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 Table of Contents  
CME IN IMAGES
Year : 2018  |  Volume : 16  |  Issue : 3  |  Page : 103-104

Trigeminal Neuralgia Secondary to Basilar Artery Dolichoectasia


Department of Neurology, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil

Date of Web Publication9-Nov-2018

Correspondence Address:
Jamir Pitton Rissardo
Rua elpídio de Menezes, 195, Santa Maria, Rio Grande do Sul,
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_16_18

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How to cite this article:
Rissardo JP, Fornari Caprara AL. Trigeminal Neuralgia Secondary to Basilar Artery Dolichoectasia. Curr Med Issues 2018;16:103-4

How to cite this URL:
Rissardo JP, Fornari Caprara AL. Trigeminal Neuralgia Secondary to Basilar Artery Dolichoectasia. Curr Med Issues [serial online] 2018 [cited 2018 Dec 15];16:103-4. Available from: http://www.cmijournal.org/text.asp?2018/16/3/103/245036


  Case Scenario Top


A 60-year-old male presented with progressively severe left facial pain with 8 years of onset. The pain was stabbing on quality and occurred in paroxysmal attacks in V2 and V3 trigeminal territories with duration of approximately 30 s–1 min. He was previously healthy and his family history was unremarkable. The neurological examination showed facial trigger points in the left maxillary region. Furthermore, he said that brushing teeth and shaving triggered pain. Laboratorial tests were within the normal limits. A noncontrast head computed tomography was requested [Figure 1].
Figure 1: Noncontrast cranial computed tomography scan.

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Questions

  1. What are the findings in the noncontrast cranial computed tomography scan?
  2. What is the most likely diagnosis taking into account this clinical scenario?
  3. What is the treatment of this condition?
  4. Which differential diagnoses are possible?


Answers

  1. The axial noncontrast cranial computed tomography reveals basilar artery elongation and distension, also known as dolichoectasia [Figure 2]
  2. Trigeminal neuralgia secondary to basilar dolichoectasia.
Figure 2: Arrows point to the basilar artery dolichoectasia.

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Trigeminal neuralgia is characterized by sudden paroxysms of neuropathic pain in the distribution of one or more divisions of the trigeminal nerve.

Pathophysiology

The most common cause is a compression of the fifth cranial nerve root by an aberrant vessel loop (90%). The mechanism of pain is thought to be related with the compression of the nerve that would lead to demyelination, which makes a region more susceptible to stimuli and possibly allows ephaptic conduction. In this way, this hypothesis suggests an explanation to the triggering of pain from innocuous stimuli, such as brushing teeth, touching, and shaving.[1],[2]

Diagnosis

In the Third Edition from the International Classification of Headache Disorders (ICHD), trigeminal neuralgia is divided into classic, secondary, and idiopathic based on clinical features.[3] The classical and idiopathic are also known as typical trigeminal neuralgia and the secondary as atypical trigeminal neuralgia. A detailed medical history and neurological examination are needed to distinguish them and help select the cases that require further evaluation. In this context, it should be emphasized that clinical clues such as younger age of symptoms onset, bilateral involvement, history of demyelinating diseases and sensory loss are associated with an increased risk of atypical trigeminal neuralgia, and in these cases, neuroimaging should be considered.[4] The third edition of the ICHD has suggested the criteria presented in [Table 1] for classic trigeminal neuralgia.[3] The differential diagnosis of trigeminal neuralgia is given in [Table 2][2],[3]
Table 1: Third beta version of the diagnostic criteria for classical trigeminal neuralgia of the international classification of headache disorders

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Table 2: Differential diagnosis of trigeminal neuralgia

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3. Pharmacologic management is the initial therapy to subjects with classic trigeminal neuralgia. Since carbamazepine is effective and the best-studied drug, it is considered one of the first-line therapies in classic trigeminal neuralgia.[2] Patients who are refractory to pharmacology therapy are candidates for surgery. In this way, a systemic review published in 2008 concluded that for these patients, the  Gasserian ganglion More Details percutaneous technique, gamma knife, and microvascular decompression might be considered. Although the surgical therapy achieve in 90% pain relief, the pain-free rates declined throughout the years[4]

4. In [Table 2], the differential diagnosis is based on the localization of the pain.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Love S, Coakham HB. Trigeminal neuralgia: Pathology and pathogenesis. Brain 2001;124:2347-60.  Back to cited text no. 1
    
2.
Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth 2013;111:95-104.  Back to cited text no. 2
    
3.
Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013;33:629-808.  Back to cited text no. 3
    
4.
Gronseth G, Cruccu G, Alksne J, Argoff C, Brainin M, Burchiel K, et al. Practice parameter: The diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): Report of the quality standards subcommittee of the american academy of neurology and the european federation of neurological societies. Neurology 2008;71:1183-90.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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