Facial Numbness Research Articles

Perioperative Evaluation and Monitoring of Percutaneous Balloon Compression in Treatment of Trigeminal Neuralgia

BACKGROUND AND OBJECTIVES: Multiple factors may influence the clinical outcomes of percutaneous balloon compression (PBC), including intraluminal balloon pressure, volume, and Meckel's cave volume. In this article, we aimed to investigate the clinical value of the perioperative assessment and monitoring of balloon compression in the treatment of trigeminal neuralgia (TN). METHODS: Thirty-seven patients who underwent PBC were prospectively enrolled. The patient underwent preoperative high-resolution 3.0-T MRI for the 3-dimensional reconstruction of Meckel's cave, while intraoperative recordings of intraluminal pressure and balloon volume were conducted simultaneously. Primary outcomes included postoperative numbness and pain recurrence up to 24 months after discharge. RESULTS: Sensory deficiency was primarily reported within the first month, and approximately 38% of the patients presented with symptomatic numbness in the facial region. Subgroup analysis indicated no statistically significant difference in intraluminal balloon pressure between patients with facial numbness and asymptomatic individuals. This impairment in trigeminal sensation eventually recovered at the 24-month follow-up. By contrast, the long-term recurrence rate of TN was approximately 25% (5/20 patients) 2 years postoperatively. Furthermore, we found that the intraluminal balloon pressure was significantly lower among patients with recurrent pain (102.8 ± 11.0 vs 135.7 ± 5.1 kPa, P < .05). Although no significant differences in balloon or Meckel's cave volume were observed between subgroups, we found a positive and significant correlation between the volume of Meckel's cave and balloon. CONCLUSION: Facial numbness remains a common but short-term symptom of PBC for TN. This study indicates that a higher intraluminal balloon pressure may be associated with a lower risk of recurrent trigeminal pain. Preoperative reconstruction of Meckel cave may help to predict the volume of intraoperative balloon compression. We consider it feasible and necessary to conduct a perioperative assessment of balloon compression in the treatment of TN.

PATH-31. COMPLETE TUMOR DISAPPEARANCE ON BRAIN MRI AFTER STANDARD CHEMORADIATION THERAPY FOR A MOLECULAR GLIOBLASTOMA

Abstract INTRODUCTION Glioblastoma (GBM) is the most aggressive brain tumor. The WHO CNS5 classification has newly incorporated three molecular criteria in diagnosing molecular GBM, including a concurrent gain of chromosome 7 and loss of chromosome 10 (+7/-10), TERT promoter mutation, or EGFR amplification. Despite new classification, the Stupp protocol remains the standard of care for all GBMs. However, it is unclear if the treatment response of the molecular GBM with low grade features is the same as the limited response of the traditional histopathological GBM. CASE REPORT A 74-year-old male presented in August of 2023 with new onset left-sided facial numbness. The numbness resolved spontaneously that day. Brain MRI was notable for a diffuse left frontal T2/Flair hyperintense lesion extending across the corpus callosum into the right frontal lobe without definite enhancement. Brain biopsy from 8 sites of the tumor demonstrated a subset of areas with mild hyper-cellularity, suggesting a low-density infiltrating glioma. However, TERT promoter mutation (-124C>T), was detected along with wild-type IDH1, supporting molecular GBM. Studies also found unmethylated MGMT gene promotor. Brain MRIs after 3 and 6 months showed no tumor progression. The patient has remained asymptomatic apart from baseline mild forgetfulness. He was started on the 6-week standard concomitant temozolomide and radiation therapy. Follow-up brain MRI after the above treatment showed complete imaging resolution of the tumor. DISCUSSION It is very rare for complete imaging resolution of GBM on brain MRI after standard 6-week chemoradiation therapy. Our case suggests that molecular GBM with low-grade features on imagine and pathology might have a better response to the standard treatment than traditional histopathological GBM even though the molecular GBM patient has unfavorable prognostic factors such as unmethylated MGMT and older age (>70 years old). Our experience emphasizes the heterogenous response of molecular GBM to the current standard treatment.

Trans-Tragal Approach for Mandibular Neck and Head Condylar Fractures.

This retrospective observational study evaluates the trans-tragal approach for the treatment of mandibular head and neck condylar fractures. From January 2009 to May 2024, 34 patients (20 males, 14 females, mean age 34 years) with 36 condylar fractures were treated using this approach. Surgical outcomes were assessed based on occlusal relationship, maximum mouth opening, and facial nerve function (House-Brackmann scale). Postoperative imaging included computed tomography scans, with follow-ups at 1, 3, 6 months, and 1 year. Complications such as wound infection, hematoma, and salivary fistula were also evaluated. Results showed satisfactory postoperative outcomes, with 32 patients maintaining normal occlusion and a mean interincisal opening distance of 40 mm. Three patients experienced complications, including temporary facial nerve numbness in one case, with complete recovery in 2 weeks, and 2 cases requiring reoperation due to condylar segment displacement. No cases of permanent facial nerve damage, salivary fistula, or tragal cartilage necrosis were observed. Aesthetic outcomes were satisfactory, with scars hidden in natural folds. The trans-tragal approach provides adequate surgical exposure to the posterior condylar region while minimizing the risk of facial nerve injury. Although the results of this study indicate favorable outcomes, further randomized controlled studies are required to validate these findings due to the non-randomized design and small sample size.

