http://neurology.medscape.com/Medscape/Neurology/journal/2001/v03.n02/ca-mn0413.01/ca-mn0413.01.html
Medscape Neurology
MEDLINE Abstracts
When trigeminal neuralgia
is associated with multiple sclerosis, it presents and responds to treatment
in unique ways. What's the latest research on the diagnosis and management
of trigeminal neuralgia in patients with multiple sclerosis? Find out in
this easy-to-navigate collection of recent MEDLINE abstracts compiled by
the editors at Medscape Neurology & Neurosurgery. [Medscape Neurology,
2001]
Trigeminal neuralgia in multiple sclerosis
Hooge JP, Redekop
WK
Neurology 1995,
45(7):1294-1296
Trigeminal neuralgia
(TN) occurred in 35 patients (1.9%) from a large multiple sclerosis (MS)
clinic population (N = 1,882). TN began on average 11.8 years after the
first MS symptom but in five patients was the first symptom of MS, preceding
the next MS symptom by 1 to 11 years. The onset of MS was later in the
patients who had TN, and bilateral TN occurred more frequently than expected
(in 14% of TN patients). The age at onset of TN was no younger than in
idiopathic TN except when TN was the first MS symptom. Most patients had
a good result from medical or surgical therapy.
Linear pontine trigeminal root lesions in multiple sclerosis: clinical and magnetic resonance imaging studies in 5 cases
Nakashima I, Fujihara
K, Kimpara T, et al.
Arch Neurol 2001,
58(1):101-104
Background:
Magnetic resonance imaging (MRI) is useful for demonstrating demyelinating
lesions in patients with multiple sclerosis (MS). Magnetic resonance imaging
studies show that MS lesions are generally not uniform in shape, size,
or distribution. Linearly shaped lesions at the trigeminal root entry zone
have been occasionally reported in single cases of MS, but, to our knowlege,
the frequency and the clinical features of such patients have not been
comprehensively characterized.
Objective: To describe
the frequency and the clinical and laboratory features of patients with
MS who had linearly shaped lesions at the trigeminal root as seen on MRI.
Design And Setting: A retrospective review of medical records and MRI films of Japanese patients with MS admitted to a university hospital and its affiliated hospital in Sendai, Japan.
Patients and Methods: Brain MRI films of 74 consecutive Japanese patients with MS (51 females and 23 males) were studied retrospectively and the clinical and laboratory features of the patients with linearly shaped lesions at the trigeminal root were also investigated retrospectively.
Results: Five patients (6.8%) were shown to have T1-weighted-hypointense, T2-weighted-hyperintense, nonenhanced linear lesions in the pons on MRI, and these were uniformly localized in the intramedullary portion of the trigeminal root. All of these patients had clinically definite MS and had various types of facial sensory disturbances, such as neuralgia (1 patient), hypesthesia (2 patients), or paresthesia (3 patients). No other clinical or laboratory feature was characteristic in these 5 patients.
Conclusions:
Linear pontine trigeminal root lesions were common in our patients with
MS. They were associated with various facial sensory symptoms. Since similar
lesions are formed in animal models of herpes simplex virus infection,
further study is needed to clarify whether these MS lesions are virally
induced.
Trigeminal neuralgia in patients
with multiple sclerosis: lesion localization with magnetic resonance imaging
Gass A, Kitchen N,
MacManus DG, et al.
We performed conventional
T2-weighted brain MRI examinations in six patients with multiple sclerosis
(MS) and trigeminal neuralgia. In all patients brainstem lesions in positions
expected to involve trigeminal fibers, particularly the entry zone of sensory
fibers, were demonstrated. Compression of the trigeminal nerve by ectatic
vessels, a recognized cause of idiopathic trigeminal neuralgia, was not
observed. We conclude that in MS trigeminal neuralgia is usually caused
by demyelinating lesions affecting pontine trigeminal pathways.
Association between trigeminal
neuralgia and multiple sclerosis: role of magnetic resonance imaging
Meaney JF; Watt JW;
Eldridge PR; Whitehouse GH; Wells JC; Miles JB
Seven consecutive
patients with multiple sclerosis and trigeminal neuralgia were investigated
with MRI to determine the occurrence of a lesion which would account for
the patients' pain. Two patients had bilateral symptoms. In the patients
with unilateral trigeminal neuralgia vascular compression of the nerve
by an artery at the root entry zone on the symptomatic side was confirmed
in three patients and an epidermoid tumour distorting the nerve on the
symptomatic side was identified in one patient. A demyelinating plaque
was identified in only one patient, affecting the trigeminal nerve at the
root entry zone at the pons. In those with bilateral symptoms neurovascular
compression was identified on both sides in one patient and on one side
only in the remaining patient. Microvascular decompression cured the pain
in two patients with neurovascular compression. The variable aetiology
of trigeminal neuralgia is stressed even in patients with coexistent neurological
conditions such as multiple sclerosis, which can cause trigeminal neuralgia
independent of other causes.
