Trigeminal neuralgia and cerebrovascular malformations. Two cases presentation

Abstract

Two rare cases of combined pathology, representing trigeminal neuralgia caused by cerebrovascular malformations (cavernous malformation, arteriovenous malformation), are detailed and analyzed. The study involved two patients, a 39-year-old woman and a 63-year-old man, with pain syndrome along the V2‒V3 branches of the left trigeminal nerve that was resistant to medical therapy. Neurological status otherwise unchanged. After thorough examination, neurosurgical treatment was performed in the form of microsurgical decompression of the trigeminal neuralgia via a retrosigmoid approach to the cerebellopontine angle and removal/mobilization of the cerebrovascular malformation, significantly improving the patients' overall condition and providing long-term pain-free postoperative periods: 5 years in the first and 6 months in the second cases. Trigeminal neuralgia may be the initial or sole manifestation of existing cerebrovascular malformations. Standard evaluation of patients with trigeminal neuralgia includes MRI of the brain using 3D sequences, particularly T2-weighted 3D DRIVE mode, for better visualization of vascular-nerve structures to identify the provocative factor, although this mode does not always provide complete reliable information regarding the microstructural features of the cerebellopontine angle. Accordingly, the surgeon must always be prepared for both standard microvascular decompression surgery and work with pathological vascular formations without disrupting blood flow in this area of the brainstem. Decompression of the trigeminal nerve root with maximal possible removal or isolation of the compressive factor plays an important role in the treatment of pain syndrome and is effective when properly performed.

Keywords

• trigeminal neuralgia; trigeminal nerve; pain syndrome; cerebrovascular malforma­tions; arteriovenous malformation; cavernous malformation; microvascular decompression; cerebellopontine angle.