Bilateral trigeminal neuralgia

Multi-metric predictors of radiofrequency-treated trigeminal neuralgias

Evaluation of neurovascular compression-related trigeminal neuralgia (NVC-TN) and its resolution through microvascular decompression are demonstrable by MRI and intraoperatively [Leal et al. (Atrophic changes in the trigeminal nerves of patients with trigeminal neuralgia due to neurovascular compression and their association with the severity of compression and clinical outcomes: Clinical article. J Neurosurg. 2014;120(6):1484-1495)]. Non-NVC-TNs treated by radiofrequency (RF) lack such detectable features. Multimodal integration of pre-surgical diffusion tensor imaging (DTI) and volumetry (VOL) with intraoperative neurophysiology (ION) could improve understanding and performance of RF among non-NVC-TN. We hypothesized that DTI disturbances' localization (central relay versus peripherally) rather than their values bares the most significant predictive value upon outcome and that ION could quantitatively both localize and assist RF of affected branches. The first pre-surgical step evaluated the differences between affected and non-affected sides (by DTI and VOL). Four TN's segments were studied, from peripheral to central relay: Meckel's cave-trigeminal ganglion (MC-TGN), cisternal portion, root entry zone (REZ) and spinal tract [Lin et al. (Flatness of the Meckel cave may cause primary trigeminal neuralgia: A radiomics-based study. J Headache Pain. 2021;22(1):104)]. In the second intraoperative step, we used both ION and patient's testimonies to confirm the localization of the affected branch, evolving hypoesthesia, pain reduction and monitoring of adverse effects [Sindou (Neurophysiological navigation in the trigeminal nerve: Use of masticatory responses and facial motor responses evoked by electrical stimulation of the trigeminal rootlets for RF-thermorhizotomy guidance. Stereotact Funct Neurosurg. 1999;73(1-4):117-121); Sindou and Tatli (Traitement de la névralgie trigéminale par thermorhizotomie. Neurochirurgie. 2009;55(2):203-210)]. Last and postoperatively, each data set's features and correlation with short-term (3 months) and long-term outcomes (23.5 ± 6.7 months) were independently analysed and blind to each other. Finally, we designed a multimodal predictive model. Sixteen non-NVC-TN patients (mean 53.6 ± SD years old) with mean duration of 6.56 ± 4.1 years (75% right TN; 43.8% V3) were included. After 23.5 ± 6.7 months, 14/16 were good responders. Age, gender, TN duration and side/branch did not correlate with outcomes. Affected sides showed significant DTI disturbances in both peripheral (MC-TGNs) and central-relay (REZ) segments. However, worse outcome correlated only with REZ-located DTI disturbances (P = 0.04; r = 0.53). Concerning volumetry, affected MC-TGNs were abnormally flatter: lower volumes and surface area correlated with worse outcomes (both P = 0.033; r = 0.55 and 0.77, respectively). Intraoperatively, ION could not differ the affected from non-affected branch. However, the magnitude of ION's amplitude reduction (ION-Δ-Amplitude) had the most significant correlation with outcomes (r = 0.86; P < 0.00006). It was higher among responders [68.4% (50-82%)], and a <40% reduction characterized non-responders [36.7% (0-40%)]. Multiple regression showed that ION-Δ-Amplitude, centrally located only REZ DTI integrity and MC-TGN flatness explain 82.2% of the variance of post-RF visual analogue score. Integration of pre-surgical DTI-VOL with ION-Δ-Amplitude suggests a multi-metric predictive model of post-RF outcome in non-NVC-TN. In multiple regression, central-relay REZ DTI disturbances and insufficiently reduced excitability (<40%) predicted worse outcome. Quantitative fine-tuned ION tools should be sought for peri-operative evaluation of the affected branches.

Efficacy and safety of percutaneous balloon compression for bilateral trigeminal neuralgia: a retrospective study

BACKGROUND

Percutaneous balloon compression (PBC) of the Gasserian ganglion is steadily gaining traction within the trigeminal neuralgia (TN) community. Bilateral trigeminal neuralgia (BTN) is a rare condition, and its treatment remains challenging. As far as we know, there are currently no research reports on the treatment outcomes of PBC for BTN.The purpose of this study is to meticulously evaluate the efficacy and safety of PBC for BTN in our medical institution.

METHODS

In this retrospective study, we collected and analyzed the medical records of all patients with BTN who underwent the PBC procedure at the Department of Neurosurgery at Hebei General Hospital from July 2017 to July 2023. After undergoing PBC therapy, all patients were promptly assessed for treatment efficacy based on the modified Barrow Neurological Institute (BNI) pain intensity grading scale.

