Diffusion tensor imaging for trigeminal neuralgia

Diffusion tensor imaging for trigeminal neuralgia

A total of 22 patients with classic trigeminal neuralgia and 22 healthy controls (HC) with matching age, gender, and education were selected. All subjects underwent 3.0 T magnetic resonance diffusion tensor imaging and high resolution T1-weighted imaging. The corpus callosum (CC) was reconstructed by DTI technology, which was divided into three substructure regions: genu, body, and splenium. Group differences in multiple diffusion metrics, including fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD), were compared between CTN patients and HC, and correlations between the white matter change and disease duration and VAS in CTN patients were assessed.

Compared with HC group, CTN patients had extensive damage to the CC white matter. The FA of the genu (P = 0.04) and body (P = 001) parts decreased, while RD (P = 0.003; P = 0.02) and MD (P = 0.002; P = 0.04) increased. In addition, the authors observed that the disease duration and VAS of CTN patients were negatively correlated with FA.

The corpus callosum substructure region has extensive damage in chronic pain, and the selective microstructural integrity damage was particularly manifested by changes in axons and myelin sheath in the genu and body of corpus callosum 1).


Diffusion tensor imaging (DTI) has revealed microstructural changes in the symptomatic trigeminal root and root entry zone of patients with unilateral TN.

Noninvasive DTI analysis of patients with TN may lead to improved trigeminal neuralgia diagnosis of TN subtypes (e.g., TN1 and TN2) and improve patient selection for surgical intervention. DTI measurements may also provide insights into prognosis after intervention, as TN1 patients are known to have better surgical outcomes than TN2 patients 2).


As diffusion tensor imaging (DTI) is able to assess tissue integrity, Leal et al., used diffusion to detect abnormalities in trigeminal nerves (TGN) in patients with trigeminal neuralgia (TN) caused by neurovascular compression (NVC) who had undergone microvascular decompression (MVD).

Using DTI sequencing on a 3-T MRI scanner, we measured the fraction of anisotropy (FA) and apparent diffusion coefficient (ADC) of the TGN in 10 patients who had undergone MVD for TN and in 6 normal subjects. We compared data between affected and unaffected nerves in patients and both nerves in normal subjects (controls). We then correlated these data with CSA and V. Data from the affected side and the unaffected side before and 4 years after MVD were compared.

RESULTS: Before MVD, the FA of the affected side (0.37 ± 0.03) was significantly lower (p < 0.05) compared to the unaffected side in patients (0.48 ± 0.03) and controls (0.52 ± 0.02), and the ADC in the affected side (5.6 ± 0.34 mm2/s) was significantly higher (p < 0.05) compared to the unaffected side in patients (4.26 ± 0.25 mm2/s) and controls (3.84 ± 0.18 mm2/s). Affected nerves had smaller V and CSA compared to unaffected nerves and controls (p < 0.05). After MVD, the FA in the affected side (0.41 ± 0.02) remained significantly lower (p < 0.05) compared to the unaffected side (0.51 ± 0.02), but the ADC in the affected side (4.24 ± 0.34 mm2/s) had become similar (p > 0.05) to the unaffected side (4.01 ± 0.33 mm2/s).

CONCLUSIONS: DTI revealed a loss of anisotropy and an increase in diffusivity in affected nerves before surgery. Diffusion alterations correlated with atrophic changes in patients with TN caused by NVC. After removal of the compression, the loss of FA remained, but ADC normalized in the affected nerves, suggesting improvement in the diffusion of the trigeminal root 3).


Herveh et al. studied the trigeminal nerve in seven healthy volunteers and six patients with trigeminal neuralgia using the diffusion tensor imaging derived parameter fractional anisotropy (FA). While controls did not show a difference between both sides, there was a reduction of FA in the affected nerve in three of six patients with accompanying nerve-vessel conflict and atrophy. Reversibility of abnormally low FA values was demonstrated in one patient successfully treated with microvascular decompression 4).


3T MR diffusion weighted, T1, T2 and FLAIR sequences were acquired for Multiple sclerosis related trigeminal neuralgia MS-TN, TN, and controls. Multi-tensor tractography was used to delineate CN V across cisternal, root entry zone (REZ), pontine and peri-lesional segments. Diffusion metrics including fractional anisotropy (FA), and radial (RD), axial (AD), and mean diffusivities (MD) were measured from each segment.

