Vascular compression in trigeminal neuralgia discloses trigeminal root somatotopic organization

Abstract BACKGROUND AND IMPORTANCE: To report on a single case of arteriovenous micromalformation (micro-AVM) of the trigeminal root that was diagnosed during microvascular decompression for trigeminal neuralgia with the use of indocyanine green (ICG) videoangiography. CLINICAL PRESENTATION: A 52-year-old woman with drug-resistant trigeminal neuralgia underwent a key hole suboccipital cerebellopontine angle exploration after the usual magnetic resonance imaging (MRI) screening had raised the suspicion of a vascular compression. In surgery, the petrosal vein was found to be bigger than usual and arterialized; the trigeminal root was embedded in a tangle of abnormal arterialized vessels. Intraoperative ICG videoangiography showed that the direction of flow in the arterialized petrosal vein was anterograde, thus allowing for the differential diagnosis between micro-AVM and tentorial dural fistula. It was possible to achieve only a partial nerve decompression because of the intimate relationship between the trigeminal root and the pathological vessels. Postoperative angiography and MRI with contrast administration confirmed the intraoperative diagnosis of micro-AVM. The patient was discharged neurologically intact on postoperative day 4. One month after surgery, she remains pain-free despite a 50% reduction in antiepileptic drugs. CONCLUSION: Surgeons performing microvascular decompression should be aware that a diagnosis of vascular compression based on MRI without contrast administration could not exclude the presence of a pontine micro-AVM. ICG videoangiography provides an elegant means of showing the flow dynamics of these pathological vessels. An MRI protocol that is suitable to avoid this kind of intraoperative drawback should be defined and systematically used in the preoperative evaluation of all such surgical candidates.

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Topography of the pain in classical trigeminal neuralgia: insights into somatotopic organization

Brain ◽

10.1093/brain/awz407 ◽

2020 ◽

Vol 143 (2) ◽

pp. 531-540 ◽

Cited By ~ 6

Author(s):

Marc Sindou ◽

Andrei Brinzeu

Keyword(s):

Trigeminal Neuralgia ◽

Odds Ratio ◽

The Other ◽

Fisher Exact Test ◽

Vascular Compression ◽

Lateral Direction ◽

Exact Test ◽

Somatotopic Organization ◽

Classical Trigeminal Neuralgia ◽

Pain Patients

Abstract Trigeminal neuralgia is defined by its clinical characteristics of paroxysmal unilateral facial pain in a well-defined territory. Distribution of the pain may be in one or several of the cutaneous and/or mucous territories of the three divisions with V2 pain being the most frequent territory followed by V3 and V1. Factors determining the distribution of pain have not yet been systematically investigated. It is now well recognized that vascular compression factor is a predominant aetiology of classical trigeminal neuralgia. In this study we aimed to find whether there is a relation between the location of the vascular compression and the peripheral distribution of the pain. Patients with classical trigeminal neuralgia in whom microvascular decompression was performed were included. Data recorded pertained to the nature of the conflict, its degree and, most importantly, location around the root: supero-median, supero-lateral or inferior. Equally, clinical data for the distribution of pain were recorded. Most of the patients 318 (89.3%) had the compression coming from above, i.e. 220 (61.7%) had compression from a supero-medial direction and 98 (27.5%) from a supero-lateral direction; inferior compression was present in 38 patients (10.7%). Distribution of the pain was significantly different according to the location of the conflict (P = 0.0005, Fisher Exact test). Odds ratios were computed for each location of compression and painful territory involved. According to the overall distribution of pain, patients with supero-medial compression had an odds ratio of 2.7 [95% confidence interval (CI) 1.66–4.41] of manifesting with V1 pain. Conversely V3 pain was less likely to occur with supero-median compression than the other types of pain (odds ratio 0.53, 95% CI 0.34–0.83). Inferior compression on the other hand was more likely to manifest with V3 pain with an odds ratio of 2.56 (95% CI 1.21–5.45). Overall V2 pain had an odds ratio close to 1 regardless of the type of compression. These findings suggest an association between the location of the neurovascular conflict with its resulting insult and the distribution of pain supporting a somatotopic view of the organization of the trigeminal root and a role of the conflict in the clinical manifestation of trigeminal neuralgia.

