Marginal Zone B-cell Lymphoma of the Gasserian Ganglion: Case Report and Review of the Literature

Primary central nervous system lymphoma (PCNSL) is a rare subtype of extranodal non-Hodgkin's lymphoma that accounts for 4% of newly diagnosed central nervous system (CNS) tumors. Most primary lymphomas of the central nervous system are of the subtype of diffuse large B-cell lymphomas, which have highly aggressive behavior and may involve the brain, leptomeninges, eyes or spinal cord without evidence of systemic disease. Primary CNS lymphomas are very rare in immunocompetent patients, but their rates are increasing. So far, only 11 primary Gasser ganglion lymphomas have been reported, with an incidence of 2.5 cases per 30,000,000 inhabitants. However, B cell lymphomas of the marginal zone of the Gasserian ganglion have been very rarely reported. We report here a clinical presentation characteristic of B cell lymphoma of the marginal zone of the Gasser ganglion in an immunocompetent patient who was treated with surgery and radiotherapy, evolving with improvement of symptoms and without recurrence in 3 months of follow-up.

Gasserian ganglion radiofrequency thermoablation in a patient with aneurysm of the anterior communicating artery

BackgroundGasserian ganglion radiofreqeucy thermoablation is a good treatment option for the management of pain in trigeminal neuralgia. We report a case in which the patient of trigeminal neuralgia combined with anterior cerebral artery aneurysm was treated successfully by gasserian ganglion thermoablation without any complication.CaseAn 85-year-old female presenting with electric shock like sensation in the gum and molar teeth was diagnosed as trigeminal neuralgia. Carbamazepine medication and trigeminal nerve blockade relieved her pain partially, but severe side effects of carbamazepine occurred. Magnetic resonance angiography of the brain showed saccular aneurysm in inferior aspect of the anterior communicating artery. Gasserian ganglion thermoablation under sedation anesthesia using nicardipine was performed carefully without any rupture of the cerebral aneurysm.ConclusionsGasserian ganglion thermoablation could be performed safely in a patient with cerebral aneurysm without any inadvertent event.

Extracranial Non-Gasserian Ganglion Application of Radiofrequency Thermocoagulation on the Mandibular Branch of the Trigeminal through the Foramen Ovale for Trigeminal Neuralgia

BACKGROUND: Percutaneous radiofrequency ablation (RFA) of the trigeminal Gasserian ganglion via the foramen ovale is still one of the classic treatments for primary trigeminal neuralgia. However, the Gasserian ganglion is deep in the middle cranial fossa. Although it is a structure outside the brain tissue, the puncture needle must enter the encephalic to reach the Gasserian ganglion and so it is difficult to completely avoid the risk of intracranial hemorrhage and infection caused by puncture damage to intracranial blood vessels. It is not clear whether if it is possible for RFA at the extracranial non-gasserian-ganglion site via the exit of the cranial channel (foramen ovale) for patients with V3 trigeminal neuralgia (TN). STUDY DESIGN: Prospective, clinical research study SETTING: Department of Anesthesiology and Pain Medical Center, Jiaxing, China. METHODS: One hundred and seven patients with isolated mandibular branch trigeminal neuralgia were included. Radiofrequency thermocoagulation was performed by CT-guided percutaneous puncture through the foramen ovale. The puncture target was the midpoint of the horizontal transverse diameter of the oval foramen. If the tingling sensation in the mandibular nerve innervation area could be detected, the radiofrequency thermocoagulation (90°C, 120 sec) under intravenous anesthesia would be performed. We investigated the inclination angle, puncture angle and depth, puncture operation time, intraoperative complications and short-term and long-term results after operation. RESULTS: After radiofrequency thermocoagulation, the pain in the mandibular branch dominant area was completely diminished in 104 patients. Two patients were cured after the second radiofrequency treatment. No intracranial hemorrhage not infection complications occurred, except for facial hematoma during operation in 21 cases. After 12-24 months of follow-up, 9 patients had recurrence and were still effective after receiving additional extracranial radiofrequency treatment. LIMITATIONS: A control group should be established and more clinical data should be collected in future work. CONCLUSION: Extracranial non-Gasserian-ganglion RF can achieve satisfactory results and improve the safety of radiofrequency treatment for trigeminal neuralgia. KEY WORDS: Trigeminal neuralgia, foramen ovale, trigeminal ganglion