How to improve ZMC fracture reconstruction due to severe enophthalmos

Introduction and importanceZygomaticomaxillary (ZMC) fractures are common, often resulting from traffic accidents, and account for 17 % of facial fractures. These fractures can lead to issues such as enophthalmos, flattened cheeks, diplopia, maxillary hypoesthesia. If the reduction is inadequate to restore facial structure, long term-functional and aesthetic complications may arise. In such cases a computed tomography (CT) scan with 3-dimensional (3D) reconstruction is valuable to assessing the fracture and planning surgery, with current technological advancements, 3D printing can now be utilised for this purpose. Presentation of caseA 24-year-old male, after a motorcycle accident and initial surgery for maxillofacial fractures, experienced persistent diplopia and facial numbness. Physical examination showed malpositioning of the right eye, and a CT scan with 3D reconstruction revealed multiple fractures and prior internal fixation. A 3D-printed model was created to plan a second surgery using rib cartilage and a silicone orbital base for orbital rim reconstruction. Post-surgery, the patient reported minimal pain and no diplopia or blurred vision in the primary gaze position. Clinical discussions3D printing is beneficial in facial reconstruction, aiding in surgical planning by allowing precise measurement and design of graft. Rib cartilage can serve as an alternative for orbital rim reconstruction, and 3D printing facilitates accurate harvesting of the rib. ConclusionIn cases of severe ZMC fracture, 3D printing was utilised as a guide during surgical preparation to achieve improved outcomes.

Effects of Raupya Suvarna Sutashekhara, a herbo-mineral-metallic formulation as adjunct Oral Ayurvedic Medicine on long-term survival in patients of malignant brain tumor

BackgroundThe incidence of brain tumors poses a significant threat, particularly with high-grade tumors that exhibit rapid growth and can significantly impair the patient's quality of life, despite treatment modalities. Ayurveda, a natural system of medicines helps to enhance health benefits when used as a complementary therapy in combination with conventional treatment through various herbal, herbo-mineral or herbo-mineral-metallic formulations. One of such formulations, Raupya Suvarna Sutshekhara (RSS), has Raupya bhasma and Suvarna bhasma (incinerated Silver and Gold respectively) ingredients and they are described as Rasayana (immunomodulatory) and possess Medhya (enhances the brain functions and intelligence) activity. ObjectiveThe study documents effects of Raupya Suvarna Sutshekhara in alleviating symptoms of malignant brain tumors. Materials and methodsThis retrospective cohort study was done for malignant brain tumor patients (n = 110) registered at our centre who were treated with Raupya Suvarna Sutshekhara 125 mg–250 mg (a herbo-mineral metallic formulation) as a treatment of choice of neural tonic along with supporting Ayurvedic medicines. Treatment response evaluation period ranged from 3 months to 5 years (median period 29 weeks). Clinical symptoms, weight, Karnofsky Performance Score (KPS), Quality of Life (QoL) score, and survival data with respect to treatment with RSS were analyzed. ResultsRSS showed a very significant (p < 0.001) effect on symptoms related to memory loss, headache, imbalance, loss of appetite, and generalized weakness while significant (p < 0.05) decrease in urinary incontinence, seizures, difficulty in thinking/articulating, and weakness in one part/side of the body. However, a not-quite significant change was seen in symptom confusion/disorientation. No significant improvement was seen in vision changes, facial numbness or tingling, swallowing difficulties, and tingling in extremities. Body weight and KPS also showed improvement. Patients with treatment between 2 and 5 years showed median survival up to 62 months. ConclusionsIt was observed that adjunct Ayurvedic treatment with RSS helped to reduce the severity of symptoms due to the tumor itself or side-effects of conventional treatments, maintain the quality of life of malignant brain tumor patients and has shown to increase survival with respect to the duration of the treatment.

Comparison of microvascular decompression and percutaneous balloon compression efficacy in patients with V2 idiopathic trigeminal neuralgia.

