Trigeminal neuralgia in the presence of ectatic basilar artery and basilar invagination: treatment by foramen magnum decompression

Radiosurgery for Trigeminal Neuralgia Secondary to Dolichoectatic Vessels: Case Series and Review of Literature

Even for seasoned neurosurgeons who have mastered the microvascular decompression (MVD) techniques, trigeminal neuralgia (TGN) secondary to vertebrobasilar dolichoectatic vessels remains a challenge. Often, patient is either medically infirm or unwilling for invasive surgical interventions. Alternative treatment options including Gamma Knife radiosurgery (GKRS) are considered in such a situation with variable success. This study aimed to evaluate the role of GKRS in patients with trigeminal neuralgia with dolichoectatic vessels and severe cross compression. We prospectively managed three male patients of intractable TGN secondary to dolichoectatic vascular compression with single-session GKRS. The cisternal component of the trigeminal nerve was targeted with 90 Gy radiation at 100% isodose with a single 4-mm collimator. The patients were regularly evaluated on clinical parameters for pain relief (Barrow Neurological Institute (BNI) score), sensory complaints, and outcome. All patients had satisfactory pain control (BNI I–IIIa) at 3 months of interval only to get recurrent pain (BNI IV–V) after 6 months. The treatment was eventually considered a failure after 6-month duration and one patient needed MVD for pain control. Post-GKRS pain control remains inferior in patients with dolichoectasia compared with typical TGN. GKRS should be offered only as a salvage or rescue procedure and should not be used as an alternative treatment of MVD in patient population with dolichoectatic vessels.

Basilar Artery Ectasia Causing Trigeminal Neuralgia: An Evolved Technique of Transpositional Suture-Pexy

BACKGROUND

Microvascular decompression for patients with trigeminal neuralgia (TGN) is widely accepted as one of the modalities of treatment. The standard approach has been retrosigmoid suboccipital craniotomy with placement of a Teflon pledget to cushion the trigeminal nerve from the offending artery, or cauterize and divide the offending vein(s). However, in cases of severe compression caused by a large artery, the standard decompression technique may not be effective.

OBJECTIVE

To describe a unique technique of vasculopexy of the ectatic basilar artery to the tentorium in a patient with TGN attributed to a severely ectatic and tortuous basilar artery. A case series of patients who underwent this technique of vasculopexy for arterial compression is presented.

METHODS

The patient underwent a subtemporal transtentorial approach and the basilar artery was mobilized away from the trigeminal nerve. A suture was then passed through the wall of the basilar artery (tunica media) and secured to the tentorial edge, to keep the artery away from the nerve.

RESULTS

The neuralgia was promptly relieved after the operation, with no complications. A postoperative magnetic resonance imaging scan showed the basilar artery to be away from the trigeminal root. In a series of 7 patients who underwent this technique of vasculopexy, no arterial complications were noted at short- or long-term follow-up.

CONCLUSION

Repositioning and vasculopexy of an ectatic basilar artery for the treatment of TGN is safe and effective. This technique can also be used for other neuropathies that result from direct arterial compression.

Trigeminal neuralgia secondary to basilar impression: A case report

We report a rare case of trigeminal neuralgia. A 23-year-old woman with a history of 1 year of typical trigeminal neuralgia manifested the characteristics of basilar impression. Magnetic resonance imaging (MRI) demonstrated basilar impression, deformity of the posterior fossa with asymmetry of petrous bone, and compression of medulla oblongata in the topography of the odontoid apophysis. The operation was performed through a suboccipital craniectomy. The neuralgia disappeared after surgery and remains completely resolved until today. This is the second reported case of trigeminal neuralgia in a patient with basilar impression in Brazil.

Trigeminal neuralgia related to megadolichobasilar artery compression: a prospective series of twenty-nine patients treated with gamma knife surgery, with more than one year of follow-up

BACKGROUND

Trigeminal neuralgia (TN) secondary to megadolichobasilar artery (MBA) compression is considerably difficult to manage surgically.

OBJECTIVE

This study aims to evaluate the safety/efficacy of Gamma Knife surgery (GKS) in this special group of patients.

METHODS

Between July 1992 and November 2010, 29 patients with >1 year of follow-up presenting with MBA compression were treated with GKS at Timone University Hospital. Radiosurgery was performed using a Gamma Knife (model B, C or Perfexion). A single 4-mm isocenter was positioned in the cisternal portion of the trigeminal nerve at a median distance of 9.1 mm (range: 6-18.2 mm) from the emergence.