CN V segments showed distinctive diffusivity patterns. The TN group showed higher FA in the cisternal segment ipsilateral to the side of pain, and lower FA in the ipsilateral REZ segment. The MS-TN group showed lower FA in the ipsilateral peri-lesional segments, suggesting differential microstructural changes along CN V in these conditions.

The study demonstrates objective differences in CN V microstrucuture in TN and MS-TN using non-invasive neuroimaging. This represents a significant improvement in the methods currently available to study pain in MS 5).


The aim of a study was to evaluate the microstructural tissue abnormalities in the trigeminal nerve in symptomatic trigeminal neuralgia not related to neurovascular compression using diffusion tensor imaging. Mean values of the quantitative diffusion parameters of trigeminal nerve, fractional anisotropy and apparent diffusion coefficient, were measured in a group of four symptomatic trigeminal neuralgia patients without neurovascular compression who showed focal non-enhancing T2-hyperintense lesions in the pontine trigeminal pathway. These diffusion parameters were compared between the affected and unaffected sides in the same patient and with four age-matched healthy controls. Cranial magnetic resonance imaging revealed hyperintense lesions in the dorsolateral part of the pons along the central trigeminal pathway on T2-fluid-attenuated inversion recovery sequences. The mean fractional anisotropy value on the affected side was significantly decreased (P = 0.001) compared to the unaffected side and healthy controls. Similarly, the mean apparent diffusion coefficient value was significantly higher (P = 0.001) on the affected side compared to the unaffected side and healthy controls. The cause of trigeminal neuralgia in our patients was abnormal pontine lesions affecting the central trigeminal pathway. The diffusion tensor imaging results suggest that microstructural tissue abnormalities of the trigeminal nerve also exist even in non-neurovascular compression-related trigeminal neuralgia 6).


DTI analysis allows the quantification of structural alterations, even in those patients without any discernible neurovascular contact on MRI. Moreover, our findings support the hypothesis that both the arteries and veins can cause structural alterations that lead to TN. These aspects can be useful for making treatment decisions 7).


The mean diameter of compression arteries (DCA) in NVC patients with TN (1.58 ± 0.34 mm) was larger than that without TN (0.89 ± 0.29 mm). Compared with NVC without TN and HC, the mean values of RD at the site of NVC with TN were significantly increased; however, no significant changes of AD were found between the groups. Correlation analysis showed that DCA positively correlated with radial diffusivity (RD) in NVC patients with and without TN (r = 0.830, p = 0.000). No significant correlation was found between DCA and axial diffusivity (AD) (r = 0.178, p = 0.077).

Larger-diameter compression arteries may increase the chances of TN, and may be a possible facilitating factor for TN 8).


Fractional anisotropy (FA) value quantitatively showed the alteration of trigeminal nerve (TGN) caused by Neurovascular compression (NVC). It provided direct evidence about the effect of NVC which facilitated the diagnosis and surgical decision of Type 2 trigeminal neuralgia (TN) . Besides, significant reduction of FA value may predict an optimistic outcome of microvascular decompression (MVD) 9).


Sophisticated structural MRI techniques including diffusion tensor imaging provide new opportunities to assess the trigeminal nerves and CNS to provide insight into TN etiology and pathogenesis. Specifically, studies have used high-resolution structural MRI methods to visualize patterns of trigeminal nerve-vessel relationships and to detect subtle pathological features at the trigeminal REZ. Structural MRI has also identified CNS abnormalities in cortical and subcortical gray matter and white matter and demonstrated that effective neurosurgical treatment for TN is associated with a reversal of specific nerve and brain abnormalities 10).