This study aims to compare the efficacy and long-term prognosis of microvascular decompression (MVD) versus percutaneous balloon compression (PBC) in patients with idiopathic V2 (maxillary branch) trigeminal neuralgia. We retrospectively analyzed the clinical information and follow-up data of patients who underwent surgical treatment for V2 idiopathic trigeminal neuralgia from January 2020 to January 2023. A total of 58 patients were included in the MVD group and 99 in the PBC group. All surgeries were performed by two physicians at the same center, with follow-up conducted by a separate, trained researcher. We compared the initial versus 12-month postoperative pain relief rates (scored using the BNI), surgical complications, and described pain relief rates after long-term follow-up in both groups using Kaplan-Meier analysis. The study included a total of 157 patients (MVD 58, PBC 99). The median age of patients in the MVD group was lower than that in the PBC group (58 [51-65] vs. 63 [58-69], p = 0.002). There was no significant difference between the two groups in terms of pain relief rates initially after surgery and at 12 months (p = 0.521, p = 0.713). However, the MVD group had significantly better outcomes regarding postoperative facial numbness (p < 0.0001), masticatory weakness (p = 0.0017), and other complications (p = 0.04). Kaplan-Meier analysis showed that MVD provided a longer duration of pain relief than PBC (p = 0.0323), with most recurrences in both groups occurring within 1-2 years after surgery. There were no significant differences in significant pain relief rates between the two groups initially after surgery and at 12 months. However, the MVD group showed a clear advantage over PBC regarding postoperative facial numbness, masticatory weakness, and other complications; moreover, Kaplan-Meier analysis revealed that MVD offers a longer duration of pain relief for patients.

Angioinvasive Rhino-Orbital-Cerebral Mucormycosis in a Patient with Type 2 Diabetes Mellitus: A Complex and Lethal Cause of Stroke

Rhino-orbital-cerebral mucormycosis is a rapidly progressive and often fatal fungal infection caused by molds of the order Mucorales, particularly affecting immunocompromised individuals. This infection is notorious for its angioinvasive properties, enabling the fungi to invade blood vessels and leading to tissue necrosis. We report the clinical course of a 59-year-old Caucasian man with poorly controlled type 2 diabetes (HbA1c 16.8%) who presented with unilateral headache, left-sided facial numbness, and incomplete left ocular motor paresis. Initial presentation raised suspicion of orbital phlegmon, leading to antibiotic and later corticosteroid pulse therapy, which worsened the patient’s condition. Subsequent imaging demonstrated extensive inflammatory changes, including wall irregularities of the left intracranial internal carotid artery, accompanied by ocular protrusion and periorbital enhancement. New palatal lesions indicated mucormycosis, which was confirmed by molecular analysis of a palatal biopsy, leading to Amphotericin B treatment. Pre-surgery imaging revealed a malignant middle cerebral artery infarction, and the patient died 16 days after symptom onset and 12 days after initial presentation under palliative care due to a poor prognosis. This case of angioinvasive mucormycosis underscores the severe and often fatal course of rhino-orbital-cerebral mucormycosis in an immunocompromised individual. The rapid progression from initially vague and unspecific symptoms to extensive vascular involvement and stroke highlights the critical need for early and accurate diagnosis, as well as prompt intervention to prevent further disease progression. Additionally, this case also illustrates the potential risks associated with corticosteroid therapy in the presence of undiagnosed fungal infections, which can exacerbate the condition and lead to serious complications. Clinicians should maintain a high index of suspicion for mucormycosis in similar clinical scenarios, prioritizing adequate antifungal treatment and careful monitoring to improve patient outcomes. Early interdisciplinary collaboration is essential for the effective management of such complex cases.

Application of mitoxantrone hydrochloride in lymph node imaging during radical thyroidectomy

Objective: To investigate the clinical application value of the new tracer mitoxantrone hydrochloride in imaging of cervical lymph nodes and identifying of parathyroid, recurrent laryngeal nerve during thyroid cancer radical surgery. Methods: A prospective controlled study was conducted between January 2022 and April 2024 at Tianjin First Central Hospital, recruiting 180 patients with thyroid cancer, including 54 males and 126 females, aged from 26 to 69 years. The patients were randomly divided into three groups: the mitoxantrone hydrochloride lymph node tracing group (MHI group), the nanocarbon lymph node tracing group (nanocarbon group), and the control group without lymph node tracers, with 60 cases in each group. All patients underwent total thyroid resection and regional lymph node dissection. The number of detected lymph nodes and positive metastatic lymph nodes and surgical field clarity scores and the identification rate of parathyroid glands and the instances of inadvertent excision were compared between the groups. Serum calcium and parathyroid hormone (PTH) levels at different perioperative time points and treatment-related complications were analyzed. One-way ANOVA, chi-square test and two independent sample non-parametric tests, were employed for statistical analyses. Results: The mean operation time, neck drainage volume and hospital stay in the MHI group and the nanocarbon group were respectively significantly lower than those in the control group (P<0.05). The mean staining intensity score, tracer success rate and surgical field clarity score in MHI group were respectively significantly higher than those in nanocarbon group (P<0.05). The mean numbers of dissected lymph nodes positive metastatic nodes and identification rates of parathyroid glands in MHI group were respectively significantly higher than those in both the nanocarbon and control groups (P<0.05). The rates of inadvertent parathyroid excision in both MHI group and nanocarbon group were significantly lower than those in control group (P<0.05). On postoperative day 1 and day 5, mean serum calcium and PTH levels in MHI group were respectively significantly higher than those in nanocarbon group and control groups. However, on postoperative day 1, there was no difference in mean serum calcium levels between the nanocarbon group and the control group (P>0.05), though PTH level in the nanocarbon group was higher than that in the control group. By postoperative day 5, both serum calcium and PTH levels were higher in the nanocarbon group compared to the control group (P<0.05). On postoperative days 30, there were no differences in serum calcium and PTH levels between the MHI group and the nanocarbon group (P>0.05). The risks of facial numbness, hand and foot tetany and choking during drinking were lower in both the MHI and nanocarbon groups compared to the control group (P<0.05). Conclusion: MHI demonstrates advantages in rapid targeted delivery and clear staining of the surgical field during regional lymph node dissection in radical thyroidectomy for thyroid cancer, effectively reducing the risk of collateral damage to the recurrent laryngeal nerve and parathyroid glands.

