Successful Endovascular Treatment of Trigeminal Neuralgia Caused by a Carotid-Cavernous Fistula: Case Report

Context: Dural arteriovenous fistulas (DAVFs) of the cavernous sinus are arteriovenous connections located in the dura mater leaflets of this region. DAVFs usually present with ocular symptoms such as diplopia, conjunctival hyperemia, involvement of cranial nerves III/IV/VI, etc. Trigeminal neuralgia caused by a cavernous DAVF is rare, being reported only three times in the literature. Case report: A 46-year-old female smoker sought care with a complaint of multiple daily episodes of shock-like right temporal headache and facial pain in the V1/V2 dermatomes, of 2 years’ duration. A clinical diagnosis of trigeminal neuralgia was established. Magnetic resonance (MR) imaging of the brain and MR angiography of the cerebral and cervical vessels were both normal. Conservative treatment and balloon compression of the trigeminal ganglion were ineffective. Therefore, we chose to perform an angiography for diagnostic clarification, which demonstrated a DAVF of the right cavernous sinus, fed by branches of the external carotid artery. We decided to catheterize the fistula and complete obliteration was achieved. Soon after the procedure the patient reported pain relief. At 3-month follow-up the patient remained pain free and required no analgesia. Conclusion: Trigeminal neuralgia caused by a cavernous DAVF is rare. The fistula in this case was only diagnosed after an angiography was performed, so clinicians must be aware that not all vascular conditions can be identified non invasively, and that cavernous DAVFs may be an underdiagnosed cause of trigeminal neuralgia.

Download Full-text

Successful Endovascular Treatment of Trigeminal Neuralgia Caused by a CarotidCavernous Fistula: Case Report

Surgical Case Reports ◽

10.31487/j.scr.2020.07.09 ◽

2020 ◽

pp. 1-4

Author(s):

Luciano Manzato ◽

Paulo M. Mesquita Filho ◽

Octavio Karam ◽

Victor E. Angeliero ◽

...

Keyword(s):

Case Report ◽

Trigeminal Neuralgia ◽

Endovascular Treatment ◽

World Literature ◽

Cranial Nerves ◽

Conjunctival Injection ◽

Arteriovenous Fistulas ◽

Fourth Report ◽

The World ◽

Dural Arteriovenous Fistulas

Dural arteriovenous fistulas (DAVFs) of the cavernous sinus are arteriovenous connections located in the dura mater leaflets of this region. The usual presentation of a DAVF is predominantly ocular, with symptoms such as diplopia, conjunctival injection, involvement of cranial nerves III/IV/VI, exophthalmos, and chemosis. Trigeminal neuralgia caused by a cavernous DAVF is extremely rare. To the best our knowledge, this is only the fourth report in the world literature. We describe the case of a patient treated by embolization in whom the only presenting symptom of DAVF was trigeminal neuralgia. After endovascular treatment, the patient became asymptomatic.

Download Full-text

Cavernous Sinus Meningioma: Tumor Decompression for Trigeminal Neuralgia and Anterior Tibial Artery Graft High-Flow Bypass for Brain Ischemia: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab185 ◽

2021 ◽

Author(s):

Zeeshan Qazi ◽

Sneha Chitra Balasubramanian ◽

Josh Abecassis ◽

Juan P Carrasco Hernandez ◽

Varadaraya S Shenoy ◽

...

Keyword(s):

Carotid Artery ◽

Trigeminal Neuralgia ◽

Cavernous Sinus ◽

External Carotid Artery ◽

High Flow ◽

External Carotid ◽

Anterior Tibial Artery ◽

Tibial Artery ◽

Artery Graft ◽

Anterior Tibial

Abstract A 62-yr-old man with left cavernous sinus tumor presented with atypical trigeminal neuralgia refractory to medical treatment. He received Gamma Knife (Elekta) radiation for the tumor. However, the facial pain worsened after radiation. Neuropsychological testing done for memory problems had revealed mild neurocognitive disorder. Neurological examination showed trigeminal distribution numbness and partial abducens nerve paralysis. Imaging revealed an enhancing left cavernous sinus and supra-cavernous mass. Angiography revealed severe stenosis of the left cavernous internal carotid artery (ICA). Computed tomography (CT) perfusion study showed diminished blood flow on the left side, and ischemic changes were seen in fluid-attenuated inversion-recovery (FLAIR) magnetic resonance imaging (MRI). Surgical resection of the tumor was preferred over ablative treatment for trigeminal neuralgia because of its effectiveness in improving cranial nerve (CN) function.1 The patient underwent staged surgeries. In the first stage, the tumor was partially excised with decompression of the trigeminal ganglion and nerve root in the lateral cavernous sinus wall, Meckel's cave. Postoperatively, MR angiography revealed worsening of the left ICA caliber. Therefore, a high-flow bypass from the external carotid artery to the middle cerebral artery (MCA) was performed with an anterior tibial artery graft. The patient recovered initially but developed enterococcus meningitis postoperatively, which was promptly identified and treated with antibiotics. At 1-yr follow-up, the graft was patent, and the patient had significant relief of his facial pain and cognitively improved. This 2-dimensional video demonstrates the technique of partial excision of cavernous sinus meningioma with CN decompression, and the technique of a high-flow bypass from the external carotid artery to M2 MCA segment using an anterior tibial artery graft. The patient gave informed consent for surgery and video recording. All relevant patient identifiers have been removed from the video and accompanying radiology slides.