Forty-three patients with trigeminal neuralgia were recruited, and diffusion tensor imaging was performed before radiofrequency rhizotomy. By selecting the cisternal segment of the trigeminal nerve manually, they measured the volume of trigeminal nerve, fractional anisotropy, apparent diffusion coefficient, axial diffusivity, and radial diffusivity. The apparent diffusion coefficient and mean value of fractional anisotropy, axial diffusivity, and radial diffusivity were compared between the affected and normal side in the same patient, and were correlated with pre-rhizotomy and post-rhizotomy visual analogue scale pain scores. The results showed the affected side had significantly decreased fractional anisotropy, increased apparent diffusion coefficient and radial diffusivity, and no significant change of axial diffusivity. The volume of the trigeminal nerve on affected side was also significantly smaller. There was a trend of fractional anisotropy reduction and visual analogue scale pain score reduction (P = 0.072). The results suggest that demyelination without axonal injury, and decreased size of the trigeminal nerve, are the microstructural abnormalities of the trigeminal nerve in patients with trigeminal neuralgia caused by neurovascular compression. The application of diffusion tensor imaging in understanding the pathophysiology of trigeminal neuralgia, and predicting the treatment effect has potential and warrants further study 11).

References

1)

Li R, Chang N, Liu Y, Zhang Y, Luo Y, Zhang T, Zhao Q, Qi X. The Integrity of the Substructure of the Corpus Callosum in Patients with Right Classic Trigeminal Neuralgia-A Diffusion Tensor Imaging Study. J Craniofac Surg. 2020 Sep 22. doi: 10.1097/SCS.0000000000007082. Epub ahead of print. PMID: 32969923.
2)

Willsey MS, Collins KL, Conrad EC, Chubb HA, Patil PG. Diffusion tensor imaging reveals microstructural differences between subtypes of trigeminal neuralgia. J Neurosurg. 2019 Jul 19:1-7. doi: 10.3171/2019.4.JNS19299. [Epub ahead of print] PubMed PMID: 31323635.
3)

Leal PRL, Roch J, Hermier M, Berthezene Y, Sindou M. Diffusion tensor imaging abnormalities of the trigeminal nerve root in patients with classical trigeminal neuralgia: a pre- and postoperative comparative study 4 years after microvascular decompression. Acta Neurochir (Wien). 2019 May 2. doi: 10.1007/s00701-019-03913-5. [Epub ahead of print] PubMed PMID: 31049710.
4)

Herweh C, Kress B, Rasche D, Tronnier V, Tröger J, Sartor K, Stippich C. Loss of anisotropy in trigeminal neuralgia revealed by diffusion tensor imaging. Neurology. 2007 Mar 6;68(10):776-8. PubMed PMID: 17339587.
5)

Chen DQ, DeSouza DD, Hayes DJ, Davis KD, O’Connor P, Hodaie M. Diffusivity signatures characterize trigeminal neuralgia associated with multiple sclerosis. Mult Scler. 2016 Jan;22(1):51-63. doi: 10.1177/1352458515579440. PubMed PMID: 25921052.
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Neetu S, Sunil K, Ashish A, Jayantee K, Usha Kant M. Microstructural abnormalities of the trigeminal nerve by diffusion-tensor imaging in trigeminal neuralgia without neurovascular compression. Neuroradiol J. 2016 Feb;29(1):13-8. doi: 10.1177/1971400915620439. PubMed PMID: 26678753; PubMed Central PMCID: PMC4978338.
7)

Lutz J, Thon N, Stahl R, Lummel N, Tonn JC, Linn J, Mehrkens JH. Microstructural alterations in trigeminal neuralgia determined by diffusion tensor imaging are independent of symptom duration, severity, and type of neurovascular conflict. J Neurosurg. 2016 Mar;124(3):823-30. doi: 10.3171/2015.2.JNS142587. PubMed PMID: 26406792.
8)

Lin W, Zhu WP, Chen YL, Han GC, Rong Y, Zhou YR, Zhang QW. Large-diameter compression arteries as a possible facilitating factor for trigeminal neuralgia: analysis of axial and radial diffusivity. Acta Neurochir (Wien). 2016 Mar;158(3):521-6. doi: 10.1007/s00701-015-2673-4. PubMed PMID: 26733127; PubMed Central PMCID: PMC4752583.
9)

