Neurovascular compression of the trigeminal and glossopharyngeal nerve: three case reports

Multi-metric predictors of radiofrequency-treated trigeminal neuralgias

Evaluation of neurovascular compression-related trigeminal neuralgia (NVC-TN) and its resolution through microvascular decompression are demonstrable by MRI and intraoperatively [Leal et al. (Atrophic changes in the trigeminal nerves of patients with trigeminal neuralgia due to neurovascular compression and their association with the severity of compression and clinical outcomes: Clinical article. J Neurosurg. 2014;120(6):1484-1495)]. Non-NVC-TNs treated by radiofrequency (RF) lack such detectable features. Multimodal integration of pre-surgical diffusion tensor imaging (DTI) and volumetry (VOL) with intraoperative neurophysiology (ION) could improve understanding and performance of RF among non-NVC-TN. We hypothesized that DTI disturbances' localization (central relay versus peripherally) rather than their values bares the most significant predictive value upon outcome and that ION could quantitatively both localize and assist RF of affected branches. The first pre-surgical step evaluated the differences between affected and non-affected sides (by DTI and VOL). Four TN's segments were studied, from peripheral to central relay: Meckel's cave-trigeminal ganglion (MC-TGN), cisternal portion, root entry zone (REZ) and spinal tract [Lin et al. (Flatness of the Meckel cave may cause primary trigeminal neuralgia: A radiomics-based study. J Headache Pain. 2021;22(1):104)]. In the second intraoperative step, we used both ION and patient's testimonies to confirm the localization of the affected branch, evolving hypoesthesia, pain reduction and monitoring of adverse effects [Sindou (Neurophysiological navigation in the trigeminal nerve: Use of masticatory responses and facial motor responses evoked by electrical stimulation of the trigeminal rootlets for RF-thermorhizotomy guidance. Stereotact Funct Neurosurg. 1999;73(1-4):117-121); Sindou and Tatli (Traitement de la névralgie trigéminale par thermorhizotomie. Neurochirurgie. 2009;55(2):203-210)]. Last and postoperatively, each data set's features and correlation with short-term (3 months) and long-term outcomes (23.5 ± 6.7 months) were independently analysed and blind to each other. Finally, we designed a multimodal predictive model. Sixteen non-NVC-TN patients (mean 53.6 ± SD years old) with mean duration of 6.56 ± 4.1 years (75% right TN; 43.8% V3) were included. After 23.5 ± 6.7 months, 14/16 were good responders. Age, gender, TN duration and side/branch did not correlate with outcomes. Affected sides showed significant DTI disturbances in both peripheral (MC-TGNs) and central-relay (REZ) segments. However, worse outcome correlated only with REZ-located DTI disturbances (P = 0.04; r = 0.53). Concerning volumetry, affected MC-TGNs were abnormally flatter: lower volumes and surface area correlated with worse outcomes (both P = 0.033; r = 0.55 and 0.77, respectively). Intraoperatively, ION could not differ the affected from non-affected branch. However, the magnitude of ION's amplitude reduction (ION-Δ-Amplitude) had the most significant correlation with outcomes (r = 0.86; P < 0.00006). It was higher among responders [68.4% (50-82%)], and a <40% reduction characterized non-responders [36.7% (0-40%)]. Multiple regression showed that ION-Δ-Amplitude, centrally located only REZ DTI integrity and MC-TGN flatness explain 82.2% of the variance of post-RF visual analogue score. Integration of pre-surgical DTI-VOL with ION-Δ-Amplitude suggests a multi-metric predictive model of post-RF outcome in non-NVC-TN. In multiple regression, central-relay REZ DTI disturbances and insufficiently reduced excitability (<40%) predicted worse outcome. Quantitative fine-tuned ION tools should be sought for peri-operative evaluation of the affected branches.

Trigeminal Autonomic Cephalalgias and Neuralgias in Children and Adolescents: a Narrative Review

PURPOSE OF REVIEW

To summarize the available literature as well as the authors' experience on trigeminal autonomic cephalalgias (TACs) and cranial neuralgias in children and adolescents.

RECENT FINDINGS

While TACs and cranial neuralgias are rare in children, several recent case series have been published. TACs in children share most of the clinical features of TACs in adults. However, there are many reported cases with clinical features which overlap more than one diagnosis, suggesting that TACs may be less differentiated in youth. Indomethacin-responsive cases of cluster headache and SUNCT/SUNA have been reported in children, whereas in adults indomethacin is usually reserved for paroxysmal hemicrania and hemicrania continua. Neuralgias appear to be rare in children. Clinical features are often similar to adult cases, though clinicians should maintain a high index of suspicion for underlying causes.

