A. Schlüter (Sangerhausen/Germany)  

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17 Years  

Female  

Head-Brain and brain nerves  

neoplastic  

An almost 17 year-old female patient complains about reoccurring, strong pain in the right side of the face, whereas these mostly are manifested in the forehead as well as the maxillary region; in the corresponding trigeminal nerve branches. The first manifestation of the illness showed itself about 4 years before the examination. Of late, the pain has increased in duration and intensity. Medicinal treatments are only difficult to treat. The patient feels a strong sense of suffering and an inhibition of her quality of life. Clinical-neurological examination showed no relevant causalities as of yet.  

The neurovascular compression is a main cause of chronic trigeminal neuralgia. Cause for this is either small vascular intertwining or - as in this case - vessels with large caliber. Only with high-resolution MRI-sequences could causes be shown. It is assumed that a chronic pulsating irritation causes the neuralgias.  

The examination showed no tumorous or inflammatory changes intracranially and in the facial skull. Noticeable was, however, a difference of course of the superior cerebellar artery (SCA) on both sides, where on the right side the certain structural contact of the vessel to the entrance in the skull of the 5th cranial nerve on the lateral pons was able to be presented. In comparing both sides, the trigeminal nerve was obviously of larger caliber on the right side.



<- view MRI 1

MRI 1: The SCA leaving the basilar artery.





<- view MRI 2

MRI 2: Parapontine course of the SCA





<- view MRI 3

MRI 3: Neurovascular compression of the right trigeminal root through the SCA





<- view MRI 4

MRI 4: Region of contact of the SCA/trigeminal nerve (purposely overly contrasted)





<- view MRI 5

MRI 5: Trigeminal nerve on the right side is thicker in comparing both sides.





<- view MRI 6

MRI 6: No pathological enhancement of the thickened trigeminal nerve of the right side. The vessels that are seen near the right trigeminal nerve are not the SCA in this image.



 

Other  

The thickening of the right trigeminal nerve could also be a result of an infection or tumorous process. The missing enhancement (T1-W) makes this etiology unlikely. T2-weighted images show no edema (no difference of signal of both sides).

Clinically, one should remember in children that such suffering could also be caused by fibrotic dysplasia in the region of the skull base.  

Since medication did not lessen the symptoms, a surgical decompression can be tried (Jannetta's Technique).

It remains hypothetical whether a thickening of the right trigeminal nerve is caused by vascular irritation. A surrounding fibrosis, a post-inflammatory state or a hypertrophy as a result of chronic alteration is conceivable -- I would welcome a discussion of this topic.

The patient has not yet decided on a surgical treatment.  

Of course, 3-D reformations of the imaging material are possible (i.e. sagittal MPR). For a better overview, I have limited myself to select serial images.  

N/A  

1. Medline:
Yoshino N, Akimoto H, Yamada I, Nagaoka T, Tetsumura A, Kurabayashi T, Honda E, Nakamura S, Sasaki T
Trigeminal neuralgia: evaluation of neuralgic manifestation and site of neurovascular compression with 3D CISS MR imaging and MR angiography
Radiology. 2003 Aug;228(2):539-45. Epub 2003 Jun 11  

Trigeminal neuralgia, Trigeminal, neuralgia, vessel, alteration, vessel alteration, SCA Alteration, Trigeminal nerve, child, childhood, pediatric radiology  

A Schlüter. Trigeminal neuralgia due to Superior Cerebellar Artery (SCA) Anomaly. PedRad [serial online] vol 4, no. 4.
URL: www.PedRad.info/?search=20040403230840