Trigeminal Neuralgia from an Arteriovenous Malformation of the Trigeminal Root Entry Zone with a Flow-Related Feeding Artery Aneurysm: The Role of a Combined Endovascular and “Tailored” Surgical Treatment

✓ A new tool in neurophysiological exploration of the trigeminal nerve has recently been introduced. It has been demonstrated that stimulation of the infraorbital nerve trunk gives rise to very reliable scalp responses reflecting the activity of the afferent pathway between the maxillary nerve and the brain stem. The authors demonstrate that alterations of such trigeminal evoked responses fit with documented pathological processes at various locations along the trigeminal pathway (maxillary sinus, parasellar region, and within the brainstem parenchyma). They report the findings in 68 patients suffering from “idiopathic” trigeminal neuralgia. Alterations of the response were detected in 33 cases, suggesting that some damage of the nerve had taken place either at the root entry zone into the pons (23 cases) or slightly distal to it (10 cases). Such results support the hypothesis that trigeminal neuralgia may be due to a compression of the trigeminal root at the pons entry zone.

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Gamma Knife Radiosurgery on the Trigeminal Root Entry Zone for Idiopathic Trigeminal Neuralgia: Results and a Review of the Literature

Yonsei Medical Journal ◽

10.3349/ymj.2020.61.2.111 ◽

2020 ◽

Vol 61 (2) ◽

pp. 111 ◽

Cited By ~ 2

Author(s):

So Hee Park ◽

Jin Woo Chang

Keyword(s):

Trigeminal Neuralgia ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Review Of The Literature ◽

Entry Zone ◽

Root Entry Zone ◽

Idiopathic Trigeminal Neuralgia ◽

Trigeminal Root

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Cluster Headache-Like Pain in Multiple Sclerosis

Cephalalgia ◽

10.1046/j.1468-2982.1999.019008732.x ◽

1999 ◽

Vol 19 (8) ◽

pp. 732-734 ◽

Cited By ~ 25

Author(s):

M Leandri ◽

G Craccu ◽

A Gottlieb

Keyword(s):

Multiple Sclerosis ◽

Trigeminal Neuralgia ◽

Cluster Headache ◽

Evoked Potentials ◽

Simultaneous Occurrence ◽

Entry Zone ◽

Root Entry Zone ◽

Trigeminal Root

We describe a case with simultaneous occurrence of cluster headache-like pain and multiple sclerosis. Both neuroimaging and neurophysiology (trigeminal evoked potentials) revealed a demyelination plaque in the pons, at the trigeminal root entry zone, on the side of pain. Although that type of lesion is usually associated with trigeminal neuralgia pain, we hypothesize that in this case it may be linked with the concomitant cluster headache, possibly by activation of trigemino-vascular mechanisms.

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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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A 10-year experience in the treatment of trigeminal neuralgia

Journal of Neurosurgery ◽

10.3171/jns.1982.57.6.0757 ◽

1982 ◽

Vol 57 (6) ◽

pp. 757-764 ◽

Cited By ~ 123

Author(s):

Harry van Loveren ◽

John M. Tew ◽

Jeffrey T. Keller ◽

Mary A. Nurre

Keyword(s):