Morphological Measurements of Innominate Foramina and Bony Spurs along the Base of Sphenoid as a Potential Risk Factor for Neurovascular Entrapment, Radiological Interpretation and Surgical Access

Background

Restricted access and compression of neurovascular structures at various anatomic variations at the skull base poses a challenge to surgeons, neurologists and anesthetists. The present study was performed with the objective of providing morphometric analysis of innominate foramina, and anomalous bony bars and spurs along the infratemporal surface of the greater wing of the sphenoid and reviewing the practical significance of dealing with this region.

Methods

A total of 100 dry-aged human adult skulls from the archives of the osteology library of the Department of Anatomy were studied. A detailed morphometric analysis of such innominate foramina and anomalous osseous structures along the base of the sphenoid was performed using a sliding digital vernier caliper.

Results

Anomalous bony bar was found in 22 skulls (25.28%). A complete bar was observed at eight (9.1%). An innominate foramen was located inferomedial to foramen ovale (5 unilateral and 3 bilateral) with a mean anteroposterior diameter of 3.44 mm and a mean transverse diameter of 3.16 mm.

Conclusion

Neurovascular structures may be compressed by abnormal bony outgrowths or while traversing through such unnamed bony foramina. The latter may also be overlooked and mistaken during radiological interpretation leading to delayed diagnosis. Such unnamed foramina and bony outgrowths need to be documented in the literature due to their surgical, and radiological implications and limited citations.

Microvascular decompression for young onset primary trigeminal neuralgia: a single-center experience

This study aims to explore the causes of primary young onset trigeminal neuralgia (TN) and the clinical outcomes of these patients. From May 2015 to December 2020, 19 primary TN patients with onset age under 30 years underwent microvascular decompression (MVD) in Nanjing Drum Tower Hospital. In this study, the clinical characteristics, surgical outcomes, and postoperative complications of these patients were analyzed retrospectively. Of the 19 patients, 5 were males and 14 were females, and the pain was located on the right side in 10 cases (52.6%). Vascular compression was observed in 17 patients, including 14 cases of superior cerebellar artery (SCA) alone, 2 cases of superior petrosal vein (SPV) alone, and 1 case of SCA and SPV combined. Two patients had no neurovascular conflict, and nerve combing was performed. After surgery, 18 patients got immediate pain relief; 1 patient improved but still had occasional pain. With a mean follow-up of 42.7 ± 22.3 months, one patient was found to have a relapse 45 months after MVD. Surgical complications including mild facial numbness in two patients and hearing impairment in one patient. Neurovascular compression is the main cause of young onset primary TN, and the most commonly encountered vascular was SCA. MVD is a safe and effective treatment for these patients.

Microvascular decompression for pediatric onset trigeminal neuralgia: patterns and variation

OBJECTIVES

Pediatric trigeminal neuralgia has been rarely reported in the literature, which were only 28 cases. Although microvascular decompression (MVD) has been widely accepted as effective therapy for trigeminal neuralgia, the etiology and surgical treatment of pediatric ones are seldom addressed. We report our experience with MVD for pediatric trigeminal neuralgia patients with emphasis on the vascular conflict patterns and surgical skills.

METHODS

This retrospective report included 11 pediatric TN patients, who underwent MVD and were followed for 3-86 months. The data were retrospectively analyzed with emphasis on the clinical features.

RESULTS

This series included 4 boys and 7 girls with average age of 13 ± 3.4 years old, their onset age were from 7 to 18 years old. The singular vein and combined artery/vein conflictions account for 7/11. 9 (81.8%) patients achieved immediate excellent outcomes. One recurrence was observed after 5 months and refused the second surgery.

CONCLUSIONS

The etiology of pediatric onset trigeminal neuralgia is still vascular conflict, whose patterns are different from adults, of which combined artery/vein and singular venous compression patterns have a much more higher proportion. Because of the smaller operative space and fragile-thin venous wall with adhesion to other structures, it is much more difficult to decompress the trigeminal nerve among pediatric patients. Sufficient arachnoid release, full exploration, and decompression along the trigeminal nerve were necessary, which will increase the excellent rate among pediatric patients.

