Right medium-sized vestibular schwannoma with trigeminal neuralgia post-fractionated radiotherapy

A patient with trigeminal neuralgia secondary to a vestibular schwannoma underwent fractionated radiotherapy without relief of her pain. She was then effectively treated with microsurgical resection of her tumor. Early identification of the lower cranial nerves and the origin of the facial and vestibulocochlear nerves is key to determining the operative corridors for vestibular schwannoma resection. To effectively treat trigeminal neuralgia, the trigeminal nerve root entry zone and motor branch are clearly identified and decompressed. Fractioned radiotherapy does not effectively treat trigeminal neuralgia secondary to vestibular schwannoma compression. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21112

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VARIANT INTRANEURAL VEIN-TRIGEMINAL NERVE RELATIONSHIPS

Neurosurgery ◽

10.1227/01.neu.0000351757.29658.c0 ◽

2009 ◽

Vol 65 (5) ◽

pp. 958-961 ◽

Cited By ~ 18

Author(s):

Gregory M. Helbig ◽

James D. Callahan ◽

Aaron A. Cohen-Gadol

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Complication Rates ◽

Entry Zone ◽

Root Entry Zone ◽

Detailed Classification ◽

Trigeminal Nerve Root

Abstract OBJECTIVE Trigeminal neuralgia is often caused by compression, demyelination, and injury of the trigeminal nerve root entry zone by an adjacent artery and/or vein. Previously described variations of the nerve-vessel relationship note external nerve compression. We offer a detailed classification of intraneural vessels that travel through the trigeminal nerve and safe, effective surgical management. CLINICAL PRESENTATION We report 3 microvascular decompression operations for medically refractory trigeminal neuralgia during which the surgeon encountered a vein crossing through the trigeminal nerve. Two types of intraneural veins are described: type 1, in which the vein travels between the motor and sensory branches of the trigeminal nerve (1 patient), and type 2, in which the vein bisects the sensory branch (portio major) (2 patients). INTERVENTION We recommend sacrificing the intraneural vein between the motor and sensory branches if the vein is small (most likely type 1). If the intraneural vein is large and bisects the sensory branch (most likely type 2), vein mobilization can be achieved, but often requires extensive dissection through the nerve. Because this maneuver may lead to trigeminal nerve injury and result in uncomfortable neuropathy and numbness (including corneal hypoesthesia), we recommend against mobilization of the vein through the nerve, suggesting instead, consideration of a selective trigeminal nerve rhizotomy. CONCLUSION Because aggressive dissection of intraneural vessels can lead to higher than normal complication rates, preoperative knowledge of vein-trigeminal nerve variants is crucial for intraoperative success.

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Microvascular relations of the trigeminal nerve

Journal of Neurosurgery ◽

10.3171/jns.1980.52.3.0381 ◽

1980 ◽

Vol 52 (3) ◽

pp. 381-386 ◽

Cited By ~ 123

Author(s):

Stephen J. Haines ◽

Peter J. Jannetta ◽

David S. Zorub

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Facial Pain ◽

Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Venous Compression ◽

Trigeminal Nerve Root ◽

Trigeminal Nerves ◽

Fine Print

✓ The vascular relationships of the trigeminal nerve root entry zone were examined bilaterally in 20 cadavers of individuals known to be free of facial pain. Fourteen of 40 nerves made contact with an artery, but only four of these showed evidence of compression or distortion of the nerve. In addition, the vascular relationships of 40 trigeminal nerves exposed surgically for treatment of trigeminal neuralgia were studied, and 31 nerves showed compression by adjacent arteries. Venous compression was seen in four of the cadaver nerves and in eight nerves from patients with trigeminal neuralgia. These data support the hypothesis that arterial compression of the trigeminal nerve is associated with trigeminal neuralgia.

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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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Basilar artery dolichoectasia an unusual and rare cause of secondary trigeminal neuralgia: a clinical report

Brazilian Dental Science ◽

10.14295/bds.2021.v24i1.2273 ◽

2020 ◽

Vol 24 (1) ◽

Author(s):

Zafar Ali Khan Ali Khan ◽

Shammas Raza Khan Raza Khan ◽

Tariq Mehmood ◽

Chaudhary Umar Asghar ◽

Naseer Ahmed

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Basilar Artery ◽

Nerve Root ◽

Neurological Deficits ◽

Clinical Report ◽

Entry Zone ◽

Root Entry Zone ◽

Trigeminal Nerve Root ◽

Corneal Reflex

Objective: Patients with Trigeminal Neuralgia often consults a dentist for relief of their symptoms as the pain seems to be arising from teeth and allied oral structures. Basilar artery Dolichoectasia is an unusual and very rare cause of secondary Trigeminal Neuralgia as it compresses the Trigeminal nerve Root Entry Zone. Case reports: We report three cases of Trigeminal Neuralgia caused by Basilar artery Dolichoectasia compression. The corneal reflex was found absent in all three of the cases along with mild neurological deficits in one case. Multiplanar T1/T2W images through the brain disclosed an aberrant, cirsoid (S-shaped) and torturous Dolichoectasia of basilar artery offending the Trigeminal nerve Root Entry Zone. Discussion: Based on these findings we propose a protocol for general dentist for diagnosis of patients with trigeminal neuralgia and timely exclusion of secondary intracranial causes. Conclusion: General dentists and oral surgeons ought to consider this diagnosis in patients presenting with chronic facial pain especially pain mimicking neuralgia with loss of corneal reflex or other neurosensory deficit on the face along with nighttime pain episodes. Timely and accurate diagnosis and prompt referral to a concerned specialist can have an enormous impact on patient survival rate in such cases. KEYWORDS Basilar artery; Cirsoid dolichoectasia; Corneal reflex; Trigeminal neuralgia.