7298 Hyperventilation Associated Hypophosphatemia, Hypocalcemia, Hypokalemia And Paralysis

Abstract Disclosure: S. Afreen: Research Investigator; Self; Tandem Diabetes Care, Yes. N. Afreen: None. Introduction: Hyperventilation is over-breathing in excess of the metabolic needs of the body, which can result in respiratory alkalosis and a wide range of electrolyte abnormalities. Case: A 38 year old male with a past history of hypertension, OSA and cholecystectomy reported having episodes of palpitations, tachypnea with respiratory rate as high as 80 breaths/ minute, associated with facial numbness and tingling, tetany, progressing to paralysis of his extremities. These episodes started 7 years ago but gradually became more frequent. He denied anxiety or stressors prior to these episodes. The episodes almost always result in emergency room visits. During one of these episodes he was found to have the following labs: ionized calcium-1 mmol/l, serum phosphorus- 0.8 mg/dl, serum potassium- 2.7 mmol/l, 1.25(OH)2D- 44pg/ml, alkaline phosphatase- 60 IU/l, glucose- 94 mg/dl and GFR- 90 ml/min/1.73m2. VBG during this episode: pH - 7.59, PCO2- 23 mm Hg, and bicarbonate - 22 mmol/l. Of note, the electrolytes are normal in between the episodes. Thyroid labs are normal. Off of phosphate supplementation for 3 days, in between episodes, his serum phos- 4.2mg/dl, cr - 0.84 mg/dl. Second morning urine phos - 84 mg/dl and urine cr - 206.81 mg/dl. Tubular phosphate reabsorption was 91.9%. He had negative Holter, nuclear stress testing and MRI of the brain. No mutations were identified on genetic analysis of CACNA15, KCNJ2, RYR1, SCN4A. During his recent endocrine clinic visit, on physical exam: height- 5 feet 11 inches, weight- 366 lbs weight, BMI- 51.1 kg/m2, BP- 129/89 mm Hg, heart rate- 81 bpm and respiratory rate- 18 breaths/minute. He did have one palpable 1.5 cm left thyroid nodule. Otherwise, the exam was unremarkable. The patient was referred to pulmonology to be evaluated for potential diaphragmatic and lung causes of his tachypnea. He was also referred to psychiatry for evaluation of underlying anxiety. Since these episodes of hyperventilation associated electrolyte abnormalities lead to paralysis, he was started on calcitriol 0.25mcg daily along with 1250 mg potassium phosphate daily. Discussion: Hyperventilation can lead to a respiratory alkalosis and corresponding increase in intracellular pH. High intracellular pH can lead to increased phosphofructokinase activity and glycolysis, resulting in increased intracellular phosphate shift. Acute respiratory alkalosis can also result in ionized calcium binding to albumin. Moreover, acute respiratory alkalosis results in reduction in hydrogen ion in the intracellular fluid with extracellular potassium ion shift into cells leading to hypokalemia.These electrolyte abnormalities can cause myopathies, cardiac arrhythmias, respiratory failure, paralysis, seizures, coma and death. Physicians should be aware of the possibility of electrolyte imbalance due to hyperventilation to prevent the development of life threatening complications. Presentation: 6/1/2024