RESULTS

The median follow-up period was 46.1 months (range: 12.9-157.9 months). Initially, all patients (100%) were pain free; the average time to complete pain relief was 13.5 days (range: 0-240 days). Their actuarial probability of remaining pain free without medication at 0.5, 1 and 2 years was 93.1, 79.3 and 75.7%, respectively, and remained stable until 13 years after treatment. The actuarial probability of hypoesthesia onset at 6 months was 4.3%; at 1 year it reached 13% and remained stable until 13 years after treatment.

CONCLUSIONS

GKS proved to be reasonably safe and effective on a long-term basis as a first- and/or second-line surgical treatment for TN due to MBA compression.

Cervical Compressive Myelopathy due to Anomalous Bilateral Vertebral Artery

We report a very rare case of cervical compressive myelopathy by an anomalous bilateral vertebral artery (VA) entering the spinal canal at the C1 level and compressing the spinal cord. A 70-year-old woman had been suffering from progressive gait disturbance. Magnetic resonance imaging revealed that a bilateral VA at the V4 segment had abnormal courses and caused compression to the high cervical cord. VA repositioning was performed by anchoring a suture between the artery and around the arachnoid membrane and dentate ligament, and then, microvascular decompression using a Teflon sponge was done between the VA and the spinal cord. The weakness in the patient improved in the lower extremity after the operation. Anomalous VA could be one of the rare causes of cervical compressive myelopathy. Additionally, an anchoring suture and microvascular decompression around the VA could be a sufficient and safe method to indirectly decompress the spinal canal.

Bilateral vasculopexy of anomalous vertebral arteries causing cervicomedullary compression: case report and technical note

INTRODUCTION

The authors report an extremely rare cause of cervicomedullary cord compression by anomalous ectatic vertebral arteries.

MATERIAL

A 50-year-old male patient presented with a 9 month history of progressive quadriparesis. Investigations revealed that the vertebral arteries on both sides had a mirror-like course and caused a deep indentation into the high cervical cord. Bilateral vasculopexy was done using Teflon slings. The treatment resulted in rapid recovery from symptoms.

CONCLUSIONS

Anomalous course of the vertebral artery can result in symptoms of high cervical cord compression. Vasculopexy can result in lasting cure from symptoms.

Trigeminal neuralgia as the initial manifestation of temporal glioma: Report of three cases and a review of the literature

BACKGROUND

It is almost an accepted scenario that trigeminal neuralgia (TN) occurs when there is a kind of vascular compression on the root entry zone of trigeminal nerve at pons. There are occasional reports about trigeminal neuralgia as the presenting sign of intracranial tumors but temporal glioma has rarely been included in the list.

CASE DESCRIPTION

We report three cases of temporal lobe glioma which presented with trigeminal neuralgia as the initial manifestation and review the relevant literature briefly. The patients were 19-, 20-, and 31-year-old males who presented with partially controlled TN. The tumor mass could be detected in paraclinical evaluations when the usual modalities of therapy for facial pain in our community were not effective. Excisional surgery led in full pain control in all the cases. Two of the patients died because of tumor recurrence after a year and the other one is being treated by adjuvants.

CONCLUSION

We add these types of intracranial tumors to the list of the etiologies for TN and the possible mechanisms for the initiation of pain in these types of intracranial tumors are discussed.

Numbness matters: a clinical review of trigeminal neuropathy

AIM

Trigeminal neuropathies are a group of clinical disorders that involve injury to primary first-order neurons within the trigeminal nerve. We review the spectrum of etiologies underlying both painful and non-painful trigeminal neuropathies, with attention to particularly dangerous processes that may elude the clinician in the absence of a meticulous evaluation. Complications and management issues specific to patients with trigeminal neuropathy are discussed.

METHODS

Retrospective literature review.

RESULTS

Facial or intraoral numbness, the hallmark of trigeminal neuropathy, may represent the earliest symptomology of malignancy or autoimmune connective tissue disease as sensory neurons are destroyed. Such numbness, especially if progressive, necessitates periodic evaluation and vigilance even years after presentation if no diagnosis can be made.

CONCLUSIONS

In the routine evaluation of patients with facial pain, the clinician will inevitably be confronted with secondary pathology of the trigeminal nerves and nuclei. The appearance of numbness, even when pain continues to be the most pressing complaint, necessitates clinical assessment of the integrity of all aspects of the trigeminal pathways, which may also include neurophysiologic, radiographic, and laboratory evaluation.