Percutaneous radiofrequency treatment of the gasserian ganglion for trigeminal neuralgia complicated by trochlear nerve palsy: a case report

BackgroundTrigeminal neuralgia (TN) has the highest incidence of disorders causing facial pain. TN is provoked by benign stimuli, like shaving, leading to severe, short-lasting pain. Patients are initially treated using antiepileptic drugs; however, multiple invasive options are available when conservative treatment proves insufficient. Percutaneous radiofrequency treatment of the trigeminal, or gasserian, ganglion (RF-G) is a procedure regularly used in refractory patients with comorbidities. RF-G involves complex needle maneuvering to perform selective radiofrequency heat treatment of the affected divisions. We present a unique case of cranial nerve 4 (CN4) paralysis after RF-G.Case presentationA male patient in his 60s presented with sharp left-sided facial pain and was diagnosed with TN, attributed to the maxillary and mandibular divisions. MRI showed a vascular loop of the anterior inferior cerebellar artery without interference of the trigeminal complex. The patient opted for RF-G after inadequate conservative therapy. The procedure was performed by an experienced pain physician and guided by live fluoroscopy. The patient was discharged without problems but examined the following day for double vision. Postprocedural MRI showed enhanced signaling between the trigeminal complex and the brainstem. Palsy of CN4 was identified by a neurologist, and spontaneous recovery followed 5 months after the procedure.ConclusionsMention of postprocedural diplopia in guidelines is brief, and the exact incidence remains unknown. Different mechanisms for cranial nerve (CN) palsy have been postulated: incorrect technique, anatomical variations, and secondary heat injury. We observed postprocedural hemorrhage and hypothesized that bleeding might be a contributing factor in injury of CNs after RF-G.

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Teflon bridge technique for endoscopic-assisted microvascular decompression of ectatic basilar artery and anterior inferior cerebellar artery for trigeminal neuralgia: operative video and technical nuances

Neurosurgical Focus: Video ◽

10.3171/2020.7.focvid2032 ◽

2020 ◽

Vol 3 (2) ◽

pp. V5

Author(s):

James K. Liu ◽

Asif Shafiq

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Basilar Artery ◽

Microvascular Decompression ◽

Facial Pain ◽

Anterior Inferior Cerebellar Artery ◽

Safe Alternative ◽

Entry Zone ◽

Root Entry Zone ◽

Cerebellar Artery

In this illustrative operative video, the authors demonstrate a Teflon bridge technique to achieve safe transposition of a large, tortuous ectatic basilar artery (BA) and anterior inferior cerebellar artery (AICA) complex to decompress the root entry zone (REZ) of the trigeminal nerve in a 61-year-old woman with refractory trigeminal neuralgia via an endoscopic-assisted retractorless microvascular decompression. Postoperatively, the patient experienced immediate facial pain relief without requiring further medications. The Teflon bridge technique can be a safe alternative to sling techniques when working in narrow surgical corridors between delicate nerves and vessels. The operative technique and surgical nuances are demonstrated.The video can be found here: https://youtu.be/hIHX7EvZc1c

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Controlled thermocoagulation of trigeminal ganglion and rootlets for differential destruction of pain fibers

Journal of Neurosurgery ◽

10.3171/jns.1974.40.2.0143 ◽

1974 ◽

Vol 40 (2) ◽

pp. 143-156 ◽

Cited By ~ 447

Author(s):

William H. Sweet ◽

James G. Wepsic

Keyword(s):

Trigeminal Neuralgia ◽

Facial Pain ◽

Electrical Heating ◽

Gasserian Ganglion ◽

Foramen Ovale ◽

Content Type ◽

Corneal Scarring ◽

Radiofrequency Heating ◽

Neurological Morbidity ◽

Fine Print

✓ The authors report their experience in the treatment of trigeminal neuralgia with controlled increments of radiofrequency heating from an electrode placed in the Gasserian ganglion or its posterior rootlets. Touch is preserved in some or all of a trigeminal zone rendered analgesic. The electrode tip is introduced through the foramen ovale and placed among the desired rootlets with the help of a combination of radiographs and the conscious patient's response to electrical stimulation with a square wave signal and gentle electrical heating. The degree of heat is measured by a thermister at the electrode tip. The patient's cooperation is maintained by the use of the neurolept anesthetic Innovar and the production of brief unconsciousness for the painful parts of the operation by methohexital (Brevital). Of 274 patients with facial pain so treated, 214 had trigeminal neuralgia; 91% of the latter group experienced relief of pain and 125 followed for 2½ to 6 years had a recurrence rate of 22%. In a total of 353 procedures, there has been no mortality and no neurological morbidity outside the trigeminal nerve. Only six of the patients with trigeminal neuralgia have complained significantly of postoperative paresthesias. The most serious undesired result has been the production of an anesthetic cornea in 28 patients, one of whom lost the sight of one eye due to corneal scarring. Correlating findings in our patients with those in studies by other authors, we conclude that the preservation of some touch is due to resistance to heating by the heavily myelinated A-beta fibers.