7120 Pituitary Prolactinoma Transforming To Invasive Aggressive Adenoma After 10 Years of Acting As Benign Adenoma

Abstract Disclosure: S.N. Polis: None. S. Nakhle: None. N.J. Vernetti: None. Prolactinomas are the most common type of secretory pituitary tumors. Symptoms occur due to hyperprolactinemia and compressive symptoms with larger tumors. The majority of the prolactinomas are benign adenomas, with up to 30-40% of them being invasive. Malignant prolactinomas are rare, counting only 0.2% of pituitary tumors with an average latency period of 4.7 years. We present a 70-year-old woman who was found to have asymptomatic mild hyperprolactinemia in 2009 with pituitary MRI that showed a 3 mm left pituitary adenoma. Treatment with cabergoline started three years later due to an increase in prolactin above 300 ng/ml. Annual pituitary MRI showed a stable mass. After four years of treatment, pituitary MRI showed an increase in pituitary adenoma size to 8 mm and prolactin level remained elevated above 300 ng/ml. The patient complained of facial and acral numbness and emotional outbursts, so cabergoline was changed to bromocriptine. A few months later, a decision was made to stop treatment as she was asymptomatic and prolactin levels remained stable with a stable adenoma on imaging. 18 months later, prolactin increased to 544 ng/ml and pituitary MRI showed an increase adenoma size to 14mm, contacting the chiasm, and cabergoline was restarted. The prolactin levels continued to climb after 5 months of treatment despite titrating the dose to 1 mg daily. The patient started to develop vision impairment and visual field testing confirmed a new central vision defect. The patient was eventually referred to neurosurgery and went for transsphenoidal surgery. Prolactin level dropped to 50 ng/ml post operatively. The pathology report showed Ki 67 10-20%. Cabergoline was restarted and the patient was enrolled in a clinical trial for temozolomide for 18 months. During that time, prolactin levels remained stable so treatment was discontinued. A year later, cabergoline was restarted as prolactin levels increased to 219 ng/ml and pituitary MRI showed an 8 mm sellar mass with optic chiasm compression. For the next year, multiple medical treatments including high dose cabergoline (1 mg daily) and temozolomide were attempted, which were intolerable due to side effects. Prolactin continued to climb (&amp;gt; 1700 ng/ml). Four years later, the patient went for a second transsphenoidal surgery. Surgical pathology revealed Ki67 20%. Prolactin levels dropped to 242 ng/ml, but a month later, went up again to over 600 ng/ml. Cabergoline was restarted with a plan for an open craniotomy and radiotherapy. Conclusion: We present this interesting case of pituitary prolactinoma that behaved as benign adenoma for over 10 years prior to invasion and showing aggressive behavior requiring multiple surgeries. This unusual presentation is worrisome for malignancy and prompting consideration for closer and longer follow up for prolactinomas, especially the ones resistant to medical treatment. Presentation: 6/2/2024

Single Fraction Radiosurgical Tolerance of Brainstem, Trigeminal Nerve, and Meckel's Cave for Facial Numbness

IntroductionThe purpose of this article is to review toxicity outcomes for a series of patients treated with stereotactic radiosurgery (SRS) for trigeminal neuralgia, focusing on dose to the brainstem, trigeminal nerve, and Meckel's cave as possible explanatory variables for the development of the most common post-treatment neuropathy, facial numbness. MaterialsA retrospective review of 136 cases treated with Cyberknife radiosurgery for trigeminal neuralgia was performed. Dose was initially (cohort 1) prescribed to 57 to 64 Gy covering a 6mm cylindrical shaped target volume at least 2mm from the dorsal root entry zone (DREZ). Subsequently a deliberate change to isocentric treatment planning occurred, resulting in delivery of 85 Gy to a spherical target (cohort 2). Brainstem, trigeminal nerve, and Meckel's cave were contoured and a variety of dosimetric and clinical factors were analyzed for association with development of treatment related facial numbness. ResultsTreatment-related numbness occurred in 59/136 (43%) patients and did not differ between the treatment cohorts. Fifty-two patients experienced BNI grade II toxicity, and 7 patients experienced BNI grade III toxicity. Time to numbness was 16.0 months for cohort 1 and 10.4 months for cohort 2 (p=0.184). The median brainstem maximum dose was 26.1 Gy, ranging from 4.2 Gy to 57.3 Gy. Maximum dose to the trigeminal nerve was 85 Gy. Mean trigeminal nerve dose was 47.3 Gy. The median Meckel's cave maximum and mean doses were 26.0 Gy and 6.8 Gy, respectively. No definitive upper limit dose threshold was detected for the structures analyzed, but trends were noted for maximum trigeminal nerve dose of 85 Gy (p=0.083) and for prescription dose (p=0.057) and trigeminal nerve V40 (p=0.077) in the Type I subset. ConclusionsBrainstem, trigeminal nerve, and Meckel's cave tolerated doses within the range delivered. Discussion of the literature is provided to guide treatment planning and management.

A retrospective comparative case series of efficacy and safety of radiofrequency thermocoagulation versus drug therapy in patients with trigeminal neuralgia: A clinical case report.