Application of Augmented Reality in Percutaneous Procedures—Rhizotomy of the Gasserian Ganglion

BACKGROUND Percutaneous rhizotomy of the Gasserian ganglion for trigeminal neuralgia is an effective therapeutic procedure. Yet, landmark-guided cannulation of the foramen ovale is manually challenging and difficult to learn. OBJECTIVE To overcome these limitations, we assessed the feasibility and accuracy of an augmented reality (AR)-guided puncture of the foramen ovale. METHODS A head phantom with soft tissue structures of the facial area was built. A three-dimensional (3D)-dataset of the phantom was generated using a stereotactic planning workstation. An optimal trajectory to the foramen ovale was created and then transferred to an AR headset. A total of 2 neurosurgeons and 2 neuroradiologists independently performed 8 AR-guided and 8 landmark-guided cannulations of the foramen ovale, respectively. For each AR-guided cannulation, the hologram was manually aligned with the phantom. Accuracy of the cannulation was evaluated using the Euclidean distance to the target point as well as the lateral deviation of the achieved trajectory from the planned trajectory at target point level. RESULTS With the help of AR guidance, a successful cannulation of the foramen ovale was achieved in 90.6% compared to the purely landmark-based method with 18.8%. Euclidean distance and lateral deviation were significantly lower with AR guidance than landmark guidance (P < .01). CONCLUSION AR greatly improved accuracy of simulated percutaneous rhizotomy of the Gasserian ganglion.

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.

Invisible compression, anterior fossa tumor causing trigeminal neuralgia

Background: Trigeminal neuralgia secondary to posterior and middle fossae tumors, whether ipsilateral or contralateral, has been well described. However, this disabling disease has never been reported in the context of anterior fossa neoplasms. Case Description: A 75-year-old female with right hemifacial pain was diagnosed with an anterior clinoid meningioma. Despite neuroimaging did not show any apparent anatomical or neurovascular conflict, a detailed MRI analysis revealed a V3 hyperintensity. Not only symptoms completely resolved after surgical resection but also this radiological sign disappeared. Nowadays, the patient remains asymptomatic and V3 hyperintensity has not reappeared during her follow-up. Conclusion: A surgical definitive treatment can be offered to patients suffering from trigeminal neuralgia secondary to lesions adjacent to Gasserian ganglion or trigeminal branches. In this respect, posterior and middle fossae tumors are well-reported etiologies. Nevertheless, in the absence of evident compression, other neoplasms located in the vicinity of these critical structures and considered as radiological findings may be involved in trigeminal pain. Microvascular and pressure gradient changes could be an underlying cause of these symptoms in anterior skull base lesions. Here, we report the case of a patient with uncontrollable hemifacial pain resolved after anterior clinoid meningioma removal.

Trigeminal Neuralgia associated with Wallenberg Syndrome, a case report

Context: Trigeminal neuralgia is typically associated with structural lesions that affect the brainstem, pre-ganglionic roots, gasserian ganglion and the trigeminal nerve. The association of trigeminal neuralgia with infarction of the dorsolateral medulla is rare, being more associated with pontine lesions, in the context of brainstem infarction. Methods: Report the case of a 55-year-old male patient, who presented with a left dorsolateral bulbar infarction, and developed a ipsilateral trigeminal neuralgia afterwards. Case report: A 55-year-old man attended to the emergency room referring sudden incoordination of the left limbs, associated with numbness of the contralateral limbs. The neurological examination showed nystagmus, numbness of the left face, ataxia of the left limbs and numbness of the right limbs. The Magnetic Resonance of the Brain revealed an area of recent infarction in the left posterolateral aspect of the medulla. He underwent thrombolysis, evolving with complete resolution of symptoms. In the week after the initial event, he returned to the outpatient clinic, reporting paroxysms of excruciating pain in the upper lip, nose and left zygomatic region, being diagnosed with neuralgia of the maxillary segment of the trigeminal nerve, improving with introduction of Gabapentin. Conclusion: Although most cases of trigeminal neuralgia are determined by vascular compression of the trigeminal nerve root entry zone, other causes must be considered. The association of this condition with dorsolateral medulla infarction is rare, with only 4 cases reported in the last 10 years.