Download Full-text

The role of radiosurgery and particulate embolization in the treatment of dural arteriovenous fistulas

Journal of Neurosurgery ◽

10.3171/jns.1996.84.5.0804 ◽

1996 ◽

Vol 84 (5) ◽

pp. 804-809 ◽

Cited By ~ 88

Author(s):

Michael J. Link ◽

Robert J. Coffey ◽

Douglas A. Nichols ◽

Deborah A. Gorman

Keyword(s):

Latency Period ◽

Venous Drainage ◽

External Carotid Artery ◽

External Carotid ◽

Content Type ◽

Arteriovenous Fistulas ◽

Ocular Symptoms ◽

Dural Arteriovenous Fistulas ◽

Feeding Vessels ◽

Cortical Venous Drainage

✓ Over the past 5 years 29 patients with dural arteriovenous fistulas (AVFs) were treated by the authors using the Leksell radiosurgical gamma knife unit. Within 2 days after radiosurgery, 17 patients with AVFs that exhibited retrograde pial or cortical venous drainage (12 patients) and/or produced intractable bruit (eight patients) underwent particulate embolization of external carotid feeding vessels. The rationale for this treatment strategy was that radiosurgery was expected to cause obliteration of most fistulas after 12 to 36 months. In patients with bruit, ocular symptoms, or in those at risk for hemorrhage, treatment with embolization after radiosurgery kept the fistulas angiographically visible for radiosurgical targeting yet offered palliation of symptoms and temporary, partial protection from hemorrhage during the latency period. In 12 patients, preobliteration embolization immediately reduced (10 patients) or eliminated (two patients) retrograde pial venous drainage. To date, no lesion has hemorrhaged after treatment. Angiography 1 to 3 years posttreatment in 18 patients showed total obliteration of 13 fistulas (72%) and partial obliteration of five (28%). Radiosurgery, followed by embolization when retrograde pial venous drainage, intractable bruit, and/or major external carotid artery supply is present, appears to be a promising treatment for selected patients with symptomatic dural AVFs.

Download Full-text

Dural arteriovenous fistulas of the cavernous sinus - clinical case and treatment

Romanian Neurosurgery ◽

10.2478/romneu-2014-0018 ◽

2014 ◽

Vol 21 (2) ◽

pp. 169-174

Author(s):

A. Chiriac ◽

N. Dobrin ◽

St.M. Iencean ◽

I. Poeata

Keyword(s):

Carotid Artery ◽

Endovascular Treatment ◽

Cavernous Sinus ◽

Clinical Case ◽

Dural Arteriovenous Fistula ◽

Clinical Symptoms ◽

External Carotid Artery ◽

External Carotid ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas

Abstract The purpose of our article is to present the results of our treatment of dural arteriovenous fistula of the cavernous sinus by glue embolization of the external carotid artery feeders. By this case presentation we try to clarify the clinical course, with the dural carotid cavernous fistula (CCF), characterizing a pallet of symptoms, paying special attention to radiological finding and endovascular treatment. Dural arteriovenous fistulas represent 10% to 15% of all intracranial arteriovenous malformations (A. Fox, G. Duckwiler, “Dural Arteriovenous Fistula,” presented at the annual meeting of the American Society of Neuroradiology, St Louis, Mo, June 1992). Dural arteriovenous fistulas are rare clinical situation, especially examples involving the cavernous sinus. Most dural fistulas are acquired conditions, typically occurring in postmenopausal women, but sometimes in other patients in association with other condition [1,3]. These dural fistulas are most often “spontaneous” cavernous carotid shunts (usually low-flow) [2, 4, 5], usually related to a past trauma or surgery. The classical triad, represented by pulsating exophthalmos, conjunctival chemosis, and pulsatile-tinnitus are well-known clinical symptoms of these lesions but are not necessary present in the majority of the patients as first indicators. The anatomy of these vascular malformations consists of multiple arterial feeders flowing into cavernous sinus. The arterial feeders are usually meningeal branches arising from the internal carotid artery (ICA) or the external carotid artery (ECA). However, there are few reports of large series [1], and the clinical entity is not widely known. The purpose of this paper is to present a clinical case of a patient with dural cavernous sinus fistulae, clarify the clinical symptoms course and special attention to results of endovascular treatment.