The trigeminal neuralgia (TN) is characterized by a unilateral, episodic, electric shock-like pain in the distribution of the trigeminal nerve. Both drug therapy and radiofrequency thermocoagulation (RT) are used to treat TN. To compare the efficacy and safety of RT and drug therapy in patients with TN. Between October 2020 and December 2022, 62 patients with TN were allocated to undergo TN treatment (group A) or drug therapy (group B). In group A, 30 patients received RT treatment, whereas 32 patients in group B receive drug treatment. Pain relief, clinical outcomes, and adverse events in both groups were evaluated. And significantly greater reduction in Visual Analogue Scale scores was noted in group A than in group B in the initial 2-week period (P < .05). The excellent rate was 93.3% (28/30) in group A, whereas it was 68.8% (22/32) in group B during the initial 2-week period (P < .05). A total of 62 patients were followed up at least 12 months, with a mean follow-up time of 14.5 months. But there were no statistically significant differences between the 2 groups at the final follow-up. A total of 24 patients had facial numbness in group A. In contrast, ten patients in group B complained of discomfort including sedation, dizziness, nausea, vomiting. During the follow-up period, 4 patients in group A and 6 patients in group B experienced recurrent pain. RT is a safety and effective treatment for patients with classic TN, providing more benefits of quicker pain relief and higher patient's satisfaction, compared with traditional drug therapy.

Neurosarcoidosis of the trigeminal nerve: clinical accompaniments, radiographic findings, and association with neuralgia.

Cranial neuropathy is a principal disease manifestation of neurosarcoidosis, but many forms remain poorly described, including trigeminal nerve disease despite its frequency in reported cohorts (5-12%). Herein, we characterize the clinical course of patients with neurosarcoidosis involving the trigeminal nerve. A single-center retrospective cohort analysis of patients with biopsy-proven sarcoidosis involving the trigeminal nerve was conducted between 1/1/2000-3/7/2023. The trigeminal nerve was affected in 14/245 (5.7%) patients, being clinically symptomatic in 5/245 (2.0%) and asymptomatic with radiographic involvement in 9/245 (3.7%). 14/14 (100.0%) patients had systemic sarcoidosis. In the symptomatic group, trigeminal neuropathy was an inaugural feature in 4/5 (80.0%), unilateral in 5/5 (100.0%) with the V1 subdivision most affected (4/5, 80.0%), and associated with neuralgia in 2/5 (40.0%). On MRI, the cisternal nerve roots (9/14, 64.3%), Meckel's cave (7/14, 50.0%), and cavernous sinus (5/14, 35.7%) were most commonly affected, and 14/14 (100.0%) patients had extra-trigeminal neuroinflammation on cranial MRI. CSF was abnormal in at least one dimension in 11/12 (91.7%) tested. All three treated patients with symptomatic trigeminal neuropathy responded to immunomodulatory treatment, and symptomatic treatments for trigeminal neuralgia were helpful in two patients. After a median follow-up period of 63 months, the median modified Rankin scale score was 1 for both subgroups. Neurosarcoidosis may involve any portion of the trigeminal apparatus, and when affected, it frequently demonstrates a mismatch in radiographic involvement from its clinical manifestations of facial numbness and pain, and typically occurs in association with other clinical or radiographic manifestations of neurosarcoidosis.

Percutaneous Balloon Compression Guided by a Compression-Time Effect in Trigeminal Nerve Branches.

Percutaneous balloon compression (PBC) is an important treatment for trigeminal neuralgia (TN). Establishing the duration of balloon compression involves a tradeoff between outcome and postoperative complications. We aimed to explore the effect of the duration of balloon compression on the numbness response in areas innervated by the branches of the trigeminal nerve. Thirty-three patients with TN were included as an exploratory cohort, and the response area and compression time to the onset of facial numbness were recorded intraoperatively. Seventy-six patients with TN were then randomly divided into experimental (EG) and control groups (CG) for validation. The EG was treated with balloon compression times adjusted to reflect the compression-time effect observed in the initial investigation, whereas the CG was treated with a standardized compression time of 180 s. Patients were followed up postoperatively for pain relief and facials to verify the reliability of the effect. We found that the mean compression time to numbness in the region innervated by the ophthalmic meridian (V1) was 89.09 ± 8.99 s; by V1 and the maxillary nerve (V2), 123.52 ± 7.97 s; and by V1, V2, and the mandibular nerve (V3), 181.33 ± 10.29 s. All 76 patients used to verify the effect had complete relief of pain, and the EG had significantly less numbness than the CG. In PBC, with the extension of balloon compression time, the numbness response of each branch of the trigeminal nerve appears in a certain order. This effect can guide PBC in mitigating complications while ensuring efficacy.

Exploring long-term outcomes following CyberKnife robotic radiosurgery for trigeminal neuralgia