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Operative Findings and Outcomes of Microvascular Decompression for Trigeminal Neuralgia in 35 Patients Affected by Multiple Sclerosis

Neurosurgery ◽

10.1227/01.neu.0000137656.59536.0e ◽

2004 ◽

Vol 55 (4) ◽

pp. 830-839 ◽

Cited By ~ 92

Author(s):

Giovanni Broggi ◽

Paolo Ferroli ◽

Angelo Franzini ◽

Vittoria Nazzi ◽

Laura Farina ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Trigeminal Neuralgia ◽

Vascular Compression ◽

Causative Role ◽

Resonance Imaging ◽

Root Entry Zone ◽

Trigeminal Root

Abstract OBJECTIVE: The concept of vascular compression of the trigeminal root as the main etiological factor in idiopathic trigeminal neuralgia has achieved widespread acceptance, and microvascular decompression (MVD) is a well-established surgical procedure for its treatment. Multiple sclerosis (MS) has long been considered to be an absolute contraindication to MVD because of the supposed exclusive causative role of a demyelinating lesion affecting the trigeminal root entry zone. Magnetic resonance imaging preoperative identification of suspicious vessels along the cisternal course of the trigeminal nerve in MS patients raises the question of a possible causative role of vascular compression in MS patients. METHODS: We describe magnetic resonance imaging findings, surgical findings, and outcomes in 35 MS patients who underwent MVD for medically intractable trigeminal neuralgia. Results were assessed by clinical follow-up and periodic phone surveys. The mean follow-up was 44 months (range, 6–108 mo). RESULTS: Magnetic resonance imaging revealed the presence of demyelinating lesions affecting the brainstem trigeminal pathways of the painful side in 26 (74%) of 35 patients. During surgery, severe neurovascular compression at the trigeminal root entry zone was found in 16 (46%) of 35 patients. The long-term outcome was excellent in 39%, good in 14%, fair in 8%, and poor in 39% of patients. No statistically significant prognostic factor predicting good outcome could be found. There was no mortality, with a 2.5% long-term morbidity rate (facial nerve palsy in one patient). CONCLUSION: Results of MVD in trigeminal neuralgia MS patients are much less satisfactory than in the idiopathic group, indicating that central mechanisms play a major role in pain genesis.

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Trigeminal root compression for trigeminal neuralgia in patients with no vascular compression

Acta Neurochirurgica ◽

10.1007/s00701-014-2300-9 ◽

2015 ◽

Vol 157 (2) ◽

pp. 323-327 ◽

Cited By ~ 13

Author(s):

Jian Cheng ◽

Ding Lei ◽

Heng Zhang ◽

Ke Mao

Keyword(s):

Trigeminal Neuralgia ◽

Vascular Compression ◽

Trigeminal Root

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Central Demyelination in the Pathogenesis of Trigeminal Neuralgia Associated With Cerebellopontine Angle Tumors

Neurosurgery ◽

10.1227/01.neu.0000367550.30165.a7 ◽

2010 ◽

Vol 66 (4) ◽

pp. E841-E842 ◽

Cited By ~ 10

Author(s):

Alfonso Lagares ◽

Juan José Rivas ◽

Luis Jiménez ◽

Marta Cicuendez ◽

Carlos Avendaño

Keyword(s):