Chen F, Chen L, Li W, Li L, Xu X, Li W, Le W, Xie W, He H, Li P. Pre-operative declining proportion of fractional anisotropy of trigeminal nerve is correlated with the outcome of micro-vascular decompression surgery. BMC Neurol. 2016 Jul 16;16:106. doi: 10.1186/s12883-016-0620-5. PubMed PMID: 27422267; PubMed Central PMCID: PMC4947245.
10)

DeSouza DD, Hodaie M, Davis KD. Structural Magnetic Resonance Imaging Can Identify Trigeminal System Abnormalities in Classical Trigeminal Neuralgia. Front Neuroanat. 2016 Oct 19;10:95. Review. PubMed PMID: 27807409; PubMed Central PMCID: PMC5070392.
11)

Chen ST, Yang JT, Yeh MY, Weng HH, Chen CF, Tsai YH. Using Diffusion Tensor Imaging to Evaluate Microstructural Changes and Outcomes after Radiofrequency Rhizotomy of Trigeminal Nerves in Patients with Trigeminal Neuralgia. PLoS One. 2016 Dec 20;11(12):e0167584. doi: 10.1371/journal.pone.0167584. PubMed PMID: 27997548.

Postoperative pain

Postoperative pain

Perioperative pain assessment and management in neurosurgical patients varies widely across the globe. There is lack of data from developing world regarding practices of pain assessment and management in neurosurgical population.

A survey aimed to capture practices and perceptions regarding perioperative pain assessment and management in neurosurgical patients among anesthesiologists who are members of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) and evaluated if hospital and pain characteristics predicted the use of structured pain assessment protocol and use of opioids for postoperative pain management.

A 26-item English language questionnaire was administered to members of ISNACC using Kwiksurveys platform after ethics committee approval. This outcome measures were adoption of structured protocol for pain assessment and opioid usage for postoperative pain management.

The response rate for this survey was 55.15% (289/524). One hundred eighteen (41%) responders informed that their hospital setup had a structured pain protocol while 43 (15%) responders reported using opioids for postoperative pain management. Predictors of the use of structured pain protocol were private setup (odds ratio [OR] 2.64; 95% confidence interval [CI] 1.52-4.59; p=0.001), higher pain intensity (OR 0.37; 95% CI 0.21-0.64; p<0.001) and use of pain scale (OR 7.94; 95% CI 3.99-15.81; p<0.001) while availability of structured pain protocol (OR 2.04; 95% CI 1.02-4.05; p=0.043) was the only significant variable for postoperative opioid use.

Less than half of the Indian neuroanesthesiologists who are members of ISNACC use structured protocol for pain assessment and very few use opioids for postoperative pain management in neurosurgical patients 1).


Studying the characteristics of postoperative pain at such an early stage allows for improved management. It helps to predict, according to the type of surgery and the anaesthesia used, those patients in which higher VAS values may be seen and to better adapt analgesic therapy 2).

Despite advances in surgical and anesthesiology techniques, many patients continue to experience postoperative pain after lumbar disc operations

The administration of tramadol with paracetamol was more effective than tramadol alone for early acute postoperative pain therapy following lumbar discectomy. Therefore while adding paracetamol in early pain management is recommended, continuing paracetamol for the late postoperative period is not advised 3).

Etiology

Epidural fibrosis and epidural adhesion after laminectomy are developed from adjacent dense scar tissue, which is a natural wound healing process 4) 5) 6) 7) , and ranked as the major contributor for postoperative pain recurrence after laminectomy or discectomy.

Treatment

The goal of postoperative pain management is to relieve pain while keeping side effects to a minimum. After hundreds of years of advances, the mainstay of pain therapy is still the opioids. While they are very effective analgesics, opioids also carry with them many undesirable side effects: sedation, respiratory depression, nausea and vomiting, hypotension and bradycardia, pruritus, and inhibition of bowel function. The treatment of complications such as nausea and pruritus may include the administration of antihistamines, which have an additive effect on sedation and respiratory depression.

