Percutaneous Balloon Compression for Trigeminal Neuralgia Because of Pontine Cavernous Angioma

Journal Pre-proof Percutaneous balloon compression for trigeminal neuralgia due to a pontine cavernous angioma: case report Wei Zhang, Xinghua Jiang, Yaping Wang PII:

S1878-8750(19)33199-7

DOI:

https://doi.org/10.1016/j.wneu.2019.12.167

Reference:

WNEU 14014

To appear in:

World Neurosurgery

Received Date: 16 September 2019 Revised Date:

26 December 2019

Accepted Date: 27 December 2019

Please cite this article as: Zhang W, Jiang X, Wang Y, Percutaneous balloon compression for trigeminal neuralgia due to a pontine cavernous angioma: case report, World Neurosurgery (2020), doi: https:// doi.org/10.1016/j.wneu.2019.12.167. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.

Case Report

Percutaneous balloon compression for trigeminal neuralgia due to a pontine cavernous angioma: case report

Running title: PBC for trigeminal neuralgia due to a CM

Wei Zhang, Xinghua Jiang*, Yaping Wang*

Department of Pain Management and Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China *

Correspondence to: Xinghua Jiang and Yaping Wang, Department of Pain

Management and Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China. E-mail address: [email protected] (Xinghua Jiang, M.D., Ph.D.) or [email protected] (Yaping Wang, M.D., Ph.D.)

Case Report

Percutaneous balloon compression for trigeminal neuralgia due to a pontine cavernous angioma: case report

Running title: PBC for trigeminal neuralgia due to a CM

Wei Zhang, Xinghua Jiang*, Yaping Wang*

Department of Pain Management and Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China *

Correspondence to: Xinghua Jiang and Yaping Wang, Department of Pain

Management and Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China. E-mail address: [email protected] (Xinghua Jiang, M.D., Ph.D.) or [email protected] (Yaping Wang, M.D., Ph.D.)

Abstract Background: A cavernous malformation (CM) with trigeminal neuralgia (TN) is relatively rare. We report a patient who presented with TN caused by a CM in the cerebellopontine angle. Case description: A 37-year-old man presented with a history of episodic,

shock-like, right facial pain of 2-month duration. Neurologic examination revealed diminished sensation in the distribution of the right trigeminal nerve. Magnetic resonance imaging showed an ipsilateral minimally enhancing lesion affecting the trigeminal nerve with characteristics of a CM and evidence of hemorrhage in the cerebellopontine angle. Results: The patient underwent percutaneous balloon compression of the Gasserian ganglion for trigeminal ganglia. The pain improved significantly after completion of this microsurgical method. Conclusions: CMs can damage the trigeminal nerve and cause TN. PBC of the Gasserian ganglion can be undertaken safely, and can relieve the pain due to TN caused by a CM in the cerebellopontine angle.

KEY WORDS: cavernous malformations, trigeminal neuralgia, percutaneous balloon compression

Introduction Cavernous malformations (CMs) are relatively rare vascular malformations. CMs can occur in any part of the central nervous system: 80% occur in the supratentorial space, 15% within an infratentorial location, and 5% within the spinal cord1, 2. The most common infratentorial location seems to be in the pons, but CMs of the pons presenting initially with TN are rare. We describe a patient who presented with TN caused by a CM located in the

cerebellopontine angle. The pain that he felt was abolished by compression of the Gasserian ganglion using a percutaneous balloon. Here, we report, to the best of our knowledge, the first case of a patient with TN caused by a CM who was successfully treated with by percutaneous balloon compression of Gasserian ganglion.

Case Report A 37-year-old man had a 2-month history of lancinating facial pain in the distribution of the right V1–V3 segments. Pain attacks were sudden and brief (10–20 s). The pain occurred 3–4 times per day initially and became more frequent until they occurred >50 times a day and facial pain was triggered by coughing or chewing. TN was the presumed diagnosis. The patient began treatment with a high dose of carbamazepine, but the pain was not relieved significantly. Neurologic examination revealed a diminished left-facial sensation to light touch in the distribution of the trigeminal nerve. His corneal reflex was normal. He had normal strength and gait. Magnetic resonance imaging (MRI) revealed a lesion of the right cerebellopontine angle which compressed the root-entry zone of the right trigeminal nerve on T1-weighted MRI (Figure 1A, C). The lesion appeared to be heterogeneous with a hemosiderin rim on T2-weighted MRI (Figure 1B). A hemosiderin susceptibility sequence (susceptibility-weighted image) was included to confirm the impressive hemosiderin deposition in the lesion (Figure 1D). Findings from magnetic resonance angiography and magnetic resonance venography were normal (data not