Trigeminal Neuralgia ◽

Cerebellopontine Angle ◽

Inflammatory Cells ◽

Complete Relief ◽

Vascular Compression ◽

Compression Injury ◽

Epidermoid Tumor ◽

Central Demyelination ◽

Trigeminal Root ◽

The Right

Abstract OBJECTIVE To describe the surgical and ultrastructural findings in the trigeminal root of a patient with trigeminal neuralgia (TN) associated with a cerebellopontine epidermoid tumor, and to relate these to literature reports of patients with vascular compression–related TN. CLINICAL PRESENTATION A 39-year-old woman presented with right TN. She had a 10-year history of lancinating pain paroxysms in the second and third trigeminal branches. Pain exhibited trigger areas and improved partially with carbamazepine. Cranial magnetic resonance imaging revealed an epidermoid tumor in the right cerebellopontine angle that distorted and compressed the right trigeminal root. TECHNIQUE The tumor was resected. At operation, the trigeminal root appeared distorted and compressed by the tumor. A small partial rhizotomy was performed, and the biopsy was processed for ultrastructural study. Complete relief of the symptoms was achieved with no deficits after the procedure. Pathologic changes in the biopsy included axonal loss, demyelination, and the presence of abundant collagen infiltrates and myelin debris. No inflammatory cells were present. In some areas, myelin-denuded axons were in close apposition, allowing the presence of axon-to-axon interactions. These findings are similar to others described previously regarding patients with vascular compression–related TN. CONCLUSION Compression injury to the trigeminal root leading to demyelination is a major determinant in the pathogenesis of TN.

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Preoperative MRI characteristics and short-term postoperative outcomes of microvascular decompression in trigeminal neuralgia with no vascular compression

Minerva Anestesiologica ◽

10.23736/s0375-9393.19.14099-0 ◽

2020 ◽

Vol 86 (3) ◽

Author(s):

Zitang Ma ◽

Yong Zhang ◽

Leilei Yu ◽

Hui Zhang ◽

Xiuzhen Zhao ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Postoperative Outcomes ◽

Vascular Compression ◽

Short Term ◽

Mri Characteristics

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Efficacy of Internal Neurolysis for Trigeminal Neuralgia without Vascular Compression

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0041-1723809 ◽

2021 ◽

Author(s):

Ming-Wu Li ◽

Xiao-feng Jiang ◽

Chaoshi Niu

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Chart Review ◽

Vascular Compression ◽

Internal Neurolysis ◽

Facial Numbness ◽

Relief Rate

Abstract Background and Objective Trigeminal neuralgia is a common neurologic disease that seriously impacts a patient's quality of life. We retrospectively investigated the efficacy and safety of internal neurolysis (nerve combing) for trigeminal neuralgia without vascular compression. Patients and Methods This study was a retrospective review of all patients with trigeminal neuralgia who were admitted between January 2014 and February 2019. A subgroup of 36 patients had no vascular compression at surgery and underwent internal neurolysis. Chart review and postoperative follow-up were performed to assess the overall outcomes of internal neurolysis. Results Thirty-six patients were identified, with a mean age of 44.89 ± 7.90 (rang: 31–65) years and a disease duration of 5.19 ± 2.61 years. The immediate postoperative pain relief (Barrow Neurological Institute [BNI] pain score of I or II) rate was 100%. The medium- to long-term pain relief rate was 91.7%. Three patients experienced recurrence. Facial numbness was the primary postoperative complication. Four patients with a score of III on the BNI numbness scale immediately after surgery had marked improvement at 6 months. No serious complications occurred. Conclusion Internal neurolysis is a safe and effective treatment for trigeminal neuralgia without vascular compression or clear responsible vessels.

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Targeting the cranial nerve: microradiosurgery for trigeminal neuralgia with CISS and 3D-Flash MR imaging sequences

Journal of Neurosurgery ◽

10.3171/jns.2005.102.s_supplement.0107 ◽

2005 ◽

Vol 102 ◽

pp. 107-110 ◽

Cited By ~ 13

Author(s):

Vasilios A. Zerris ◽

Georg C. Noren ◽

William A. Shucart ◽

Jeff Rogg ◽

Gerhard M. Friehs

Keyword(s):

Mr Imaging ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Trigeminal Nerve ◽