References

1)

Sriganesh K, Bidkar PU, Krishnakumar M, Singh GP, Hrishi AP, Jangra K. Perioperative Analgesia In Neurosurgery (PAIN): A national survey of pain assessment and management among neuroanesthesiologists of India. Int J Clin Pract. 2020 Sep 23:e13718. doi: 10.1111/ijcp.13718. Epub ahead of print. PMID: 32966673.
2)

Cabedo N, Valero R, Alcón A, Gomar C. Prevalence and characterization of postoperative pain in the Postanaesthesia Care Unit. Rev Esp Anestesiol Reanim. 2017 Mar 28. pii: S0034-9356(16)30211-0. doi: 10.1016/j.redar.2016.11.006. [Epub ahead of print] English, Spanish. PubMed PMID: 28363327.
3)

Uztüre N, Türe H, Keskin Ö, Atalay B, Köner Ö. Comparison of Tramadol versus Tramadol with Paracetamol for efficacy of postoperative pain management in lumbar discectomy: a randomized controlled study. Int J Clin Pract. 2019 Sep 11. doi: 10.1111/ijcp.13414. [Epub ahead of print] PubMed PMID: 31508863.
4)

Alkalay RN, Kim DH, Urry DW, Xu J, Parker TM, Glazer PA. Prevention of postlaminectomy epidural fibrosis using bioelastic materials. Spine (Phila Pa 1976) 2003;28:1659–1665.
5)

Hsu CJ, Chou WY, Teng HP, Chang WN, Chou YJ. Coralline hydroxyapatite and laminectomy-derived bone as adjuvant graft material for lumbar posterolateral fusion. J Neurosurg Spine. 2005;3:271–275.
6)

Temel SG, Ozturk C, Temiz A, Ersozlu S, Aydinli U. A new material for prevention of epidural fibrosis after laminectomy: oxidized regenerated cellulose (interceed), an absorbable barrier. J Spinal Disord Tech. 2006;19:270–275.
7)

Yu CH, Lee JH, Baek HR, Nam H. The effectiveness of poloxamer 407-based new anti-adhesive material in a laminectomy model in rats. Eur Spine J. 2012;21:971–979.

Percutaneous foramen ovale puncture

Percutaneous Foramen Ovale Puncture

Foramen ovale (FO) puncture allows percutaneous trigeminal rhizotomy, Foramen ovale electrode placement, and selected biopsy studies.

Balloon compression of the gasserian ganglion has been a well-established percutaneous treatment of trigeminal neuralgia since the 1980s. However, puncture of the foramen ovale by conventional single-plane fluoroscopy can be difficult in cases of local anatomic abnormalities.

Mendes et al. presented the case of a 49-year-old woman diagnosed with idiopathic trigeminal neuralgia refractory to pharmacological treatment. After failure of puncture by conventional fluoroscopy for percutaneous gasserian ganglion balloon compression due to a narrow foramen ovale, the patient was submitted to puncture guided by computed tomography.

Alternative imaging methods, such as computed tomography, should be considered when Percutaneous Foramen Ovale Puncture by conventional single-plane fluoroscopy fails, to minimize the risk of potential complications triggered by frustrated puncture attempts 1).

Complications

Although Gasserian ganglion block is an established treatment for trigeminal neuralgia, the foramen ovale cannot always be clearly visualized by classical X-ray radiography.

Cannulation procedures, including those utilizing neuronavigational technology, are occasionally complicated by anatomical variation of the FO, sometimes resulting in miscannulation and subsequent adverse events. The FO, while commonly thought of as oval-shaped, has also been described as “almond,” “banana,” “D shape,” “pear,” and “triangular.” 2).

Advancement of the catheter more than 10 mm from the foramen ovale is likely to damage the internal carotid artery and the abducens nerve at the medial side of the petrolingual ligament. Thermocoagulation of the lateral wall of the cavernous sinus may damage the cranial nerves by heat, giving rise to pareses 3).


Guo et al., described a technique that includes a stereotactic approach in the preoperative plan in cases where the foramen ovale is difficult to access for radiofrequency thermocoagulation of the Gasserian ganglion.

The study included 395 patients for whom three-dimensional computed tomographic reconstruction of the skull base, maxilla, and mandible was conducted before surgery. Accessibility of the foramen ovale was defined using numerical data from the three-dimensional computed tomographic reconstruction images. In those patients for whom accessibility of the foramen ovale was considered difficult, the authors used a stereotactic frame to design an individual operative plan. Adjustments of a single point of data,-that is, a change in X axis, Y axis, or an arc angle-were guided by radiographic fluoroscopy images. After verifying successful cannulation and electroneurophysiology, thermocoagulation targets-especially multiple targets recorded as data on the Z axis of the stereotactic approach-were identified and treated.