RESULTS

All 37 patients with BTN experienced significant pain relief (BNI I-IIIb) immediately following unilateral PBC treatment. Among these patients, 25 reported relief from pain on the non-operative side, which was effectively managed with medication. Out of the 12 patients who did not experience improvement in contralateral symptoms, 11 received contralateral PBC. Out of the 48 treated sides, 47 sides (97.9%) achieved excellent pain control following a single PBC procedure. The follow-up times ranged from 2 to 62 months. At the 1-year follow-up, 94.6% of the patients maintained excellent therapeutic outcomes.Three recurrent patients underwent repeated unilateral PBC, and all of them maintained excellent pain control postoperatively. At the last follow-up, satisfaction was at 91.7% (measured using the Likert scale), with no severe complications occurring.

CONCLUSIONS

The results indicate that PBC is an effective and relatively safe method for treating BTN, offering a valuable option for pain control in these rare cases of TN.

Management of bilateral trigeminal neuralgia with trigeminal radiofrequency rhizotomy: a treatment strategy for the life-long disease

BACKGROUND

The objective of this study was to evaluate the effectiveness of percutaneous controlled radiofrequency trigeminal rhizotomy (RF-TR) in patients with bilateral trigeminal neuralgia (BTN). Patients were analyzed after RF-TR in terms of outcome, safety and complications.

METHODS

Eighty-nine BTN patients underwent 186 RF-TR procedures. Eighty-seven patients had idiopathic trigeminal neuralgia (ITN) and two patients had multiple sclerosis (2.2%). Fifty-six (62.9%) were women and 33 (37.1%) were men. Ages ranged from 29 to 85 years. Anesthesia was administered at a determined optimal level, allowing patient cooperation for controlled and selective lesioning.

RESULTS

The mean follow-up period was 101.71 ± 77.7 months. Familial occurrence was seen in two (2.2%) patients. Synchronized pain was observed in 25 (28.2%) patients. Pain occurrence on the contralateral side was observed with an average duration of 124.7 ± 87.13 months. Fifty-four of the 89 patients underwent 146 RF-TR procedures for both sides and 35 underwent 40 RF-TR procedures for one side. Complete pain relief or partial satisfactory pain relief was achieved on the medically treated side in 35 patients. During follow-up, 36 patients required the second procedure and 7 required the third procedure. Acute pain relief was reported in 86 (96.6%) patients. Early (<6 months) pain recurrence was observed in 11 (12.3%) and late (>6 months) recurrence in 25 (28.0%) patients. Complications included diminished corneal reflex in four (2.1%) patients, keratitis in two (1.1%), masseter dysfunction in four (2.1%), dysesthesia in two (1.1%), and anesthesia dolorosa in one (0.5%).

CONCLUSIONS

RF-TR is an effective, selective, well-controlled, and effortlessly repeatable procedure for treating BTN, especially in the elderly, in terms of low morbidity and mortality rates and high rate of satisfactory pain relief.

Combined hyperactive dysfunction syndrome of the cranial nerves: trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia: 11-year experience and review

OBJECTIVE

A pathological condition caused by vascular compression at the root entry/exit zone of the cranial nerves is designated hyperactive dysfunction syndrome (HDS) of the cranial nerves. Patients with HDS who exhibited a combination of trigeminal neuralgia (TN), hemifacial spasm (HFS), and/or glossopharyngeal neuralgia were retrospectively reviewed, to study the incidence, etiological factors, and demographic characteristics for this combined HDS group.

METHODS

Medical and surgical records were analyzed for 41 patients with combined HDS, of 1472 consecutive patients with HDS who were treated between 1984 and 1994.

RESULTS

The combined HDS group accounted for 2.8% of all patients with HDS; 19 patients (1.3%) exhibited bilateral symptoms, i.e., 14 cases of TN, 3 of combined TN and HFS, and 2 of HFS. Twenty-two patients (1.5%) exhibited ipsilateral symptoms, i.e., 19 cases of TN and HFS and 3 of TN and glossopharyngeal neuralgia. Excluding three patients whose symptoms were associated with brain tumors or arteriovenous malformations, this patient group was older (63.2 versus 55.3 yr, P = 0.0009) and exhibited an increased percentage of associated hypertension (47.4 versus 17.5%, P = 0.000008), with a female predominance (86.8 versus 71.3%, P = 0.07), compared with the single HDS group. Thirty-six of these patients underwent a total of 61 microvascular decompression procedures, with favorable outcomes. The offending vessels were similar to those in single HDS, which were usually conventional and multiple.

CONCLUSION

The associated etiological factors for vascular compression syndromes were more evident in the combined HDS group than in the single HDS group. Progressive arteriosclerotic vasculoarchitectural changes of the vertebrobasilar system, accelerated by aging and hypertension, bring about the development of combined HDS, with a remarkable female predominance.

Recurrent headaches: what every allergist should know

OBJECTIVE

To provide the allergist information regarding the recognition, diagnosis, classification, and management of headaches.