shown). The MRI appearance of the lesion was highly suggestive of a CM. The location of the lesion, involvement of vital structures, and the patient’s concerns about the risk of undergoing surgery, meant that a surgical procedure to remove the lesion was not possible. Radiofrequency thermocoagulation of the semilunar ganglion was undertaken in another hospital, but failed to relieve the pain, so percutaneous balloon compression (PBC) was undertaken in our hospital. The surgical procedure that we carried out has been described by Mullan and Lichtor3. Briefly, after the induction of general anesthesia with intratracheal intubation, a 14-G canula was used to enter the foramen ovale. Following satisfactory placement of a canula, a number-4 Fogarty balloon catheter was inserted through the canula. The balloon catheter was inflated by injecting 0.4 mL of dilute ionic radiocontrast slowly through a 1-mL syringe under continuous fluoroscopy. The duration of compression was ~4 min and a “pear”-shaped image obtained (Figure 2). After PBC, the patient’s lancinating facial pain disappeared completely, and his right face felt slightly numb. At 8-month follow-up, the patient no longer complained of the right face pain, the numeric rating scale (NRS) value was 1-2 and the patient ceased all medication.

Discussion TN can be classified as “classical”, “secondary” or “idiopathic” according to the etiology4. The most common type of TN is classical, and is caused by the microvascular conflict with the trigeminal nerve root. In secondary TN, the etiology

for the symptoms has been identified. The patient with a prior history of hemorrhage, and he never presented with facial pain before the hemorrhage from the CM, this process suggested that his pain was associated with the CM. TN caused by a CM is secondary TN and is relatively rare. A cavernous angioma in the spinal cord or brainstem presenting with symptoms of pain resembling TN has been reported only a few times. Saito et al. reported a case of TN with a medullary cavernous angioma in the upper cervical spinal cord, and the pain was relieved after it was removed by surgery5. Vitek et al. described TN with a cavernous angioma in the brachium pontis, and the pain was alleviated by gabapentin6. Stellmann et al. detailed a case of TN caused by a small cavernoma in the caudal part of the trigeminal nucleus, and the facial pain stopped spontaneously7. Muzumda et al. described a CM in the interpeduncular cistern associated with TN, and the pain was relieved after the CM had been totally excised8. Deshmukh et al. reported a case of TN caused by a CM at the nerve root-entry zone of the trigeminal nerve, and the pain resolved after surgical excision of the CM9. Cenzato et al. described a case of a pontine cavernous angioma associated with TN, and the pain disappeared after surgical removal of the cavernous angioma10. Adachi et al. reported TN due to a CM located in the cerebellopontine angle, and the pain disappeared after the lesion was removed by surgery11. Frossard et al. described TN with a rapidly growing CM in the distribution of the trigeminal nerve, and the pain was replaced gradually by complete left-facial anesthesia before surgical removal of the CM and the root of the trigeminal nerve12.

PBC was described first by Mullan and Lichtor3 in 1983. It was considered to be efficacious and inexpensive therapy for TN, especially for classical or idiopathic types13,

14

. PBC has also been reported to have a good effect on some types of

secondary TN, such as TN caused by multiple sclerosis15, 16. In our case, using PBC resolved the TN caused by an intrapontine CM. As mentioned above, most cases of TN caused by a CM have involved surgery to remove the lesions, but resection of a CM in the brainstem carries the risk of re-hemorrhage and other postoperative complications17. Indeed, if the excision is incomplete, the risk of re-hemorrhage can be ≤43%18. Although the patient’s pain was controlled by PBC, the CM is still existence and has not been treated. It is noted that the history of prior hemorrhage is the most important risk factor for subsequent hemorrhage19, radical surgical excision of CM can eliminate the risk of subsequent bleeding, and we still recommend the patient undergo an excision surgery of CM. PBC for the treatment of TN is a well-established method and, compared with open surgery, PBC is less invasive, technically easier and associated with fewer postoperative complications. PBC is thought to injure large myelinated fibers selectively by compression of the trigeminal ganglion. Also, PBC can produce pain relief in an acceptable time, though ipsilateral hemifacial hypoesthesia may be expected during the postoperative period20. For patients who are reluctant to pursue open surgery, such minimally invasive treatment may be a better choice.

Conclusions

PBC can be a reasonable treatment option for TN secondary to a CM if the effect of the medication alone is poor and the patient does not want open surgery.

Conflict of interest: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest Funding sources. Funding sources: This work was supported by National Natural Science Foundation of China [Grant No. 81671962].

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Figure legends Figure 1. T1-weighted axial MRI shows a large lesion (arrow) compressing the pons and root-entry zone of the trigeminal nerve (A). T2-weighted MRI shows a large hemorrhagic mass in the right cerebellopontine angle with mixed signal intensity (B). An irregular lesion on the T1-weighted image (parasagittal view) (C). A susceptibility

sequence depicting a high degree of hemosiderin deposition (D).

Figure 2. Radiograph (lateral view) shows a pear-like balloon shape. The tip of the pear is indicated by a red asterisk.

Abbrevations CM: cavernous malformation TN: trigeminal neuralgia MRI: magnetic resonance imaging PBC: percutaneous balloon compression