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Evaluation of the Relationship Between the Internal Acoustic Canal Anatomy and Loops of the Anterior Inferior Cerebellar Artery Using 3-Tesla Magnetic Resonance Imaging

Iranian Journal of Radiology ◽

10.5812/iranjradiol.112305 ◽

2021 ◽

Vol 18 (4) ◽

Author(s):

Murat Bayav ◽

Murat Sahin

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Anatomical Variations ◽

3 Tesla ◽

Anterior Inferior Cerebellar Artery ◽

Resonance Imaging ◽

Cerebellar Artery ◽

The Relationship ◽

Internal Acoustic Canal ◽

Vascular Loop

Background: Anatomical variations in vascular structures are frequently encountered. In the cerebellopontine region, anatomical variations, especially variations in the anterior inferior cerebellar artery (AICA) in relation to cranial nerves passing through the internal acoustic canal (IAC), are common. Magnetic resonance imaging (MRI) provides detailed information for the evaluation of the cerebellopontine region and the IAC anatomy. Objectives: This study aimed to examine the relationship between the IAC anatomy and AICA loop variations and to investigate the frequency of anatomical variations and its correlation with demographic variables. Patients and Methods: In this study, 253 patients (age > 18 years), who underwent 3-Tesla MRI of the temporal bone between July 2019 and December 2019, were retrospectively evaluated. The exclusion criteria were images of poor diagnostic quality due to technical or patient-related reasons and the presence of a localized tumor that could disrupt the IAC. Four patients were excluded from the study because they had tumors related to IAC. The AICA variations were categorized according to the Chavda classification. The IAC size, canal diameter, canal length, and meatus width were measured, and the canals were characterized as cylindrical, funnel-shaped, and bud-shaped. Results: A total of 249 patients were included in this study. The Chavda type I vascular loop was the most common type on both sides. The mean size measurements of IACs were significantly higher in the group of vascular loops compared to the group without vascular loops. The presence of a vascular loop was significantly more common in funnel- and bud-shaped IACs compared to cylindrical IAC. Also, there was a negative correlation between the patient’s age and all IAC dimensions. Conclusion: The results of the present study showed that the AICA loop variations were closely related to the size and shape of the IAC.

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CPA Epidermoid Cyst with Rare Anatomic Variant: Anterior Inferior Cerebellar Artery Embedded in the Subarcuate Fossa: Operative Video and Technical Nuances

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1675165 ◽

2018 ◽

Vol 80 (S 03) ◽

pp. S323-S324

Author(s):

Carlos Candanedo ◽

Sergey Spektor

Keyword(s):

Trigeminal Neuralgia ◽

Epidermoid Cyst ◽

Abducens Nerve ◽

Residual Tumor ◽

Benign Tumors ◽

Anterior Inferior Cerebellar Artery ◽

Surgical Removal ◽

Anatomical Variant ◽

Cerebellar Artery ◽

Subarcuate Artery

Intracranial epidermoid cysts are considered benign tumors with a good general prognosis; however, their radical removal, including tumor capsule, is associated with significant morbidity, especially when the capsule is attached to neurovascular structures. We show an operative video describing main steps and surgical nuances in the resection of a large right cerebellopontine angle (CPA) epidermoid cyst in a 42-year-old male patient who presented with intractable trigeminal neuralgia. Craniectomy was performed to exposure the transverse-sigmoid sinus junction. A mold for a polymethylmethacrylate (PMMA) bone flap was built before opening the dura to avoid potentially neurotoxic effects on the cerebellum. The video illustrates the management of the rare anatomical variant of the anterior inferior cerebellar artery (AICA). Its loop was embedded in the dura, covering the subarcuate fossa where it gives off the subarcuate artery. Near total removal of the epidermoid cyst was achieved, leaving only a tiny capsule remnant adhering to the abducens nerve. Postoperatively the patient's trigeminal neuralgia was fully relieved and medications were discontinued. The patient's hearing was preserved per audiometry at the preoperative level (Gardner–Robertson II). Postoperative magnetic resonance imaging (MRI) revealed no signs of residual tumor. In this case, it was not possible to obtain optimal surgical exposure of the CPA without handling a rare anatomical anomaly of the AICA in the dura of the subarcuate fossa, which demanded coagulation and transection of the subarcuate artery and transposition of AICA with the dural cuff. This manipulation enabled optimal surgical removal of the epidermoid and didn't cause any neurological deficit.The link to the video can be found at: https://youtu.be/lLZqBHlu-uA.

