus and mimicking an extra-axial tumor in an immunocompetent 65 year-old male. The patient had been suffering from left trigeminal neuralgia and a horizontal diplopia since 4 months. Physical examination featured a left complete ophtalmoplegia and an hyperesthesia of the left maxillary nerve. Radiological examination showed a left temporal extra-axial temporal expanding intracranial lesion, involving the left cavernous sinus with extension to the sphenoidal sinus. A large tumor resection was performed through a left fronto-temporal craniotomy with no postoperative complications. Pathologic examination and specimen culture concluted to an Aspergillus fumigatus. Authors discuss the clinical, radiological features and management of such lesion through a literature review.

Typical trigeminal neuralgia by an atypical compression: case report and review of the literature

Trigeminal neuralgia is a disabling form of facial pain that causes a considerable discomfort and a marked reduction in the quality of life. Although neurovascular compression is often associated with trigeminal neuralgia, other intracranial pathologies can result in compression along the nerve. The authors report a case of a patient suffering from a typical left trigeminal neuralgia affecting both the second and the third branches. Neuroradiological examinations showed the presence of an arachnoid cyst located in the left temporal lobe, contiguous with the Meckel's cave, eroding the greater wing of the sphenoid bone. Following a meticulous decision-making process the patient underwent conservative treatment with success. A properly modulation of the drug dosage allowed pain relief to be achieved. This is a rare case reporting a typical trigeminal neuralgia by an arachnoid cyst of the Meckel's cave mimicking a neurovascular compression syndrome. Our findings, behind the review of the current literature, point out the importance of such a pathological condition when dealing with patients affected by cranial nerve dysfunction syndrome.

Exacerbation of secondary trigeminal neuralgia due to osteomyelitis in a case of Romberg facial hemiatrophy

Progressive facial hemiatrophy or Romberg syndrome, is a sporadic disease of unknown etiology characterized by progressive and self limited shrinking and deformation of one hemiface accompanied by various neurologic complication, including trigeminal neuralgia. We present the case of a 31-year-old Caucasian female with exacerbation of a left trigeminal neuralgia two weeks after a dental extraction. The severe pain was due to osteitis of the left mandible and a fracture through the 38 alveola. After removing the necrotic tissue and mandibulo-maxilary fixation the evolution was favorable with no signs of infection or wound dehiscence and the symptoms of pain were relieved.

Transposition of the Vertebral Artery With Fibrin Glue Adhesive in Microvascular Decompression

A 70-year-old male had suffered from left trigeminal neuralgia, and magnetic resonance images showed that the left dolichoectatic vertebral artery compressed the trigeminal nerve upward and the left superior cerebellar artery compressed the root entry zone. In microvascular decompression surgery, the dolichoectatic vertebral artery was transposed and fixed to the dura with fibrin glue adhesive, and a wide working space was acquired. Then, the superior cerebellar artery was confirmed to compress the trigeminal nerve root and was transposed from the root entry zone. The patient was relieved of the trigeminal neuralgia after the surgery. Vascular transposition using fibrin glue adhesive is safer and easier than other methods, even for transposition of the vertebral artery. The highest priority should be given to the safety of the method in functional neurosurgical operations.

Malignant Transformation of an Intracranial Large Epidermoid Cyst With Leptomeningeal Carcinomatosis -Case Report-

A 64-year-old female presented with rapid onset of left ophthalmoplegia and truncal ataxia, after experiencing diplopia due to left abducens nerve palsy for a year. She had undergone surgery twice for left trigeminal neuralgia caused by a large intracranial epidermoid cyst at the age of 48 and 52 years. The intracranial epidermoid cyst grew and became predominantly enhanced by contrast medium on computed tomography (CT) and T(1)-weighted magnetic resonance (MR) imaging, which had not been observed earlier. The tumor was partially removed and the histological diagnosis was squamous cell carcinoma (SCC). Radiation therapy was administered, but she presented with paraplegia of the bilateral lower extremities and anesthesia due to spinal multiple metastases of SCC one year later. Radiation therapy was administered for the spinal lesions, but she died of multiple metastases to the cerebellum and medulla oblongata with hydrocephalus 2 years after the third surgery. Transformation of intracranial epidermoid cysts to SCC appears as predominant enhancement on CT or T(1)-weighted MR imaging with rapid deterioration of neurological features. All reported cases of malignant transformation of intracranial epithelial cysts to SCC with leptomeningeal carcinomatosis have occurred in intracranial epidermoid cysts.