Background and purposeRadiosurgery has been extensively studied for its efficacy and safety in the management of trigeminal neuralgia (TN). However, among the plethora of relevant studies in the literature, only a restricted number have been conducted targeting an elongated trigeminal nerve segment with the CyberKnife radiosurgery (CKRS) system. Herein, we report long-term clinical outcomes of TN patients treated with CKRS. Materials and methodsFifty patients treated with CKRS for medically refractory TN were analyzed. Pain response and sensory dysfunction post CKRS were assessed using the Barrow Neurological Institute (BNI) scale. Kaplan-Meier analysis was used to assess the maintenance of pain control and the risk of onset of facial numbness. The Cox proportional hazards regression model was employed for both univariate and multivariate analyses to identify predictive factors among the collected variables. ResultsThe median follow-up period was 63 months (range: 12–174 months). The median values of treated nerve volume, prescription dose, and integral dose were 59 mm3, 60 Gy and 3.9 mJ, respectively. Pain control (BNI I-III) was achieved in 37 patients (74%). Among them, the actuarial freedom from pain (FFP) rate was 82%, 78% and 74% at 24, 36 and beyond 48 months post-CKRS, respectively. A correlation of FFP rate with patient gender, treated nerve volume, and mean dose was revealed in multivariate analysis. Twenty-three patients (62%) reported onset of new or aggravation of pre-existing, facial numbness with twenty-one of them (57%) characterizing it as “mild facial numbness, not bothersome” (BNI-II) and two (5%) as “somewhat bothersome” (BNI-III). We did not encounter any case with very bothersome facial numbness (BNI-IV). ConclusionsLong-term results of this work contribute to the body of evidence supporting the safety and efficacy of CKRS in the treatment of TN patients, in view of excellent pain control for an acceptable toxicity profile.

Journey to the Centre of the Ovale: A Novel, Combined Percutaneous Fluoroscopic and Image-Guided Approach to Biopsy a Meckel's Cave Lesion

Abstract Introduction The percutaneous Hartel's technique is a well-described approach to targeting lesions in the Meckel's cave. It is used as the standard approach for all percutaneous trigeminal neuralgia procedures for accessing the Gasserian ganglion through the foramen ovale, be it for a balloon compression, glycerol rhizolysis, or radiofrequency ablation. It has also been described in the literature as an approach to biopsy lesions in the Meckel's cave and cavernous sinus using fluoroscopic guidance; however, there were a significant number of nondiagnostic samples. No one to date has described a combined fluoroscopic and image-guided approach to improve safety and accuracy. Methods The patient had a 3-month history of left-sided facial numbness and a left VIth palsy causing diplopia and a squint. The computed tomography of the chest, abdomen, and pelvis was unremarkable as were the serum tumor markers. We describe the novel approach of using a percutaneous biopsy needle to obtain a cytological sample of a Meckel's cave lesion using a combination of X-ray and electromagnetic image guidance with use of StealthStation S8 System (Medtronic Sofamor Danek, Memphis, Tennessee, United States). The need for a craniotomy and its associated morbidity and technical challenges was therefore obviated. Results The procedure was performed under general anesthesia and eight core samples were sent to neuropathology for analysis. The lesion was histologically confirmed to be lymphoma, and the patient subsequently received oncological treatment. The patient had no immediate or postoperative complications, and the use of the aforementioned combined approach improved safety and accuracy of targeting the lesion in real time. Conclusion A combined percutaneous fluoroscopic and image-guided approach to biopsy a Meckel's cave lesion is recommended, as it improves safety and accuracy.

Treatment of recurrent trigeminal neuralgia after microvascular decompression: How to select

BackgroundThis study aimed to investigate individualized treatment strategies and clinical outcomes in patients with recurrent trigeminal neuralgia after undergoing microvascular decompression (MVD). MethodsOne hundred forty-four patients with recurrent trigeminal neuralgia after MVD were retrospectively examined and grouped according to treatment. Surgical efficacy and pain recurrence were analyzed as outcomes. ResultsRepeat craniotomy was performed in 31 patients (21.5 %), percutaneous balloon compression (PBC) in 67 (46.5 %), and radiofrequency thermocoagulation (RFT) in 46 (32.0 %). Effectiveness did not differ among the three types of treatment (P = 0.052). The incidence of postoperative complications, including trigeminal nerve cardiac reflex, facial numbness, and mastication weakness, was lower in the craniotomy group than the PBC and RFT groups (P < 0.001). The 5-year pain recurrence rate was significantly higher than the 1-year rate in all groups. Although the 1-year pain recurrence rate did not differ among the groups, the 5-year rate was significantly lower in the repeat craniotomy group than the other groups (P < 0.001). ConclusionPatients with recurrent trigeminal neuralgia after MVD should be treated based on imaging evaluation and general condition. Repeat craniotomy, PBC, and RFT are all effective. Incidence of postoperative complications and long-term pain recurrence-free survival are superior for repeat craniotomy.

CT-guided radiofrequency ablation of facial and mandibular nerves in the treatment of compound Meige’s syndrome

This retrospective study examined the clinical outcomes and complications in 6 cases of compound Meige’s syndrome, presenting with blepharospasm and masticatory muscle spasm, following treatment with CT-guided radiofrequency ablation targeting bilateral facial nerves and mandibular branches of the trigeminal nerve. After the operation, the symptoms of eyelid spasm and masticatory muscle spasm resolved, but mild facial paralysis and numbness of mandibular nerve innervation persisted. Follow-up for 4–28 months showed that the symptoms of facial paralysis resolved within 2–5 (3.17 ± 0.94) months after the operation, whereas the numbness in the mandibular region persisted, accompanied by a decrease in masticatory function. During the follow-up period, none of the 6 patients experienced a recurrence of Meige’s syndrome. These findings suggest that CT-guided radiofrequency ablation of the bilateral facial nerve and mandibular branches of the trigeminal nerve may offer a promising approach to treating compound Meige’s syndrome.