There were 24 patients who met the predetermined criteria for having a difficult-to-access foramen ovales-that is, they had at least two contributing factors and/or involvement of division V1 . Twenty-one of the 24 patients required a single satisfactory puncture; three patients required two to three punctures to successfully access the foramen ovale. There were no permanent complications from the procedure.

The authors conclude that this stereotactic approach combined with three-dimensional computed tomographic reconstruction model can improve the accuracy, safety, and efficiency of percutaneous radiofrequency thermocoagulation in patients with trigeminal neuralgia for whom the foramen ovale is difficult to access 4).


Ding et al., assessed the feasibility of accessing the Gasserian ganglion through the FO from a mandibular angle under computed tomography (CT) and neuronavigation guidance.A total of 108 patients with TN were randomly divided into 2 groups (Group G and Group H) using a random number table. In Group H, anterior Hartel approach was used to puncture the FO; whereas in Group G, a percutaneous puncture through a mandibular angle was used to reach the FO. In both groups, procedures were guided by CT imaging and neuronavigation. The success rates, therapeutic effects, complications, and recurrence rates of the 2 groups were compared.The puncture success rates in Group H and Group G were 52/54 (96.30%) and 49/54 (90.74%), respectively (P = 0.24). The 2 procedural failures in Group H were rescued by using submandibular trajectory, and the 5 failures in Group G were successfully reapproached by Hartel method. Therapeutic effects as measured by Barrow Neurological Institute Pain Scale (P = 0.03) and quality of life (QOL) scores (P = 0.04) were significantly better in Group G than those in Group H at 36 months posttreatment. Hematoma developed in 1/54 (1.85%) cases in Group H, and no cases of hematoma were observed in Group G (P = 0.33). In Group H, RFT resulted in injury to the unintended trigeminal nerve branches and motor fibers in 27/52 (51.92%) cases; in Group G, it resulted in the same type of injury in 7/49 cases (14.29%) (P < 0.01). In Group H, the 24- and 36-month recurrence rates were 12/51 (23.53%) and 20/51 (39.22%), respectively; in Group G, these recurrence rates were 7/49 (12.24%) and 9/49 (16.33%, P = 0.03), respectively.CT- and neuronavigation-guided puncture from a mandibular angle through the FO into the Gasserian ganglion can be safely and effectively used to deliver RFT for the treatment of pTN. This method may represent a viable option to treat TN in addition to Hartel approach 5).


The goals of a study of Peris-Celda et al., were to demonstrate the anatomical basis of complications related to FO puncture, and provide anatomical landmarks for improvement of safety, selective lesioning of the trigeminal nerve (TN), and optimal placement of electrodes.

Both sides of 50 dry skulls were studied to obtain the distances from the FO to relevant cranial base references. A total of 36 sides from 18 formalin-fixed specimens were dissected for Meckel cave and TN measurements. The best radiographic projection for FO visualization was assessed in 40 skulls, and the optimal trajectory angles, insertion depths, and topographies of the lesions were evaluated in 17 specimens. In addition, the differences in postoperative pain relief after the radiofrequency procedure among different branches of the TN were statistically assessed in 49 patients to determine if there was any TN branch less efficiently targeted.

Most severe complications during FO puncture are related to incorrect needle placement intracranially or extracranially. The needle should be inserted 25 mm lateral to the oral commissure, forming an approximately 45° angle with the hard palate in the lateral radiographic view, directed 20° medially in the anteroposterior view. Once the needle reaches the FO, it can be advanced by 20 mm, on average, up to the petrous ridge. If the needle/radiofrequency electrode tip remains more than 18 mm away from the midline, injury to the cavernous carotid artery is minimized. Anatomically there is less potential for complications when the needle/radiofrequency electrode is advanced no more than 2 mm away from the clival line in the lateral view, when the needle pierces the medial part of the FO toward the medial part of the trigeminal impression in the petrous ridge, and no more than 4 mm in the lateral part. The 40°/45° inferior transfacial-20° oblique radiographic projection visualized 96.2% of the FOs in dry skulls, and the remainder were not visualized in any other projection of the radiograph. Patients with V1 involvement experienced postoperative pain more frequently than did patients with V2 or V3 involvement. Anatomical targeting of V1 in specimens was more efficiently achieved by inserting the needle in the medial third of the FO; for V2 targeting, in the middle of the FO; and for V3 targeting, in the lateral third of the FO.

