Trigeminal Neuralgia: Case Report and Review

Abstract

We report the case of an 86-year-old female who described 15-years of sharp, stabbing pain that radiated down the distribution of the second and third divisions of her right trigeminal nerve. She described two trigger points, one on her right cheek and a second intra-oral trigger. Her symptoms were often triggered by eating and she had begun to loose weight secondary to the pain. She denied having any baseline pain between the episodes of lancinating pain. She denied any contralateral pain, dysasthetic pain or any burning pain sensation. She denied any pain along the first trigeminal division and did not recently undergo any dental work or have a history of dental carries. Her symptoms had been initially well controlled with Carbamazepine 200 mg BID, but had recently worsened despite increasing the dosage to 600 mg BID when she started to develop medication-related side effects. Her past medical history was unremarkable, and on examination she was neurologically intact. Her brain magnetic resonance imaging (MRI) showed no masses or gross abnormalities, and she was diagnosed with trigeminal neuralgia. Neurosurgical intervention was pursued because the patient was refractory to medical therapy and had worsening symptoms. Non-invasive Gamma Knife radiosurgery was recommended because of the patient's surgical risk profile and preference for a non-invasive procedure. Using Leksell stereotactic frame, a stereotactic MRI dataset was generated with a gradient echo and CISS sequence. On the Leksell gamma planning workstation we identified the right trigeminal nerve and prescribed 90 Gy to the 100% isodose line using a single 4-mm shot such that the 20% isodose line was tangential to the brainstem. The patient tolerated the procedure well and reported complete resolution of her symptoms at one-month follow-up.