Establishment of a Clinical Prediction Model Based on the Study of Risk Factors for Pain Recurrence after Percutaneous Radiofrequency Thermocoagulation in Patients with Primary Trigeminal Neuralgia

Objectives: This study aimed to investigate the follow-up outcomes and risk factors associated with pain recurrence after percutaneous radiofrequency thermocoagulation (PRT) among patients with primary trigeminal neuralgia (PTN) and to establish a clinical prediction model based on these risk factors. Methods: The data of PTN patients who underwent PRT were collected in our study. All subjects were randomly divided at a 7:3 ratio into a training group (T Group) and a test group (C Group) to select risk factors. According to the follow-up results, the patients were divided into a recurrence group (F Group) and a nonrecurrence group (NF Group). Predictive factors were selected through LASSO regression analysis based on T Group. The identified variables were subjected to multivariate logistic regression analysis to construct a nomogram. Receiver operating characteristic (ROC) curves and calibration curves were uesd to evaluate discrimination and calibration ability separately. Results: A total of 884 patients were initially included, 857 patients achieved satisfactory results, and the pain relief rate at discharge was 96.95%. A total of 529 subjects were included after screening, and the recurrence rate was 27.22% after 1 year. Six non-zero variables were selected through LASSO regression analysis: the disease course, atypical pain, previous surgery, facial numbness before PRT, neurovascular contact (NVC), and operation duration. Six variables were included in the multivariate logistic regression analysis, and the results showed that they were independent risk factors (P&lt;0.05). The predictive model is represented by a nomogram. The area under the curves (AUC) of the ROC curves were 0.868 (0.826~0.909) and 0.874 (0.802~0.950) for T Group and C Group, respectively. The prediction curves for T Group (P=0.784) and C Group (P=0.293) fit the ideal prediction curve, and the Brier scores were 0.120 and 0.099 for T Group and C Group, which indicates that the probability predicted by the model is consistent with the actual occurrence. Conclusion: The Pain relief rate at discharge was 96.95% for PTN patients after PRT, and the recurrence rate was 27.22% after 1 year. The disease course, atypical pain, previous surgery, facial numbness before PRT, NVC, and operation duration are independent risk factors for the recurrence of pain. A nomogram model for pain recurrence was established, which has good predictive ability.

Efficacy and safety of microvascular decompression with or without partial sensory rhizotomy: a comprehensive meta-analysis and systematic review in treating trigeminal neuralgia.

Classical trigeminal neuralgia (TN), caused by vascular compression of the nerve root, is a severe cause of pain with a considerable impact on a patient's quality of life. While microvascular decompression (MVD) has lower recurrence rates when compared with partial sensory rhizotomy (PSR) alone, refractoriness can still be as high as 47%. We aimed to assess the efficacy and safety profile of MVD + PSR when compared to standalone MVD for TN. We searched Medline, Embase, and Web of Science following PRISMA guidelines. Eligible studies included those with ≥ 4 patients, in English, published between January 1980 and December 2023, comparing MVD vs. MVD + PSR for TN. Endpoints were pain cure, immediate post-operative pain improvement, long-term effectiveness, long-term recurrence, and complications (facial numbness, hearing loss, and intracranial bleeding). We pooled odds ratios (OR) with 95% confidence intervals with a random-effects model. I2 was used to assess heterogeneity, and sensitivity and Baujat analysis were conducted to address high heterogeneity. Eight studies were included, comprising a total of 1,338 patients, of whom 1,011 were treated with MVD and 327 with MVD + PSR. Pain cure analysis revealed a lower likelihood of pain cure in patients treated with MVD when compared to patients treated with MVD + PSR (OR = 0.30, 95% CI: 0.13 to 0.72). Immediate postoperative pain improvement assessment revealed a lower likelihood of improvement in the MVD group when compared with the MVD + PSR group (OR = 0.31, 95% CI: 0.10 to 0.95). Facial numbness assessment revealed a lower likelihood of occurrence in MVD alone when compared to MVD + PSR (OR = 0.08, 95% CI: 0.04 to 0.15). Long-term effectiveness, long-term recurrence, hearing loss, and intracranial bleeding analyses revealed no difference between both approaches. Our meta-analysis identified that MVD + PSR was superior to MVD for pain cure and immediate postoperative pain improvement for treating TN. However, MVD + PSR demonstrated a higher likelihood of facial numbness complications. Furthermore, identified that hearing loss and intracranial bleeding complications appear comparable between the two treatments, and no difference between long-term effectiveness and recurrence.