Trigeminal Neuralgia ◽

Neurovascular Compression ◽

Entry Zone ◽

Content Type ◽

Root Entry Zone ◽

Significant Difference ◽

Technical Advances ◽

Trigeminal Root ◽

Fine Print

✓ Of 1000 patients with classic trigeminal neuralgia who were treated during the last 10 years, 90% had an initial favorable response to medical therapy, but 75% (750 patients) failed to achieve satisfactory long-term relief. Of these, 700 patients were treated by percutaneous stereotaxic rhizotomy (PSR) and 50 were selected for posterior fossa exploration (PFE). Of the 50 patients undergoing PFE, 82% had neurovascular contact at the trigeminal root entry zone, but only 46% were judged to have had significant neurovascular compression. Exploration was negative in 16% of patients and revealed neural compression by bone in 2%. Patients with neurovascular compression were treated by microvascular decompression (MVD); all other patients with exploratory surgery underwent partial sensory rhizotomy. At 3 years after PFE, 84% of patients are pain-free. Results are excellent in 68%, good in 12%, fair in 4%; 12% had a recurrence of their neuralgia. The 700 patients treated by PSR have been followed for 6 years. Results are excellent in 61%, good in 13%, fair in 5%, and poor in 1%; 20% had a recurrence. This study indicates that there is no significant difference in results between PSR and PFE in the treatment of trigeminal neuralgia. The concept that neurovascular compression is a mechanical factor in the etiology of trigeminal neuralgia was supported, but neurovascular compression was less common than previously reported. Percutaneous stereotaxic rhizotomy is a less formidable procedure than PFE, and is easily repeated. Recent technical advances have improved the results obtained with PSR. Therefore, PSR remains the procedure of choice for the majority of patients with trigeminal neuralgia.

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TRIGEMINAL NEURALGIA

The Professional Medical Journal ◽

10.29309/tpmj/2005.12.04.5091 ◽

2005 ◽

Vol 12 (04) ◽

pp. 408-411

Author(s):

SHAHZAD SHAMS ◽

FARHAN SHAHZAD BUTT

Keyword(s):

Trigeminal Neuralgia ◽

Recurrence Rate ◽

Cranial Nerve ◽

Superior Cerebellar Artery ◽

Entry Zone ◽

Root Entry Zone ◽

Cerebellar Artery ◽

Trigeminal Root ◽

Lancinating Pain ◽

Vascular Decompression

Objectives: trigeminal Neuralgia is a severe lancinating pain and isassociated with conflict between a vessel and 5th cranial nerve. Micro vascular Decompression (MVD) of the nerverelieves this pain. Material & Methods: We reviewed 60 patients who underwent MVD for medically intractabletrigeminal neuralgia. The outcome of procedure was assessed retrospectively. Results: Preoperative symptoms rangedfrom 3 months to 10 years. Right side of face was affected in 32 and left in 28 patients. Mandibular division (21.6%)was the most commonly involved branch for referred pain. Superior cerebellar artery was the commonest offendingvessel in 86.6% of cases. Trigeminal root entry zone location (70%) was the commonest site of conflict. Postoperativepain relief showed excellent results in 86.6%, good in 10.0% and poor in 3.4%. Recurrence rate was 1.5% per year.Conclusion: MVD is safe, effective and treatment of choice for trigeminal neuralgia.

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Glial Plasticity in the Trigeminal Root Entry Zone of a Rat Trigeminal Neuralgia Animal Model

Neurochemical Research ◽

10.1007/s11064-019-02824-2 ◽

2019 ◽

Vol 44 (8) ◽

pp. 1893-1902 ◽

Cited By ~ 4

Author(s):

DaoShu Luo ◽

Ren Lin ◽

LiLi Luo ◽

QiuHua Li ◽

Ting Chen ◽

...

Keyword(s):

Animal Model ◽

Trigeminal Neuralgia ◽

Entry Zone ◽

Root Entry Zone ◽

Trigeminal Root

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Trigeminal Neuralgia and Multiple Sclerosis: A Historical Perspective

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.196 ◽

2017 ◽

Vol 44 (5) ◽

pp. 589-593 ◽

Cited By ~ 3

Author(s):

David B. Burkholder ◽

Peter J. Koehler ◽

Christopher J. Boes

Keyword(s):

Multiple Sclerosis ◽

Trigeminal Neuralgia ◽

English Language ◽

Language Translation ◽

Original Text ◽

Entry Zone ◽

Root Entry Zone ◽

Trigeminal Root ◽

Early English ◽

Hermann Oppenheim

AbstractTrigeminal neuralgia (TN) associated with multiple sclerosis (MS) was first described in Lehrbuch der Nervenkrankheiten für Ärzte und Studirende in 1894 by Hermann Oppenheim, including a pathologic description of trigeminal root entry zone demyelination. Early English-language translations in 1900 and 1904 did not so explicitly state this association compared with the German editions. The 1911 English-language translation described a more direct association. Other later descriptions were clinical with few pathologic reports, often referencing Oppenheim but citing the 1905 German or 1911 English editions of Lehrbuch. This discrepancy in part may be due to the translation differences of the original text.