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Trigeminal Neuralgia Due to Anterior Inferior Cerebellar Artery Loop: A Case Report

Journal of Child Neurology ◽

10.1177/0883073809332403 ◽

2009 ◽

Vol 24 (8) ◽

pp. 989-990

Author(s):

Roshan Koul ◽

Amna Alfutaisi ◽

Rajeev Jain ◽

Faisal Alzri

Keyword(s):

Case Report ◽

Trigeminal Neuralgia ◽

Anterior Inferior Cerebellar Artery ◽

Cerebellar Artery

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Microvascular Decompression by Interposition Method for Treatment of Trigeminal Neuralgia Due to Vertebrobasilar Dolichoectasia: A Retrospective Single-Center Study

10.21203/rs.3.rs-1180077/v1 ◽

2021 ◽

Author(s):

Feng Yu ◽

Jia Yin ◽

Pei-gang Lu ◽

Zhen-yu Zhao ◽

Yong-qiang Zhang ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Long Term Results ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Symptom Duration ◽

Free Survival ◽

Kaplan Meier ◽

Vertebrobasilar Dolichoectasia ◽

Cerebellar Artery

Abstract Trigeminal neuralgia (TN) due to vertebrobasilar dolichoectasia (VBD) is a rare disease that can be challenging to treat. The objectives of this study are to investigate the characteristics of patients with TN due to VBD and to analyze the efficacy of microvascular decompression (MVD) by the interposition method for treatment of the condition. From 2010 till 2020, the data of 30 patients with TN due to VBD who were treated with MVD by the interposition method were analyzed retrospectively. The characteristics of the patients were compared with those of patients with non-VBD TN (n = 815). Kaplan–Meier survival analysis was performed to determine pain-free survival. The 30 patients (21 males, 9 females; mean age, 63.03 years) accounted for 3.55% of all patients with TN during the study period. In 30 patients, the offending vessel was the basilar artery (BA) in 1 patient, the vertebral artery (VA) in 6 patients, the VA plus the superior cerebellar artery (SCA) in 6 patients, the VA plus the anterior inferior cerebellar artery (AICA) in 12 patients, and the VA+SCA+AICA in 5 patients. Compared to non-VBD TN patients, those with TN due to VBD were significantly more likely to be male, to have TN of the left side, and to have hypertension (all P < 0.001). Mean age at surgery (P = 0.057) and symptom duration (P = 0.308) were comparable between the two groups. All 30 patients had immediate relief of facial pain after MVD and could stop medication. There were no postoperative complications. Over mean follow-up of 76.67 months, 3 patients had recurrence. The mean duration of pain-free survival was 70.77 months. In conclusions, TN due to VBD appears to be more likely in males, in those with hypertension, and to involve the left side. The interposition method performed by experienced and skilled neurosurgeons is a safe and effective treatment for TN due to VBD. Further studies are needed to analyze the associated long-term results and the pain recurrence rate among this special population.

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Radiofrequency Thermocoagulation Through Foramen Rotundum Versus Foramen Ovale for the Treatment of V2 Trigeminal Neuralgia

January 2018 - Pain Physician ◽

10.36076/ppj/2019.22.e609 ◽

2019 ◽

Vol 6 (22;6) ◽

pp. E609-E614

Author(s):

Cong-yang Yan

Keyword(s):