Cranial Neuralgias in Children and Adolescents A review of the literature

Cranial neuralgias are a well-established cause of headache-related morbidity in the adult population. These disorders are poorly studied in general due to their relative rarity, particularly in children and adolescents, and they are likely underdiagnosed in these populations. Recognizing these disorders and differentiating them from more common headache disorders, such as migraine, is important, as secondary disease is common. This review will cover the basic epidemiology, diagnosis, and treatment of trigeminal, occipital, glossopharyngeal and other, less common, cranial neuralgias. We have reviewed pediatric case reports of these conditions. For trigeminal neuralgia, the most common of these disorders, we have compiled the clinical features and treatment response of previous reports.

Treatment of trigeminal and glossopharyngeal neuralgia in an adolescent: a case report

Background

Hyperactive dysfunction syndrome (HDS) refers to a constellation of symptoms developing from cranial nerve overactivity caused by neurovascular compression at the root entry or exit zone near the brainstem. Although the combined features of HDS are seen in the elderly, there are no reports of such cases in adolescents, to date.

Case presentation

A 17-year-old male was diagnosed with right glossopharyngeal neuralgia and treated with microvascular decompression. He experienced new-onset right facial pain later and was diagnosed with right trigeminal neuralgia, which required prompt radiofrequency thermocoagulation of the right mandibular nerve. Follow-up in the third post-treatment year revealed the absence of symptom recurrence.

Discussion

We report the treatment of a rare case of adolescent-onset combined HDS presenting as trigeminal and glossopharyngeal neuralgia. This report highlights the possibility of combined hyperactive dysfunction syndrome in younger age groups. It is crucial to establish a diagnosis early on for prompt management.

Young-onset trigeminal neuralgia: a clinical study and literature review

OBJECTIVE

Trigeminal neuralgia (TN) primarily occurs in elderly adults and is thought to be induced by neurovascular compression. However, a few children and young adults may present with the clinical features of TN. In this study, we aim to retrospectively assess the data of young patients with TN from a single center.

METHODS

Of 783 consecutive patients with TN treated at our center between 2007 and 2017, 11 young patients under the age of 30 years with TN met the inclusion criteria and were enrolled. Their clinical records, surgical treatments, and long-term outcomes were obtained and analyzed.

RESULTS

All the 11 patients with TN underwent microvascular decompression (MVD). The average age at symptom onset was 24 years (range, 14-29 years), and the average age at the time of surgery was 28.9 years (range, 25-35 years). Further, 5 patients had left-sided symptoms, and 6 had right-sided symptoms. Surgery revealed only venous compression in 3 patients, only arterial compression in 5 patients, and both venous and arterial compression in 3 patients. The average duration of symptoms was 4.9 years, and the average follow-up duration was 7.4 years (range, 4.5-12.9 years). The long-term outcome was excellent in 9 patients and good in 2 patients, and there were no long-term complications.

CONCLUSIONS

The symptoms and surgical findings presented in this cohort for young-onset TN are similar to those reported in elderly adults. MVD appears to be a safe and effective treatment for young patients with TN.

Trigeminal neuralgia management after microvascular decompression surgery: two case reports

Trigeminal neuralgia (TN) involves chronic neuropathic pain, characterized by attacks of repeating short episodes of unilateral shock-like pain, which are abrupt in onset and termination. Anticonvulsants, such as carbamazepine, are the gold standard first-line drugs for pharmacological treatment. Microvascular decompression (MVD) surgery is often the course of action if pharmacological management with anticonvulsants is unsuccessful. MVD surgery is an effective therapy in approximately 83% of cases. However, persistent neuropathic pain after MVD surgery may require reintroduction of pharmacotherapy. This case report presents two patients with persistent pain after MVD requiring reintroduction of pharmacological therapy. Although MVD is successful for patients with failed pharmacological management, it is an invasive procedure and requires hospitalization of the patient. About one-third of patients suffer from recurrent TN after MVD. Often, alternative treatment protocols, including the reintroduction of medications, may be necessary to achieve improvement. This case report presents two cases of post-MVD recurrent pain. Further research is lacking on the success rates of subsequent medication therapy after MVD has proven less effective in managing TN.

Pediatric glossopharyngeal neuralgia: a comprehensive review

INTRODUCTION

Debilitating facial pain can seriously affect an individual's daily living. Given that the pathophysiology behind neuropathic and myofascial pain is not fully understood, when chronic facial pain goes undiagnosed, it has been proposed that one of the two is the likely cause. Since their discovery, glossopharyngeal neuralgia (GN) and Eagle's syndrome have been considered mostly conditions afflicting the adult population. However, when pediatric patients present with symptoms resembling GN or Eagle's syndrome, physicians are less apt to include these as a differential diagnosis simply due to the low prevalence and incidence in the pediatric population.

