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Trigeminal neuralgia (NT) is a chronic neuropathic pain syndrome affecting the facial region. Considered maybe the strongest pain, probably because the facial area has a very dense distribution of sensory nerve endings per square centimeter.
It constitutes her more frequent facial neuralgia and occurs mainly in women aged 50-70 yearswithout, of course, cases in children being absent.
It is divided into idiopathic, the most common form, in which no clear cause is found, and symptomatic, where there is an underlying condition. This may be pressure on the nerve from a structure, such as a tumor or vessel, or multiple sclerosis.
The diagnosis is made by taking a detailed history, neurological examination and MRI of the brain with intravenous contrast.
The first line of treatment is medication. If the symptoms persist or there are serious side effects from the drugs, invasive treatments are chosen.
How is trigeminal neuralgia pain characterized?
Trigeminal neuralgia is characterized by bouts of intense pain, describedi like multiple stabs or electric currents (piercing pain). The pain is sudden and very intense, lasts for fractions of a second and returns after a while. This can be repeated for up to an hour.
It is distributed unilaterally on the face, usually on the right. If the upper or lower jaw branch is affected, there is pain in the lips, gums and chin, while if the eye branch is affected, the pain is located in the forehead and the eye.
In some cases, before the attack, there is mild pain or numbness, like “pins and needles”. When the crisis has passed, the pain subsides completely or there is a slight discomfort, which the patient finds it difficult to describe.
Noteworthy is the existence of so-called “trigger zones”, located on the face, lips and tongue, and their irritation or movement leads to a seizure. For example, brushing the teeth, chewing food and washing the face are habits that can trigger an attack, as well as being cold or shaving.
There may be periods of recession, where seizures are rarer and milder, for a period of months, but as the years pass, the problem intensifies, the frequency of seizures increases, and the need for treatment becomes imperative. Trigeminal neuralgia can be so intense and excruciating that it leads to suicide. It has not been called “suicide disease” unfairly.
What are the causes of trigeminal neuralgia?
Trigeminal neuralgia is divided into idiopathic and symptomatic.
Idiopathic has no known cause. It belongs to the spectrum of aesthetic epilepsy and the pain is relieved with antiepileptic drugs. In the neurological examination there are no objective neurological findings. Paroxysms appear after simple contact or chewing and last up to 1-2 minutes. It is also referred to as a “painful tic” (tic douloureux), in contrast to painless motor tics, given the sudden grimace due to facial contraction caused by the sudden onset of pain.
THE symptomatic neuralgia may be due to:
• brain aneurysms
• abnormal course of arteries (eg superior cerebellar artery)
• brain tumors (acoustic neurinoma, glioblastoma, cerebellar angle tumors)
• chronic meningitis
• sarcoid granuloma
• multiple sclerosis (in 2-4% of patients)
What is the treatment of trigeminal neuralgia
The first line of treatment for trigeminal neuralgia is medication with antiepileptic drugs such as carbamazepine, gabapentin and pregabalin. In case of side effects or ineffectiveness in the patient, the interventional treatments are recommended, which are:
1. Local infiltration (neurolysis) of the trigeminal ganglion (gasserian ganglion) with RFA thermocautery
2. Stereotactic radiation (gamma-Knife / cyber Knife): Radiation is applied to the point where the trigeminal nerve exits the brain. This operation does not ensure permanent results and there is usually a recurrence in the first 3 years.
3. Neurovascular decompression (microvascular decompression): It is the main method of surgical treatment. The aim is to remove through a craniotomy the vessel that is adjacent to and presses on the trigeminal nerve. The success rate is 92%.
The role of Interventional Radiology
The Interventional Radiologist under fluoroscopic guidance will place the electrode in the ganglion of the trigeminal nerve and then, with the help of a special generator, thermocautery with radio frequencies (RF Ablation) will be performed.
The treatment is done on an outpatient basis, that is, the patient does not need to stay in the Hospital afterwards. In 98% of patients we achieve relief from pain and medication. A percentage of 15-20% recur after 12-18 months, where a repeat ablation is needed.
in conclusion
Trigeminal cauterization is a difficult invasive procedure due to the dangerous anatomy of the area. It should be performed with great care and by experienced interventional radiologists.
Drug therapy remains the first choice.
THE RF Ablation it should be considered in patients who have exhausted their medicinal doses and they cannot tolerate the side effects of the drugs.
Interventional radiology refers to diagnostic and therapeutic techniques using special tools and imaging guidance (x-ray, digital angiography, CT, MRI, PET) to accurately approach the target. This means minimally invasive techniques, fewer complications and a shorter stay in the Clinic.
The Interventional Radiology Department of HYGEIA, is under the direction of Mr. Dimitrios Tzavoulis, and is one of the most developed in Europe and covers the following operations: vascular operations (angioplasty, treatment of aneurysms, carotid stenosis, etc., treatment of pulmonary embolism, venous stenosis , diseases in the liver and bile ducts, genitourinary, respiratory, digestive, cervical and thyroid.