British Journal of Neurosurgery, February 2015; 29(1): 113–114 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.957159
NEUROSURGICAL IMAGE
Trigeminal neuralgia from an Arteriovenous malformation: An intra-operative diagnosis Bodiabaduge A. P. Jayasekera1, Francesco Vergani1, Anil Gholkar2 & Alistair J. Jenkins1 1Department of Neurosurgery, Royal Victoria Hospital, Newcastle Upon Tyne, UK, and 2Department of Neuroradiology,
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
Royal Victoria Hospital, Newcastle Upon Tyne, UK
hospital for a microvascular decompression (MVD). Being initially responsive to carbamazepine, her neuralgia had been refractory for 1 year. Magnetic resonance imaging (MRI) disclosed vasculature abutting the fifth cranial nerve (Fig. 1). Intra-operatively, an arteriovenous malformation (AVM) was identified, around the fifth cranial nerve (Fig. 2). The compressive branch was obliterated with diathermy. Separation of the vessels from the trigeminal nerve was abandoned after repeated bleeding. A post-operative angiogram confirmed the presence of an AVM in the left cerebellopontine angle, supplied by a hypertrophied basilar artery perforator and left superior cerebellar artery (Fig. 3). Five months post procedure this lady was free from her trigeminal neuralgia with minimal hypo-anaesthesia. She has been referred for stereotactic radiosurgery. Rates of TN from AVM in the literature vary from 0.24 to 1.78%.1 Tsubaki reported 10 AVMs.2 Seven were not visualised on pre-operative computed tomography with contrast or DSA. Pre-operative MRI/MRA (magnetic resonance angiography) has a sensitivity of 96% for neurovascular compression.3 Its utility with AVMs is unknown.
Abstract We report the case of a 72-year-old lady with a magnetic resonance imaging (MRI) occult arteriovenous malformation (AVM) causing trigeminal neuralgia (TN). The possibility of an AVM when managing patients with TN should be borne in mind. Where possible, decompression of the trigeminal nerve should be attempted, as first-line therapy. Keywords: arteriovenous malformation; microvascular decompression; trigeminal neuralgia
Neurosurgical images A 72-year-old lady with a 6-year history of typical trigeminal neuralgia (TN) (V1 and V3 distribution) was referred to our
Fig. 1. Sagittal (A) and axial (B) MRI T2 SPACE sequences. Trigeminal nerve with evidence of surrounding complex neurovasculature (Black arrows). Sagittal (C) and axial (D) MRI T1 with gadolinium sequences. Complex vasculature not visible in same region.
Fig. 2. Following cerebellar retraction (†), trigeminal nerve was seen surrounded and infiltrated by AVM (Black arrowhead). Surrounding AVM seen on the surface of the Pons (∗).
Correspondence: Mr B.A.P. Jayasekera, Department of Neurosurgery, Royal Victoria Infirmary, Newcastle Upone Tyne NE1 4LP, UK. Tel: ⫹ 0191 28221907. E-mail: [email protected] Received for publication 18 May 2014; accepted 14 August 2014
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B. A. P. Jayasekera et al. Decompression of the trigeminal nerve and excision of the AVM should be considered. For residual AVMs, the risk of bleeding is unknown. Radiosurgery for brain stem AVMs does not eliminate the risk with a 4% annual rate of post-treatment bleeding.6 Percutaneous procedures should be considered as last-line therapy for pain.
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
References Fig. 3. Vertebral artery digital subtraction angiogram with evidence of supply of AVM (∗) from a hypertrophied basilar artery perforator (arrowhead) and possibly a branch from the left superior cerebellar artery (arrow).
Garcia-Pastor1 described good results with MVD for TN from AVMs. 4 of 5 patients experienced resolution of their symptoms, 2 had failed preceding thermocoagulation of the gasserian ganglion. AVM of 1 patient was excised. Edwards4 reported resolution of TN in 5 patients with excision of their micro-AVMs. Variable results have been described with percutaneous procedures.1 In one case, treatment with radiosurgery resulted in resolution of pain after 13 months.5
1. Garcia-Pastor C, Lopez-Gonzalez F, Revuelta R, Nathal E. Trigeminal neuralgia secondary to arteriovenous malformations of the posterior fossa. Surg Neurol 2006;66:207–11; discussion 11. 2. Tsubaki S, Fukushima T, Tamagawa T, et al. Parapontine trigeminal cryptic angiomas presenting as trigeminal neuralgia. J Neurosurg 1989;71:368–74. 3. Vergani F, Panaretos P, Penalosa A, et al. Preoperative MRI/MRA for microvascular decompression in trigeminal neuralgia: consecutive series of 67 patients. Acta Neurochir 2011;153:2377–81; discussion 82. 4. Edwards RJ, Clarke Y, Renowden SA , Coakham HB. Trigeminal neuralgia caused by microarteriovenous malformations of the trigeminal nerve root entry zone: symptomatic relief following complete excision of the lesion with nerve root preservation. J Neurosurg 2002;97:874–80. 5. Anderson WS, Wang PP, Rigamonti D. Case of microarteriovenous malformation-induced trigeminal neuralgia treated with radiosurgery. J Headache Pain 2006;7:217–21. 6. Kurita H, Kawamoto S, Sasaki T, et al. Results of radiosurgery for brain stem arteriovenous malformations. J Neurol Neurosurg Psychiatry 2000;68:563–70.