Download Full-text

Gamma Knife surgery for low-flow cavernous sinus dural arteriovenous fistulas

Journal of Neurosurgery ◽

10.3171/2010.8.gks10977 ◽

2010 ◽

Vol 113 (Special_Supplement) ◽

pp. 21-27 ◽

Cited By ~ 5

Author(s):

Hyun Ho Jung ◽

Jong Hee Chang ◽

Kum Whang ◽

Jin Soo Pyen ◽

Jin Woo Chang ◽

...

Keyword(s):

Gamma Knife ◽

Cavernous Sinus ◽

Transarterial Embolization ◽

Gamma Knife Surgery ◽

Low Flow ◽

Close Monitoring ◽

Arteriovenous Fistulas ◽

Ocular Symptoms ◽

Dural Arteriovenous Fistulas

Object The purpose of this study was to assess the efficacy of Gamma Knife surgery (GKS) for treating cavernous sinus dural arteriovenous fistulas (CSDAVFs). Methods Of the 4123 GKSs performed between May 1992 and March 2009, 890 procedures were undertaken to treat vascular lesions. In 24 cases, the vascular lesion that was treated was a dural arteriovenous fistula, and in 6 of these cases, the lesion involved the cavernous sinus. One of these 6 cases was lost to follow-up, leaving the other 5 cases (4 women and 1 man) to comprise the subjects of this study. All 5 patients had more than 1 ocular symptom, such as ptosis, chemosis, proptosis, and extraocular movement palsy. In all patients, CSDAVF was confirmed by conventional angiography. Three patients were treated by GKS alone and 2 patients were treated by GKS combined with transarterial embolization. The median follow-up period after GKS in these 5 cases was 30 months (range 9–59 months). Results All patients experienced clinical improvement, and their improvement in ocular symptoms was noticed at a mean of 17.6 weeks after GKS (range 4–24 weeks). Two patients received embolization prior to GKS but did not display improvement in ocular symptoms. An average of 20 weeks (range 12–24 weeks) was needed for complete improvement in clinical symptoms. There were no treatment-related complications during the follow-up period. Conclusions Gamma Knife surgery should be considered as a primary, combined, or additional treatment option for CSDAVF in selected cases, such as when the lesion is a low-flow shunt without cortical venous drainage. For those selected cases, GKS alone may suffice as the primary treatment method when combined with close monitoring of ocular symptoms and intraocular pressure.

Download Full-text

Recurrent keratoconjunctivitis as the sole manifestation of COVID-19 infection: A case report

European Journal of Ophthalmology ◽

10.1177/11206721211006583 ◽

2021 ◽

pp. 112067212110065

Author(s):

Satria Audi Hutama ◽

Firas Farisi Alkaff ◽

Ryan Enast Intan ◽

Citra Dewi Maharani ◽

Luki Indriaswati ◽

...

Keyword(s):

Case Report ◽

Foreign Body ◽

Foreign Body Sensation ◽

Polymerase Chain Reaction Test ◽

Nasopharyngeal Swab ◽

Conjunctival Hyperemia ◽

Blurred Vision ◽

Ocular Symptoms ◽

Body Sensation ◽

Fluorescence Test

Introduction: Ocular symptoms are uncommon manifestations of coronavirus disease 2019 (COVID-19) infection. Earlier study reported that dry eye, blurred vision, foreign body sensation, tearing, itching, conjunctival secretion, conjunctival congestion, ocular pain, and photophobia are among the ocular symptoms that could be found in COVID-19 patients. However, there are only a few reports available regarding corneal involvement in this disease. Here we report a case of keratoconjunctivitis as the only symptom of COVID-19 infection. Case description: A 27-year-old man who worked as an obstetrics and gynecology resident came to the outpatient clinic with the chief complaints of eye discomfort, foreign body sensation, conjunctival hyperemia, lacrimation, and photophobia in his right eye for the past 3 weeks. Fluorescence test showed a small corneal lesion. The patient was then diagnosed with keratoconjunctivitis. A week after the treatment, all symptoms were resolved. A month later, the patient came to the emergency room with the same eye complaints but with a more severe pain. The fluorescence test showed wider corneal lesion compared to last month. The result from the corneal swab is negative for bacterial or fungal infection, indicating a viral infection. Afterwards, reverse transcriptase polymerase chain reaction test from nasopharyngeal swab was performed and revealed that the patient was positive for COVID-19. Conclusions: This case report showed that keratoconjunctivitis may occur as the only manifestation of COVID-19 infection. Thus, patient presented with unexplainable eye symptoms should be evaluated for COVID-19 infection.

