Radiofrequency trigeminal rhizolysis for the treatment of trigeminal neuralgia secondary to brainstem infarction

Abstract

<jats:p>Although percutaneous radiofrequency trigeminal rhizolysis (RFL) has been used to treat idiopathic trigeminal neuralgia thought secondary to multiple sclerosis, the use of RFL for trigeminal neuralgia caused by brainstem infarction has not been advocated. The authors report two patients with trigeminal neuralgia following pontine infarction in whom aggressive medical management failed, but who were successfully treated with RFL. Pain relief has persisted for the 3- and 6-year duration of follow-up examinations. Descending trigeminal reticular fibers may be affected by brainstem infarction and result in trigeminal neuralgia; thus, treatment by rhizotomy may be effective in decreasing the peripheral afferent input into the spinal trigeminal nucleus thus decreasing the pain. These two cases demonstrate the utility of RFL in the relief of ischemia-induced trigeminal neuralgia and lead the authors to suggest that its use be broadened to include this indication.</jats:p>

Postischemic Trigeminal Neuropathy Treated With Radiofrequency Ablation

“…The timing of onset of ischemic trigeminal neuropathy is another distinguishing factor from trigeminal neuralgia in that it typically presents within two weeks of the inciting infarct rather than as a sudden onset without inciting factors [8,10]. Most reported cases of trigeminal neuropathy from ischemia are found at the trigeminal nerve root entry zone or the principal sensory nucleus located in the pons; however, infarct along any portion of the trigeminal nerve pathway including in the medulla or along the spinal trigeminal accessory pathway has been reported to cause symptoms consistent with trigeminal neuropathy [1][2][3][6][7][8][9][10]. The exact mechanism by which ischemia of the trigeminal nerve sensory pathway results in symptoms of trigeminal neuralgia is unknown; the most accepted hypothesis is that irritation from the glial scar and inflammation secondary to the infarct forms an epileptogenic focus causing random depolarizations, which are perceived as pain [3].…”

“…The timing of onset of ischemic trigeminal neuropathy is another distinguishing factor from trigeminal neuralgia in that it typically presents within two weeks of the inciting infarct rather than as a sudden onset without inciting factors [ 8 , 10 ]. Most reported cases of trigeminal neuropathy from ischemia are found at the trigeminal nerve root entry zone or the principal sensory nucleus located in the pons; however, infarct along any portion of the trigeminal nerve pathway including in the medulla or along the spinal trigeminal accessory pathway has been reported to cause symptoms consistent with trigeminal neuropathy [ 1 - 3 , 6 - 10 ].…”

“…This is the fourth case of post-ischemic trigeminal neuropathy that has been successfully treated with percutaneous intervention (Table 3 ) [ 6 , 7 ]. The patient was originally treated with glycerol injection, which successfully alleviated his V2 and V3 pain but apparently unmasked his previously undescribed V1 pain.…”

“…Three cases of post-ischemic trigeminal neuropathy successfully treated with percutaneous intervention have been reported (Table 3 ). Foroohar et al [ 6 ] described a 50-year-old woman who developed right trigeminal neuropathy after stroke to the right pons. Initially, she responded to carbamazepine, but after seven months she re-presented with severe symptoms and failed conservative management with multiple medications.…”

“…Such cases have been categorized as classical trigeminal neuralgia [1][2][3]. Other causes of trigeminal pain have also been identified, such as multiple sclerosis and ischemic infarct, as well as other disorders affecting the normal trajectory of the nerve [3][4][5][6][7]. These cases have been categorized as trigeminal neuropathy [7].…”