Knowledge of the extracranial and intracranial anatomical relationships of the FO is essential to understanding and avoiding complications during FO puncture. These data suggest that better radiographic visualization of the FO can improve lesioning accuracy depending on the part of the FO to be punctured. The angles and safety distances obtained may help the neurosurgeon minimize complications during FO puncture and TN lesioning 6).


Koizuka et al., presented a new method for percutaneous radio-frequency thermocoagulation of the Gasserian ganglion, in which computed tomography (CT) fluoroscopy is used to guide needle placement.

In the present study, 15 patients with trigeminal neuralgia underwent percutaneous radio-frequency thermocoagulation of the Gasserian ganglion guided by high-speed real-time CT fluoroscopy.

RESULTS: Trigeminal neuralgia was improved in all patients after treatment without any severe complications. Moderate dysesthesia occurred in only one case.

CT fluoroscopy-guided percutaneous radio-frequency thermocoagulation of the Gasserian ganglion was safe, quick, and effective for patients with intractable idiopathic trigeminal neuralgia 7).

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References

1)

Mendes PD, Martins da Cunha PH, Monteiro KKO, Quites LV, Fonseca Filho GA. Percutaneous Foramen Ovale Puncture: Usefulness of Intraoperative CT Control, in the Eventuality of a Narrow Foramen [published online ahead of print, 2020 Sep 16]. Stereotact Funct Neurosurg. 2020;1-4. doi:10.1159/000509821
2)

Zdilla MJ, Fijalkowski KM. The Shape of the Foramen Ovale: A Visualization Aid for Cannulation Procedures. J Craniofac Surg. 2016 Dec 23. doi: 10.1097/SCS.0000000000003325. [Epub ahead of print] PubMed PMID: 28027173.
3)

Kaplan M, Erol FS, Ozveren MF, Topsakal C, Sam B, Tekdemir I. Review of complications due to foramen ovale puncture. J Clin Neurosci. 2007 Jun;14(6):563-8. Epub 2006 Dec 13. PubMed PMID: 17169562.
4)

Guo Z, Wu B, Du C, Cheng M, Tian Y. Stereotactic Approach Combined with 3D CT Reconstruction for Difficult-to-Access Foramen Ovale on Radiofrequency Thermocoagulation of the Gasserian Ganglion for Trigeminal Neuralgia. Pain Med. 2016 Sep;17(9):1704-16. doi: 10.1093/pm/pnv108. Epub 2016 Feb 13. PubMed PMID: 26874883.
5)

Ding W, Chen S, Wang R, Cai J, Cheng Y, Yu L, Li Q, Deng F, Zhu S, Yu W. Percutaneous radiofrequency thermocoagulation for trigeminal neuralgia using neuronavigation-guided puncture from a mandibular angle. Medicine (Baltimore). 2016 Oct;95(40):e4940. PubMed PMID: 27749549; PubMed Central PMCID: PMC5059051.
6)

Peris-Celda M, Graziano F, Russo V, Mericle RA, Ulm AJ. Foramen ovale puncture, lesioning accuracy, and avoiding complications: microsurgical anatomy study with clinical implications. J Neurosurg. 2013 Nov;119(5):1176-93. doi: 10.3171/2013.1.JNS12743. Epub 2013 Apr 19. PubMed PMID: 23600929.
7)

Koizuka S, Saito S, Sekimoto K, Tobe M, Obata H, Koyama Y. Percutaneous radio-frequency thermocoagulation of the Gasserian ganglion guided by high-speed real-time CT fluoroscopy. Neuroradiology. 2009 Sep;51(9):563-6. doi: 10.1007/s00234-009-0541-8. Epub 2009 Jun 5. PubMed PMID: 19499214.
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