Cranial Nerve ◽

Fusion Imaging ◽

Vascular Compression ◽

Content Type ◽

History Of ◽

Fine Print

Object.The authors undertook a study to identify magnetic resonance (MR) imaging techniques that can be used reliably during gamma knife surgery (GKS) to identify the trigeminal nerve, surrounding vasculature, and areas of compression.Methods.Preoperative visualization of the trigeminal nerve and surrounding vasculature as well as targeting the area of vascular compression may increase the effectiveness of GKS for trigeminal neuralgia. During the past years our gamma knife centers have researched different MR imaging sequences with regard to their ability to visualize cranial nerves and vascular structures. Constructive interference in steady-state (CISS) fusion imaging with three-dimensional gradient echo sequences (3D-Flash) was found to be of greatest value in the authors' 25 most recent patients.In 24 (96%) out of the 25 patients, the fifth cranial nerve, surrounding vessels, and areas of compression could be reliably identified using CISS/3D-Flash. The MR images were acceptable despite patients' history of microvascular decompression, radiofrequency (RF) ablation, or concomitant disease. In one of 25 patients with a history of multiple RF lesions, the visualization was inadequate due to severe trigeminal nerve atrophy.Conclusions.The CISS/3D-Flash fusion imaging has become the preferred imaging method at the authors' institutions during GKS for trigeminal neuralgia. It affords the best visualization of the trigeminal nerve, surrounding vasculature, and the precise location of vascular compression.

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Comparison of Clinical Symptoms and Magnetic Resonance Angiographic (MRA) Results in Patients with Trigeminal Neuralgia and Persistent Idiopathic Facial Pain. Medium-Term Outcome after Microvascular Decompression of Cases with Positive MRA Findings

Cephalalgia ◽

10.1111/j.1468-2982.2005.01030.x ◽

2006 ◽

Vol 26 (3) ◽

pp. 266-276 ◽

Cited By ~ 41

Author(s):

A Kuncz ◽

E Vörös ◽

P Barzó ◽

J Tajti ◽

P Milassin ◽

...

Keyword(s):

Magnetic Resonance ◽

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Facial Pain ◽

Clinical Symptoms ◽

Vascular Compression ◽

Term Outcome ◽

Persistent Idiopathic Facial Pain ◽

Venous Compression ◽

Imaging Results

To evaluate whether NC could be demonstrated preoperatively, high-resolution magnetic resonance angiography (MRA) was performed in 287 consecutive patients with TN and persistent idiopathic facial pain (PIFP) on a 0.5-T and a 1-T MR unit. Depending on the clinical symptoms, the TN cases were divided into typical TN and trigeminal neuralgia with non-neuralgic interparoxysmal pain (TNWIP) groups. Microvascular decompression (MVD) was performed in 103 of the MRA-positive cases. The patients were followed up postoperatively for from 1 to 10 years. The clinical symptoms were compared with the imaging results. The value of MRA was assessed on the basis of the clinical symptoms and surgical findings. The outcome of MVD was graded as excellent, good or poor. The clinical symptoms were compared with the type of vascular compression and the outcome of MVD. The MRA image was positive in 161 (56%) of the 287 cases. There were significant differences between the clinical groups: 66.5% of the typical TN group, 47.5% of the TNWIP group and 3.4% of the PIFP group were positive. The quality of the MR unit significantly determined the ratio of positive/negative MRA results. The surgical findings corresponded with the MRA images. Six patients from the MRA-negative group were operated on for selective rhizotomy and no NC was found. Venous compression of the trigeminal nerve was observed in a significantly higher proportion in the background of TNWIP than in that of typical TN on MRA imaging (24.1% and 0.8%, respectively) and also during MVD (31.2% and 1.2%, respectively). Four years following the MVD, 69% of the patients gave an excellent, 23% a good and 8% a poor result. The rate of some kind of recurrence of pain was 20% in the typical TN and 44% in TNWIP group. The rate of recurrence was 57% when pure venous compression was present. The only patient who was operated on from the PIFP group did not react to the MVD. The clinical symptoms and preoperative MRA performed by at least a 1-T MR unit furnish considerable information, which can play a role in the planning of the treatment of TN.

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