Magnetic resonance imaging used
to assess patients with trigeminal neuralgia
Yang J, Simonson
TM, Ruprecht A, et al.
To assess the value
of magnetic resonance imaging in the evaluation of trigeminal neuralgia,
51 patients were studied by magnetic resonance imaging after a trigeminal
protocol. Clinical and magnetic resonance imaging results were correlated.
Seventeen (33%) nonvascular abnormalities and 27 (53%) vascular contacts
or compressions of the trigeminal nerve were demonstrated. Of the patients
younger than of 29 and 39 years of age, 100% and 45%, respectively, had
a tumor or multiple sclerosis compared with 20% and 18% of those older
than 40 and 60 years of age, respectively. One third of the patients with
pain in more than one branch of the trigeminal nerve had tumors. On the
basis of this study, magnetic resonance imaging may be useful in discovering
underlying pathoses associated with trigeminal neuralgia if patients have
failed to respond to an initial conservative treatment. The patients most
likely to exhibit significant magnetic imaging resonance findings are young
and with pain in more than one trigeminal branch.
Cluster headache-like pain in
multiple sclerosis
Leandri M, Cruccu
G, Gottlieb A
We describe a case
with simultaneous occurrence of cluster headache-like pain and multiple
sclerosis. Both neuroimaging and neurophysiology (trigeminal evoked potentials)
revealed a demyelination plaque in the pons, at the trigeminal root entry
zone, on the side of pain. Although that type of lesion is usually associated
with trigeminal neuralgia pain, we hypothesize that in this case it may
be linked with the concomitant cluster headache, possibly by activation
of trigemino-vascular mechanisms.
Low-dose gabapentin combined
with either lamotrigine or carbamazepine can be useful therapies for trigeminal
neuralgia in multiple sclerosis.
Solaro C, Messmer
Uccelli M, Uccelli A, et al.
Paroxysmal symptoms
occur frequently in multiple sclerosis (MS). Usually they are treated with
carbamazepine (CBZ) and phenytoin, although these medications are often
interrupted due to adverse effects. We report 11 MS patients with trigeminal
neuralgia (TN): 6 intolerant to a therapeutic dosage of CBZ, showing serious
adverse effects and subsequently treated with a combination of low-dose
CBZ and gabapentin (GBP) (group 1); 5 treated with lamotrigine (LMT), showing
adverse effects and subsequently treated with GBP (group 2). Subjective
pain level and impairment in performing daily activities were rated utilizing
a 3-point scale at time 0 and at optimal dosage time (T1). GBP was initiated
at 300 mg daily and titrated, until pain control was achieved without new
adverse effects, to a maximum dose of 1,200 mg daily. CBZ or LMT were reduced
to a level which no longer produced adverse effects, although resulting
in a lack of efficacy in relieving pain. Pain control was obtained in all
patients but 1, with no side effects. The plasma level analysis, performed
in 5 patients, resulted in normal values. The mean dosages at T1 were:
group 1 CBZ 400 mg and GBP 850 mg daily; group 2 LMT 150 mg and GBP 780
mg daily. Combining drugs with complementary modes of action may provide
a rational pharmacological approach to the management of TN in MS. Copyright
2000 S. Karger AG, Basel.
Percutaneous controlled radiofrequency
rhizotomy in the management of patients with trigeminal neuralgia due to
multiple sclerosis.
Kanpolat Y, Berk
C, Savas A, et al.
Between the years
1974 and 1999, 1,672 patients with medically intractable trigeminal neuralgia
(TN) were treated by percutaneous controlled radiofrequency (RF) rhizotomy
by the senior author and co-workers at the Department of Neurosurgery,
Ankara University School of Medicine. Sixteen hundred cases (95.7%) were
found to have idiopathic TN, while 72 cases (4.3%) were classified as symptomatic.
In the latter group, TN was found to be caused by multiple sclerosis (MS)
in 17 cases (23.6%), one of whom had bilateral TN. All patients having
TN with MS (17 cases) underwent percutaneous controlled radiofrequency
rhizotomy (25 procedures) as the procedure of choice. The MS patients were
followed for an average of 60 months (range: 6-141 months). Complete pain
relief was achieved with a single procedure in 12 of the 17 MS cases (70.6%).
Early (less than 2 weeks) pain recurrence was seen in two patients (11.8%),
while the overall recurrence rate was 29.4%. A second procedure was required
to control TN in three cases (17.6%), a third in one (5.9%), and twice
for each side for the case with bilateral TN (5.9%). Pain was completely
relieved in 14 cases (82.4%) with single or multiple RF rhizotomies. In
three cases (17.6%), partial pain control was achieved with RF rhizotomy,
and the patients continued to receive adjunctive medical therapy. No complications
were observed. All 17 patients (100%) were classified to have done well
with RF rhizotomy. Satisfactory results and good long-term pain control
were obtained in patients having TN due to MS with percutaneous controlled
RF rhizotomy. The authors propose that RF rhizotomy may be a safe and effective
procedure in the neurosurgical armamentarium for the treatment of patients
having TN due to MS.