Trigeminal Neuralgia ◽

Facial Pain ◽

Operation Time ◽

Controlled Clinical Trial ◽

Gasserian Ganglion ◽

Internal Opening ◽

Foramen Ovale ◽

Maxillary Nerve ◽

Radiofrequency Thermocoagulation ◽

Foramen Rotundum

Background: Percutaneous radiofrequency thermocoagulation through the foramen rotundum (FR) is a new approach for the treatment of V2 trigeminal neuralgia (TN). Objectives: This study aimed to compare the efficacy and safety of the FR approach with that of the foramen ovale (FO) approach. Study Design: Nonrandomized controlled clinical trial. Setting: The study was conducted at Huaian Hospital of Huaian City, Huaian, China. Methods: From July 2014 to December 2016, 80 consecutive patients with V2 TN were prospectively assigned into the FO group (n = 40) or the FR group (n = 40). All radiofrequency thermocoagulation procedures were performed under the guidance of digital subtraction angiography (DSA). Patients in the FO group were treated with Gasserian ganglion ablation through the Hartel approach. Patients in the FR group received ablation of the maxillary nerve at the internal opening of the FR. Facial pain was evaluated using the Visual Analog Scale preoperatively and postoperatively at 1 week, 6 months, and 1 year. Results: All surgical procedures were successfully completed using DSA guidance. The FR group had no facial pain at postoperative 1 week, 6 months, and 1 year. The facial fain was not relieved in 4 patients of the FO group. They were treated with radiofrequency thermocoagulation of the maxillary nerve through the FR and maintained painless at postoperative 1 week, 6 months, and 1 year. At postoperative 1 year, another 3 patients relapsed in the FO group. The incidences of facial numbness and swelling did not differ significantly between the 2 groups (all P > 0.05). There was no postoperative corneal involvement or masticatory weakness in the FR group. However, corneal involvement and masticatory weakness occurred postoperatively in 22 (55%) patients and 31 (77.5%) patients in the FO group. The FR group had significantly shorter operation time than the FO group (19.3 ± 5.9 vs. 32.7 ± 8.7 minutes; P < 0.05). Limitations: We were unable to avoid the V1 and V3 branches, despite multiple adjustments of the needed position in 35 of the 40 patients in this group. Conclusions: For the treatment of V2 TN, thermocoagulation of the maxillary nerve through the FR had better efficacy and fewer complications in comparison with the Gasserian ganglion ablation through the FO

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Radiofrequency Thermoablation of the Gasserian Ganglion Versus the Peripheral Branches of the Trigeminal Nerve for Treatment of Trigeminal Neuralgia: A Randomized, Control Trial

January 2018 - Pain Physician ◽

10.36076/ppj/2019.22.147 ◽

2019 ◽

Vol 2 (22.2) ◽

pp. 147-154

Author(s):

Neerja Bharti

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Facial Pain ◽

Control Group ◽

Study Group ◽

Gasserian Ganglion ◽

Idiopathic Trigeminal Neuralgia ◽

Radiofrequency Thermoablation

Background: Trigeminal neuralgia is the most painful condition of facial pain leading to impairment of routine activities. Although radiofrequency thermoablation (RFT) of the Gasserian ganglion is widely used for the treatment of idiopathic trigeminal neuralgia in patients having ineffective pain relief with medical therapy, the incidence of complications like hypoesthesia, neuroparalytic keratitis, and masticatory muscles weakness is high. Recent case reports have shown the effectiveness of RFT of the peripheral branches of the trigeminal nerve for relief of refractory chronic facial pain conditions including trigeminal neuralgia. Objectives: This study was conducted to compare the efficacy and safety of RFT of the peripheral branches of the trigeminal nerve with RFT of the Gasserian ganglion for the management of idiopathic trigeminal neuralgia. Study Design: Prospective, randomized, observer-blinded, clinical trial. Setting: Tertiary care hospital and medical education and research institute. Methods: A total of 40 adult patients of idiopathic trigeminal neuralgia were randomly allocated into 2 groups. The control group received RFT of the Gasserian ganglion while the study group received RFT of the peripheral branches of trigeminal nerve. The procedures were performed in the operation room under all aseptic precautions with fluoroscopic guidance. Post-procedure, the patients were assessed for loss of sensation along the nerve distribution and the adequacy of pain relief on the Numerical Rating Scale (NRS). The patients were followed up for 3 month to assess the quality of pain relief by the NRS and the Barrow Neurological Institute (BNI) pain intensity scale. Improvement in pain was considered excellent if patients had complete pain relief without any medication, good if there was significant reduction in pain (> 50%) with or without medication, and poor if there was less than 50% reduction in pain with medications. Patients were also assessed for numbness and any other side effects. Patients’ satisfaction with the procedure was recorded. Results: Nineteen patients in the control group and 18 in study group had effective pain relief of up to 3 months. Their pain scores were comparable at all time intervals, though the number of patients receiving supplementary medications was more in study group at 2 months (P = 0.015). The patients showed overall satisfaction score of 8.5 (8-9) and 8 (7-9) in control and study groups respectively. The average procedure duration was 30 (30-38) minutes in the control group and 28 (25-40) minutes in the study group. Most of the patients in both groups had mild numbness after the procedure. One patient in the control group had lower eyelid swelling and another had mild weakness of the masseter muscle, which resolved few days later. No major complication was reported in the study group except for 1 patient who reported local ecchymosis. Limitations: The main limitation of the study is that the patients and the investigator performing the procedure were not blinded, though the person who assessed the patient during follow-up was blinded to the group assignment. Another limitation is that we could not follow up with the patients after 3 months due to time constraints. Conclusion: We found that radiofrequency thermoablation of the peripheral branches of the trigeminal nerve is an effective and safe procedure for the management of idiopathic trigeminal neuralgia. Key words: Idiopathic trigeminal neuralgia, radiofrequency thermoablation, Gasserian ganglion, peripheral nerve branches, pain, trigeminal nerve

