More MS news articles for April 2001

Multiple Sclerosis-Associated Trigeminal Neuralgia

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.
Neurology 1997, 49(4):1142-1144

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
J Neurol Neurosurg Psychiatry 1995;59(3):253-259

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.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996; 81(3):343-350

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
Cephalalgia Oct 1999, 19(8):732-734

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.
Eur Neurol 2000, 44(1): 45-48

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.
Acta Neurochir 2000, 142(6):685-9; discussion 689-90

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.
J Neurol Neurosurg Psychiatry 2000, 68(1):59-64

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
Semin Neurol 1997, 17(4): 367-372

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.
Surg Neurol 1996, 46(4):358-361; discussion 361-362

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.