Microvascular decompression
for trigeminal neuralgia: comments on a series of 250 cases, including
10 patients with multiple sclerosis
Broggi G, Ferroli
P, Franzini A, et al.
Objective:
To examine surgical findings and results of microvascular decompression
(MVD) for trigeminal neuralgia (TN), including patients with multiple sclerosis,
to bring new insight about the role of microvascular compression in the
pathogenesis of the disorder and the role of MVD in its treatment.
Methods: Between
1990 and 1998, 250 patients affected by trigeminal neuralgia underwent
MVD in the Department of Neurosurgery of the "Istituto Nazionale Neurologico
C Besta" in Milan. Limiting the review to the period 1991-6, to exclude
the "learning period" (the first 50 cases) and patients with less than
1 year follow up, surgical findings and results were critically analysed
in 148 consecutive cases, including 10 patients with multiple sclerosis.
Results: Vascular
compression of the trigeminal nerve was found in all cases. The recurrence
rate was 15.3% (follow up 1-7 years, mean 38 months). In five of 10 patients
with multiple sclerosis an excellent result was achieved (follow up 12-39
months, mean 24 months). Patients with TN for more than 84 months did significantly
worse than those with a shorter history (p<0.05). There was no mortality
and most complications occurred in the learning period. Surgical complications
were not related to age of the patients.
Conclusions:
Aetiopathogenesis of trigeminal neuralgia remains a mystery. These findings
suggest a common neuromodulatory role of microvascular compression in both
patients with or without multiple sclerosis rather than a direct causal
role. MVD was found to be a safe and effective procedure to relieve typical
TN in patients of all ages. It should be proposed as first choice surgery
to all patients affected by TN, even in selected cases with multiple sclerosis,
to give them the opportunity of pain relief without sensory deficits.
Surgical treatment of trigeminal
neuralgia
Brisman R
Patients with medically
intractable trigeminal neuralgia characterized by paroxysmal, triggered,
trigeminally distributed pain are excellent candidates for neurosurgical
intervention, which can not only relieve the pain of trigeminal neuralgia,
but also eliminate the unpleasant side effects of medicines used to treat
it. The two major neurosurgical choices are percutaneous denervation and
microvascular decompression (MVD). Percutaneous denervation is done best
when the surgeon has available radiofrequency and glycerol and uses one,
the other, or both depending on technical circumstances that pertain to
each patient. The percutaneous denervation is less likely than MVD to cause
death, stroke, facial weakness, or hearing loss, but more likely to be
associated with recurrence or dysesthesias. Patients with multiple sclerosis,
medical illness, or who are elderly are much better candidates for percutaneous
denervation. For any patient, a number of other factors also must be considered
before deciding on a particular procedure. These include response to previous
interventions, ability to tolerate carbamazepine, risk tolerance for various
complications, preference regarding duration of hospital stay and postoperative
recovery, presence of pain outside the trigeminal distribution, and findings
on a high resolution magnetic resonance imaging (MRI) scan.
Microvascular decompression
for trigeminal neuralgia in patients with multiple sclerosis.
Resnick DK, Jannetta
PJ, Lunsford LD, et al.
Background:
Microvascular decompression (MVD) of the trigeminal nerve is a well-established
procedure for the treatment of idiopathic trigeminal neuralgia. Multiple
sclerosis (MS) has long been considered a contraindication for this procedure,
due to the known polycentric nature of the disease. Medical treatment followed
by percutaneous procedures provide relief for the great majority of these
patients. There exists a small subgroup of patients with trigeminal neuralgia
who are diagnosed with MS only after a microvascular decompression procedure
has been performed. Furthermore, management of the patient with known MS
whose pain continues to recur, despite maximal medical therapy and multiple
percutaneous procedures, can be exceedingly difficult.
Methods: Five
patients with MS, three who had undergone multiple unsuccessful percutaneous
procedures and two in whom the diagnosis of MS had not been established,
underwent exploration of the cerebellopontine angle. Three patients underwent
MVD alone, and two (both with known MS) underwent MVD and partial section
of the trigeminal nerve.
Results: Patients
who underwent microvascular decompression alone did not have satisfactory
relief of pain. Patients who underwent partial sectioning of the nerve
did better.
Conclusions:
Patients with MS and symptoms of typical trigeminal neuralgia may benefit
from exploration of the cerebellopontine angle and partial sectioning of
the nerve. MVD alone fails to provide adequate or reliable relief of pain.
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