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Microvascular Decompression for Trigeminal Neuralgia: Our Experiences at Bir Hospital

Nepal Journal of Neuroscience ◽

10.3126/njn.v14i2.19697 ◽

2017 ◽

Vol 14 (2) ◽

pp. 3-7

Author(s):

Gopal R Sharma ◽

Rajiv Jha ◽

Prakash Poudel ◽

Dhrub R Adhikari ◽

Prakash Bista

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Medical Treatment ◽

Treatment Options ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Recurrent Pain ◽

Cerebellar Artery

Trigeminal neuralgia (TGN) is a very peculiar disease, mostly characterized by unilateral paroxysmal facial pain, often described by patient as ‘one of the worst pain in my life’. This condition is also known as ‘Tic Douloureus’. The annual incidence of TN is about 4.7/100000 population, male and female are equally affected. The diagnosis is usually made by history, clinical fi ndings and cranial imaging is required to rule out compressing vascular loop, organic lesions and Multiple Sclerosis (MS) at Trigeminal nerve (TN). Treatment of TGN ranged from medical to surgical intervention. Between September 2007 and April 2015, 20 patients underwent micro vascular decompression (MVD) of TN for TGN who were refractory to medical treatment at department of Neurosurgery, Bir Hospital. All decompressions were performed using operating microscope. Follow up period ranged from 22 months to 8 years.There were 9 males and 11 females and age ranged from 30-70 years. The neuralgic pain was localized on right side in 13 patients and left on 7 patients. Pain distribution was on V3 (mandibular branch) dermatome in 11, V2( Maxillary branch ) in 4, V2-3 in 2 and V1- 2-3 in 3 patients respectively. On intraoperative fi ndings TN was compressed by superior cerebellar artery ( SCA ) in 8, tumors in 4, unidentifi ed vessels in 3, veins in 2, anterior inferior cerebellar artery ( AICA ) in 1 and no cause was found in 2 patients. 7 patients suffered postoperative complications which included hyposthesia in 3, pseudomeningocele in 3 and meningitis in 1. There was no mortality in this series. 20 patients felt pain relief immediately after procedure and 1 patients came after 3 years with recurrent pain requiring second surgery. In conclusion, MVD for TGN in younger patients who are refractory to medical treatment is one of the best treatment options which is safe and long term pain relief is achieved in majority of cases.Nepal Journal of Neuroscience, Vol. 14, No. 2, 2017 Page:11-15

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Vascular Transposition of the Superior Cerebellar Artery Using a Fenestrated Clip and Fibrin Glue in Trigeminal Neuralgia: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz291 ◽

2019 ◽

Vol 19 (1) ◽

pp. E50-E51 ◽

Cited By ~ 3

Author(s):

Karl R Abi-Aad ◽

Evelyn Turcotte ◽

Devi P Patra ◽

Matthew E Welz ◽

Tanmoy Maiti ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Fibrin Glue ◽

Trigeminal Nerve ◽

Facial Pain ◽

Superior Cerebellar Artery ◽

Entry Zone ◽

Root Entry Zone ◽

Cerebellar Artery ◽

Trigeminal Nerve Root ◽

Made In

Abstract This is the case of an 86-yr-old gentleman who presented with left facial pain exacerbated by eating, drinking, chewing, and shaving (distribution: V2, V3). The patient was diagnosed with trigeminal neuralgia and was refractory to medications. Imaging showed a superior cerebellar artery (SCA) loop adjacent to the trigeminal nerve root entry zone and a decision to perform a microvascular decompression of the fifth nerve was presented to the patient. After patient informed consent was obtained, a standard 3 cm × 3 cm retrosigmoid craniotomy was performed with the patient in a supine head turned position and in reverse Trendelenburg. The arachnoid bands tethering the SCA to the trigeminal nerve were sharply divided. A slit was then made in the tentorium and a 3 mm fenestrated clip was then used to secure the transposed SCA away from the trigeminal nerve. The SCA proximal to this was slightly patulous in its course so a small amount of a fibrin glue was also used to secure the more proximal SCA to the tentorium. The patient was symptom-free postoperatively and no longer required medical therapy. Additionally, imaging was consistent with adequate separation of the nerve from adjacent vessels.1-5

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