Download Full-text

Concurrent Glossopharyngeal Neuralgia and Hemi-Laryngopharyngeal Spasm (HeLPS): A Case Report and a Review of the Literature

Neurosurgery ◽

10.1093/neuros/nyz546 ◽

2019 ◽

Vol 87 (5) ◽

pp. E573-E577

Author(s):

C Michael Honey ◽

Marie T Krüger ◽

Alan R Rheaume ◽

Josue M Avecillas-Chasin ◽

Murray D Morrison ◽

...

Keyword(s):

Case Report ◽

Literature Review ◽

Microvascular Decompression ◽

Medical Condition ◽

Posterior Inferior Cerebellar Artery ◽

Cranial Nerves ◽

Conversion Disorder ◽

Glossopharyngeal Neuralgia ◽

Neurovascular Compression ◽

Patient Reported

Abstract BACKGROUND AND IMPORTANCE Hemi-laryngopharyngeal spasm (HeLPS) has been recently described but is not yet widely recognized. Patients describe intermittent coughing and choking and can be cured following microvascular decompression of their Xth cranial nerve. This case report and literature review highlight that HeLPS can co-occur with glossopharyngeal neuralgia (GN) and has been previously described (but not recognized) in the neurosurgical literature. CLINICAL PRESENTATION A patient with GN and additional symptoms compatible with HeLPS is presented. The patient reported left-sided, intermittent, swallow-induced, severe electrical pain radiating from her ear to her throat (GN). She also reported intermittent severe coughing, throat contractions causing a sense of suffocation, and dysphonia (HeLPS). All her symptoms resolved following a left microvascular decompression of a loop of the posterior inferior cerebellar artery that was pulsating against both the IXth and Xth cranial nerves. A review of the senior author's database revealed another patient with this combination of symptoms. An international literature review found 27 patients have been previously described with symptoms of GN and the additional (but not recognized at the time) symptoms of HeLPS. CONCLUSION This review highlights that patients with symptoms compatible with HeLPS have been reported since 1926 in at least 4 languages. This additional evidence supports the growing recognition that HeLPS is another neurovascular compression syndrome. Patients with HeLPS continue to be misdiagnosed as conversion disorder. The increased recognition of this new medical condition will require neurosurgical treatment and should alleviate the suffering of these patients.

Download Full-text

Retromandibular Fossa Approach to the High Cervical Internal Carotid Artery: An Anatomic Study

Operative Neurosurgery ◽

10.1227/01.neu.0000326020.07187.6b ◽

2008 ◽

Vol 62 (suppl_5) ◽

pp. ONS363-ONS370 ◽

Cited By ~ 2

Author(s):

Yusuf Izci ◽

Roham Moftakhar ◽

Mark Pyle ◽

Mustafa K. Basşkaya

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Average Length ◽

Cranial Nerves ◽

External Carotid Artery ◽

External Carotid ◽

Digastric Muscle ◽

High Cervical ◽

Cervical Internal Carotid Artery

Abstract Objective: Access to the high cervical internal carotid artery (ICA) is technically challenging for the treatment of lesions in and around this region. The aims of this study were to analyze the efficacy of approaching the high cervical ICA through the retromandibular fossa and to compare preauricular and postauricular incisions. In addition, the relevant neural and vascular structures of this region are demonstrated in cadaveric dissections. Methods: The retromandibular fossa approach was performed in four arterial and venous latex-injected cadaveric heads and necks (eight sides) via preauricular and postauricular incisions. This approach included three steps: 1) sternocleidomastoid muscle dissection; 2) transparotid dissection; and 3) removal of the styloid apparatus and opening of the retromandibular fossa to expose the cervical ICA with the internal jugular vein along with Cranial Nerves X, XI, and XII. Results: The posterior belly of the digastric muscle and the styloid muscles were the main obstacles to reaching the high cervical ICA. The high cervical ICA was successfully exposed through the retromandibular fossa in all specimens. In all specimens, the cervical ICA exhibited an S-shaped curve in the retromandibular fossa. The external carotid artery was located more superficially than the ICA in all specimens. The average length of the ICA in the retromandibular fossa was 6.8 cm. Conclusion: The entire cervical ICA can be exposed via the retromandibular fossa approach without neural and vascular injury by use of meticulous dissection and good anatomic knowledge. Mandibulotomy is not necessary for adequate visualization of the high cervical ICA.

Download Full-text