NEUROSURGICAL IMAGE
Trigeminal neuralgia from an Arteriovenous malformation: An intra-operative diagnosis Bodiabaduge A. P. Jayasekera1, Francesco Vergani1, Anil Gholkar2 & Alistair J. Jenkins1 1Department of Neurosurgery, Royal Victoria Hospital, Newcastle Upon Tyne, UK, and 2Department of Neuroradiology,
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
Royal Victoria Hospital, Newcastle Upon Tyne, UK
hospital for a microvascular decompression (MVD). Being initially responsive to carbamazepine, her neuralgia had been refractory for 1 year. Magnetic resonance imaging (MRI) disclosed vasculature abutting the fifth cranial nerve (Fig. 1). Intra-operatively, an arteriovenous malformation (AVM) was identified, around the fifth cranial nerve (Fig. 2). The compressive branch was obliterated with diathermy. Separation of the vessels from the trigeminal nerve was abandoned after repeated bleeding. A post-operative angiogram confirmed the presence of an AVM in the left cerebellopontine angle, supplied by a hypertrophied basilar artery perforator and left superior cerebellar artery (Fig. 3). Five months post procedure this lady was free from her trigeminal neuralgia with minimal hypo-anaesthesia. She has been referred for stereotactic radiosurgery. Rates of TN from AVM in the literature vary from 0.24 to 1.78%.1 Tsubaki reported 10 AVMs.2 Seven were not visualised on pre-operative computed tomography with contrast or DSA. Pre-operative MRI/MRA (magnetic resonance angiography) has a sensitivity of 96% for neurovascular compression.3 Its utility with AVMs is unknown.
Abstract We report the case of a 72-year-old lady with a magnetic resonance imaging (MRI) occult arteriovenous malformation (AVM) causing trigeminal neuralgia (TN). The possibility of an AVM when managing patients with TN should be borne in mind. Where possible, decompression of the trigeminal nerve should be attempted, as first-line therapy. Keywords: arteriovenous malformation; microvascular decompression; trigeminal neuralgia
Neurosurgical images A 72-year-old lady with a 6-year history of typical trigeminal neuralgia (TN) (V1 and V3 distribution) was referred to our
Fig. 1. Sagittal (A) and axial (B) MRI T2 SPACE sequences. Trigeminal nerve with evidence of surrounding complex neurovasculature (Black arrows). Sagittal (C) and axial (D) MRI T1 with gadolinium sequences. Complex vasculature not visible in same region.
Fig. 2. Following cerebellar retraction (†), trigeminal nerve was seen surrounded and infiltrated by AVM (Black arrowhead). Surrounding AVM seen on the surface of the Pons (∗).
Correspondence: Mr B.A.P. Jayasekera, Department of Neurosurgery, Royal Victoria Infirmary, Newcastle Upone Tyne NE1 4LP, UK. Tel: ⫹ 0191 28221907. E-mail: [email protected] Received for publication 18 May 2014; accepted 14 August 2014
113
114
B. A. P. Jayasekera et al. Decompression of the trigeminal nerve and excision of the AVM should be considered. For residual AVMs, the risk of bleeding is unknown. Radiosurgery for brain stem AVMs does not eliminate the risk with a 4% annual rate of post-treatment bleeding.6 Percutaneous procedures should be considered as last-line therapy for pain.
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
References Fig. 3. Vertebral artery digital subtraction angiogram with evidence of supply of AVM (∗) from a hypertrophied basilar artery perforator (arrowhead) and possibly a branch from the left superior cerebellar artery (arrow).
Garcia-Pastor1 described good results with MVD for TN from AVMs. 4 of 5 patients experienced resolution of their symptoms, 2 had failed preceding thermocoagulation of the gasserian ganglion. AVM of 1 patient was excised. Edwards4 reported resolution of TN in 5 patients with excision of their micro-AVMs. Variable results have been described with percutaneous procedures.1 In one case, treatment with radiosurgery resulted in resolution of pain after 13 months.5
1. Garcia-Pastor C, Lopez-Gonzalez F, Revuelta R, Nathal E. Trigeminal neuralgia secondary to arteriovenous malformations of the posterior fossa. Surg Neurol 2006;66:207–11; discussion 11. 2. Tsubaki S, Fukushima T, Tamagawa T, et al. Parapontine trigeminal cryptic angiomas presenting as trigeminal neuralgia. J Neurosurg 1989;71:368–74. 3. Vergani F, Panaretos P, Penalosa A, et al. Preoperative MRI/MRA for microvascular decompression in trigeminal neuralgia: consecutive series of 67 patients. Acta Neurochir 2011;153:2377–81; discussion 82. 4. Edwards RJ, Clarke Y, Renowden SA , Coakham HB. Trigeminal neuralgia caused by microarteriovenous malformations of the trigeminal nerve root entry zone: symptomatic relief following complete excision of the lesion with nerve root preservation. J Neurosurg 2002;97:874–80. 5. Anderson WS, Wang PP, Rigamonti D. Case of microarteriovenous malformation-induced trigeminal neuralgia treated with radiosurgery. J Headache Pain 2006;7:217–21. 6. Kurita H, Kawamoto S, Sasaki T, et al. Results of radiosurgery for brain stem arteriovenous malformations. J Neurol Neurosurg Psychiatry 2000;68:563–70.