MATERIALS AND METHODS

A literature review was performed with the aim to better understand the history of reported cases and to provide a comprehensive report of the anatomical variations that lead to these two conditions as well as the way these variations dictated medical and surgical management. Articles were obtained through Google Scholar and PubMed. Search criteria included key phrases such as pediatric glossopharyngeal neuralgia and pediatric Eagle syndrome. These key phrases were searched independently. PubMed was searched primarily then cross-referenced articles were found via Google Scholar. Results from non-English articles were excluded.

RESULTS

A total of 58 articles were reviewed. Most of the articles focused on adult glossopharyngeal neuralgia, and the majority was comprised of case reports. When searched via PubMed, a total of 16 articles and 2 articles returned for glossopharyngeal neuralgia and Eagle's syndrome, respectively. After criteria selection and cross-referencing, a total of seven articles were found with respect to pediatric glossopharyngeal neuralgia.

CONCLUSIONS

While they are rare conditions, there are multiple etiologies that lead to the debilitating symptoms of GN and Eagle's syndrome. The clinical anatomy proved notable as multiple causes of GN and Eagle's syndrome are due to variation in the anatomy of the neurovascular structures surrounding the glossopharyngeal nerve, an elongated styloid process, a calcified stylohyoid ligament as well as a calcified stylomandibular ligament. Due to the success of different treatment modalities, the treatment of choice is dependent on clinical judgment.

Surgical Management of Trigeminal Neuralgia in Children

BACKGROUND

Trigeminal neuralgia (TN) is a well-recognized facial pain syndrome. Discrete forms with disparate pain symptoms include classic and atypical. However, atypical facial pain includes neuralgiform pain along a spectrum. Most cases of TN are diagnosed in the adult population. Case reports and series of children have presented TN as a similar entity, with treatment similar to that for adults. We reviewed the pertinent data and present 2 pediatric TN cases successfully treated with microvascular decompression (MVD).

CASE DESCRIPTION

Two pediatric patients (age 12 and 15 years) with TN refractory to previous medical therapy were identified. Both patients were deemed appropriate surgical candidates and underwent MVD to manage their TN. TN compression was arterial in both cases and involved portions of the anterior inferior cerebellar artery. Patient 1 was pain free 6 months after the procedure. Patient 2 was pain free immediately after the procedure and had been weaned off preoperative symptomatic management at the latest follow-up visit. The most recent follow-up examination was 12 and 8 months for patients 1 and 2, respectively, with both experiencing continued freedom from pain.

CONCLUSIONS

Few studies have reported on the effectiveness of MVD in the pediatric population for the management of TN. The supporting data and our 2 cases have demonstrated that MVD is effective for pediatric patients to treat their TN. Furthermore, the side effects appear to be minimal, with excellent pain relief after MVD in this patient population.

Trigeminal Neuralgia, Glossopharyngeal Neuralgia, and Myofascial Pain Dysfunction Syndrome: An Update

Neuropathic pain is a common phenomenon that affects millions of people worldwide. Maxillofacial structures consist of various tissues that receive frequent stimulation during food digestion. The unique functions (masticatory process and facial expression) of the maxillofacial structure require the exquisite organization of both the peripheral and central nervous systems. Neuralgia is painful paroxysmal disorder of the head-neck region characterized by some commonly shared features such as the unilateral pain, transience and recurrence of attacks, and superficial and shock-like pain at a trigger point. These types of pain can be experienced after nerve injury or as a part of diseases that affect peripheral and central nerve function, or they can be psychological. Since the trigeminal and glossopharyngeal nerves innervate the oral structure, trigeminal and glossopharyngeal neuralgia are the most common syndromes following myofascial pain dysfunction syndrome. Nevertheless, misdiagnoses are common. The aim of this review is to discuss the currently available diagnostic procedures and treatment options for trigeminal neuralgia, glossopharyngeal neuralgia, and myofascial pain dysfunction syndrome.

Can pontine trigeminal T2-hyperintensity suggest herpetic etiology of trigeminal neuralgia?

BACKGROUND

Trigeminal neuralgia (TN) is usually classified into two different categories: idiopathic and secondary. We have investigated the frequency of brainstem pontine lesions in patients with idiopathic TN without multiple sclerosis (MS) or stroke, and their association with herpes zoster (HZ) infection.