DATA SOURCES

Literature and relevant articles pertaining to various types of headache are reviewed and the clinical experience of the authors is presented.

CONCLUSIONS

After reading this article, the allergist should know the various causes of headache, recognize the warning signs of serious neurologic disease, and determine whether allergy or adverse food reactions are playing a role.

Trigeminal neuralgia (tic douloureux)

Trigeminal neuralgia is not common, but is a debilitating pain syndrome. After the diagnosis is established, a stepwise approach to treatment is recommended. Carbamazepine is the drug of choice. When carbamazepine fails to relieve pain, baclofen and then phenytoin are used. A number of second-line drugs, such as clonazepam, divalproex sodium, chlorphenesine carbamate, and pimozide can also be tried. A large number of patients will respond to one or another drug or to a combination of two drugs. When medical treatment fails, several surgical procedures have been found to be effective. Percutaneous radiofrequency gangliolysis is the most widely used procedure with a high success rate. All surgical procedures must be performed by an experienced physician in order to achieve the lowest possible rate of serious complications.

Bilateral trigeminal neuralgia: a 14-year experience with microvascular decompression

Thirty-five patients with trigeminal neuralgia (TN) bilaterally underwent posterior fossa microvascular decompression (MVD) between 1971 and 1984. They comprised 5.0% of a larger series of 699 patients with TN who underwent MVD during that interval. Compared to the subgroup of 664 patients with only unilateral symptoms, the population with bilateral TN included a greater percentage of females (74% vs. 58%, p less than 0.1), a higher rate of "familial" TN (17% vs. 4.1%, p less than 0.001), and an increased incidence of additional cranial nerve dysfunction (17% vs. 6.6%, p less than 0.05) and hypertension (34% vs. 19%, p less than 0.05). Of the 35 patients with bilateral TN, 10 underwent bilateral MVD (22 procedures) and 25 underwent unilateral MVD (30 procedures). In the latter patients, pain on the nonoperative side was well controlled with medication alone or had previously been treated by ablative procedures. Good or excellent pain control was achieved after one MVD was performed in 40 of the 45 sides treated (89%), and was maintained 1, 5, and 10 years after surgery in 82%, 66%, and 60%, respectively, based on life-table analysis. Six of 10 patients with recurrent symptoms underwent repeat unilateral MVD. Good or excellent long-term pain control was maintained in all six. With these repeat procedures included, symptom control at 1, 5, and 10 years after initial surgery was maintained in 87%, 78%, and 78% of the treated sides, respectively. Overall, 26 of 35 patients (74%) maintained good or excellent pain relief throughout the duration of the study (mean follow-up period 75 months) without resumption of regular medication usage. Although preoperative neurological deficits resulting from previous ablative procedures were seen in the majority of patients before MVD, no patient developed new major trigeminal sensory loss or masseter weakness after MVD. Operative mortality was zero. The results indicate that posterior fossa MVD is an effective and relatively safe treatment for the majority of patients with bilateral "idiopathic" TN, avoiding the risks of bilateral trigeminal nerve injury seen with other approaches.

Bilateral trigeminal neuralgia

Bilateral trigeminal neuralgia occurred in 32 (11.9%) of 269 consecutive patients who were treated with radiofrequency electrocoagulation (RFE). This is a higher incidence than has been reported before and may be explained by the prospective nature of the present study, the long follow-up period, and the inclusion of patients with mild bilateral symptoms. Multiple sclerosis is the most common predisposing factor and occurred in 18% of those with bilateral trigeminal neuralgia. Although patients with bilateral trigeminal neuralgia were more likely to have had prior surgery than those with unilateral neuralgia, they did not have a higher recurrence rate following treatment. Percutaneous RFE of the retrogasserian rootlets and gasserian ganglion, with or without glycerol, is effective in managing patients whose pain is intractable to medical therapy. The preservation of most trigeminal sensory and motor functions, the low morbidity rate, and the ability to repeat the procedure are particularly advantageous for patients with bilateral involvement.

[Neurovascular decompression in trigeminal neuralgia. Analysis of 70 cases]

This paper analyses the surgical findings and results obtained with the neurovascular decompression technique in the treatment of 70 patients with essential trigeminal neuralgia. Except for 3 patients in whom nothing was found, vessels were seen touching or compressing the nerve root in all the other patients, being the arteries responsible for the pain in 73% of the cases. The surgical results improved with the increased familiarity of the technique, being of 73% the excellent results obtained in the first group of 23 patients, and 95% in the remaining two groups. Only 3 patients were lost in the follow-up which ranged from 2 months to 4 years. Recurrences occurred in 4 patients. There were no important complications except for a death from a post-operative gastrointestinal hemorrhage. Our results and those published in the literature confirm that neurovascular decompression is a safe procedure in experienced hands, and that it should be the chosen method in the treatment of trigeminal neuralgia in order to preserve the sensibility of the face.