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Microvascular Relations of the Trigeminal Nerve: An Anatomical Study

Neurosurgery ◽

10.1227/00006123-198610000-00007 ◽

1986 ◽

Vol 19 (4) ◽

pp. 535-539 ◽

Cited By ~ 42

Author(s):

Boris Klun ◽

Borut Prestor

Keyword(s):

Trigeminal Neuralgia ◽

Anatomical Study ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Marked Contrast ◽

Entry Zone ◽

Root Entry Zone ◽

Cerebellar Artery ◽

History Of ◽

Trigeminal Root

Abstract The neurovascular relationships in the trigeminal root entry zone were studied in 130 trigeminal root entry zones of 65 cadavers. No history of facial or trigeminal pain had been obtained during life in these subjects. The technique of intravascular injection, which allowed good visualization and evaluation of the neurovascular relationships, is described. A total of 42 examples of contact with the root entry zone and 10 examples of compression were identified. In 30 of the examples of contact, the finding could be related to an artery; in the other examples, it appeared to be due to veins. Of the arterial compressions, the superior cerebellar artery was responsible in 53.8%, the anterior inferior cerebellar artery was responsible in 25.6%, and pontine branches of the basilar artery were responsible for the remaining 20.6%. Only one instance of unequivocal compression by a vein was found. Other anatomical observations of interest are reported. The absence of a history of trigeminal neuralgia in the 7% of examined nerves in which root entry zone showed arterial compression is in marked contrast to the finding of 80% or more in the operative series for trigeminal neuralgia. It seems that vascular compressions may be the predominant but not the sole cause of trigeminal neuralgia.

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Intrinsic Arteriovenous Malformation of the Trigeminal Nerve in a Patient with Trigeminal Neuralgia: Case Report

Neurosurgery ◽

10.1227/01.neu.0000143147.57383.aa ◽

2004 ◽

Vol 55 (6) ◽

pp. E1445-E1449 ◽

Cited By ~ 21

Author(s):

Hiroshi Karibe ◽

Reizo Shirane ◽

Hidefumi Jokura ◽

Takashi Yoshimoto

Keyword(s):

Trigeminal Neuralgia ◽

Arteriovenous Malformation ◽

Trigeminal Nerve ◽

Three Dimensional ◽

Vascular Lesion ◽

Superior Cerebellar Artery ◽

Entry Zone ◽

Root Entry Zone ◽

Cerebellar Artery ◽

Offending Artery

Abstract OBJECTIVE AND IMPORTANCE: Intrinsic arteriovenous malformation (AVM) of the trigeminal nerve is extremely uncommon and may be associated with trigeminal neuralgia. CLINICAL PRESENTATION: A 55-year-old man experienced severe lightning pain in the second and third divisions of the left trigeminal nerve territory. Vertebral angiography demonstrated an AVM fed by the superior cerebellar artery. Magnetic resonance imaging with three-dimensional spoiled gradient recalled acquisition at steady state revealed an AVM intrinsic to the left trigeminal nerve and a small arterial loop causing compression at the root entry zone of the trigeminal nerve. INTERVENTION: Intraoperative inspection revealed an indentation of the root entry zone caused by a small arterial loop but not by the AVM. The offending artery was displaced to decompress the root entry zone using a prosthesis without resection of the AVM. The patient was relieved of the neuralgia immediately after surgery without further neurological deficit. He has been free of trigeminal neuralgia during a follow-up period of 2 years and is scheduled to undergo stereotactic radiosurgery for the treatment of the AVM. CONCLUSION: Intrinsic AVM of the trigeminal nerve may cause trigeminal neuralgia. However, as in the present case, a coexistent vascular lesion rather than the intrinsic AVM could be a cause of the neuralgia.

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