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Microvascular decompression for trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/jns.1982.57.4.0487 ◽

1982 ◽

Vol 57 (4) ◽

pp. 487-490 ◽

Cited By ~ 33

Author(s):

Robert Breeze ◽

Ronald J. Ignelzi

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Late Recurrence ◽

Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Early Success ◽

Trigeminal Nerve Root ◽

Fine Print

✓ Fifty-one consecutive patients with trigeminal neuralgia underwent 52 procedures for microvascular decompression of the trigeminal nerve root entry zone. There was an 85% early success rate; however, after a longer follow-up period, a 13% late recurrence rate was found. In all, 60% of the patients experienced some form of complication, but in only 23% was the complication persistent.

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Neurovascular relationships of the root entry zone of lower cranial nerves: A microsurgical anatomic study in fresh cadavers

British Journal of Neurosurgery ◽

10.3109/02688699109002861 ◽

1991 ◽

Vol 5 (4) ◽

pp. 349-356 ◽

Cited By ~ 8

Author(s):

R. Murali ◽

Mathew J. Chandy ◽

Vedantam Rajshekhar

Keyword(s):

Cranial Nerves ◽

Anatomic Study ◽

Entry Zone ◽

Root Entry Zone ◽

Lower Cranial Nerves

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Trigeminal neuralgia caused by microarteriovenous malformations of the trigeminal nerve root entry zone: symptomatic relief following complete excision of the lesion with nerve root preservation

Journal of Neurosurgery ◽

10.3171/jns.2002.97.4.0874 ◽

2002 ◽

Vol 97 (4) ◽

pp. 874-880 ◽

Cited By ~ 38

Author(s):

Richard J. Edwards ◽

Yvonne Clarke ◽

Shelley A. Renowden ◽

Hugh B. Coakham

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Nerve Root ◽

Preoperative Imaging ◽

Posterior Fossa Surgery ◽

Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Trigeminal Nerve Root ◽

Fine Print

Object. Within a series of 341 consecutive patients who underwent posterior fossa surgery for trigeminal neuralgia (TN), in five the cause was found to be a microarteriovenous malformation (micro-AVM) located in the region of the trigeminal nerve root entry zone (REZ). The surgical management and clinical outcomes of these cases are presented. Methods. Patients were identified from a prospectively collected database of all cases of TN treated at one institution between 1980 and 2000. Presentation was clinically indistinguishable from TN caused by vascular compression. Preoperative imaging, including computerized tomography scanning (two cases) and magnetic resonance (MR) imaging and MR angiography (three cases), failed to demonstrate an AVM except for one case in which multiple abnormal vessels were identified in the trigeminal REZ on an MR image obtained using a 1.5-tesla magnet. All patients underwent a standard retromastoid craniotomy. In all cases a small AVM embedded in the trigeminal REZ was identified and completely excised, with preservation of the trigeminal nerve. All patients experienced immediate relief of pain following surgery. Postoperatively, in one patient a small pontine hematoma developed, resulting in permanent trigeminal nerve anesthesia in the V2 and V3 divisions. All patients were free from pain at a mean follow-up period of 30 months. Conclusions. These rare lesions are usually angiographically occult, but may sometimes be identifiable on high-resolution MR images. Total microsurgical resection with nerve preservation is possible, although operative complications are relatively common, reflecting the intimate association between these lesions and the pons. Complete resection is advised not only for symptom relief, but also to eliminate the theoretical risk of pontine hemorrhage.

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Pathophysiology of trigeminal neuralgia: new evidence from a trigeminal ganglion intraoperative microneurographic recording

Journal of Neurosurgery ◽

10.3171/jns.2004.101.5.0872 ◽

2004 ◽

Vol 101 (5) ◽

pp. 872-873 ◽

Cited By ~ 23

Author(s):

Kim J. Burchiel ◽

Thomas K. Baumann

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Ganglion ◽

Physiological Mechanism ◽

Vascular Compression ◽

Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Trigeminal Ganglion Neurons ◽

Ganglion Neurons ◽

New Evidence

✓ The origin of trigeminal neuralgia (TN) appears to be vascular compression of the trigeminal nerve at the root entry zone; however, the physiological mechanism of this disorder remains uncertain. The authors obtained intraoperative microneurographic recordings from trigeminal ganglion neurons in a patient with TN immediately before percutaneous radiofrequency-induced gangliolysis. Their findings are consistent with the idea that the pain of TN is generated, at least in part, by an abnormal discharge within the peripheral nervous system.

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