METHODS

Brain magnetic resonance imaging (MRI) studies of 28 patients with TN were retrospectively reviewed.

RESULTS

We found seven patients with clinical suspicion of HZ infection and pontine T2 hyperintense lesions, associated with nerve atrophy in one case. Fifteen patients had a neurovascular conflict (NVC) without brainstem involvement, two of them associated with trigeminal atrophy, while four patients had only volumetric reduction of the nerve. In all patients MRI findings were ipsilateral to the side of TN.

CONCLUSIONS

Pontine T2 hyperintensities could be considered as a MRI sign of TN in patients without NVCs. This "trigeminal pontine sign" (TPS) is frequently found in association with herpetic infections.

Frameless Stereotactic Radiosurgery, a Feasible Alternative to the Frame-Based Technique for the Treatment of Refractory Trigeminal Neuralgia

Classic trigeminal neuralgia (TN) causes severe facial pain. Several treatment options exist for classic TN refractory to medical therapy, including stereotactic radiosurgery (SRS). Most studies in the medical literature used a frame-based SRS technique. Improvements in linear accelerator-based treatment systems and image guidance have led to the use of frameless SRS as a safe and feasible alternative to the frame-based technique for the treatment of refractory TN. We present a case of refractory TN successfully treated with frameless SRS.

Update on neuropathic pain treatment for trigeminal neuralgia. The pharmacological and surgical options

Trigeminal neuralgia is a syndrome of unilateral, paroxysmal, stabbing facial pain, originating from the trigeminal nerve. Careful history of typical symptoms is crucial for diagnosis. Most cases are caused by vascular compression of the trigeminal root adjacent to the pons leading to focal demyelination and ephaptic axonal transmission. Brain imaging is required to exclude secondary causes. Many medical and surgical treatments are available. Most patients respond well to pharmacotherapy; carbamazepine and oxcarbazepine are first line therapy, while lamotrigine and baclofen are considered second line treatments. Other drugs such as topiramate, levetiracetam, gabapentin, pregabalin, and botulinum toxin-A are alternative treatments. Surgical options are available if medications are no longer effective or tolerated. Microvascular decompression, gamma knife radiosurgery, and percutaneous rhizotomies are most promising surgical alternatives. This paper reviews the medical and surgical therapeutic options for the treatment of trigeminal neuralgia, based on available evidence and guidelines.

A review of episodic and chronic pediatric headaches of brief duration

BACKGROUND

Headaches that last less than an hour in duration are uncommon, except for atypical migraine, and without a practitioner's appropriate knowledge, may result in misdiagnosis. Although most of these headaches are classified as primary headache syndromes, some have secondary etiologies such as structural lesions.

METHODS

This pediatric-specific review updates these headache syndromes. Included are atypical migraine, the trigeminal autonomic cephalgias, idiopathic stabbing headache, cranial neuralgias, occipital neuralgia, thunderclap headache, nummular headache, the red ear syndrome, and the numb-tongue syndrome.

CONCLUSION

Knowledge of the clinical characteristics of these headache patterns in children allows physicians to quickly establish the headache diagnosis and develop the optimal treatment plan.

Surgical treatment of pediatric trigeminal neuralgia: case series and review of the literature

PURPOSE

Pediatric trigeminal neuralgia (TN) is a rare entity. The purpose of this study was to retrospectively analyze a small series of pediatric patients diagnosed with TN and surgically treated with microvascular decompression (MVD) at a single center.

METHODS

Nine patients were identified who presented with TN symptoms that began before the age of 18. Four were excluded because of delayed surgical intervention or successful medical management. We retrospectively reviewed the charts of 5 patients with classical TN who underwent MVD at or before the age of 18.

RESULTS

Patient ages ranged from 3 to 18 years (average, 11.7) at the time of procedure. All five patients were female. Four patients underwent a single procedure and one had bilateral MVDs. In all six cases, vascular compression of the trigeminal nerve was found during surgery. Compression was venous in three cases, arterial in two, and both in one. Pain relief was complete following the procedure in five of six cases. Pain relief was incomplete but substantial in one patient, allowing her to discontinue anticonvulsant medications. Follow-up duration ranges from 9.1 to 24.8 months with an average of 15.3 (± 6.1) and a median of 12.7 months follow-up. There were no complications such as CSF leak, infection, or cranial nerve deficits.

CONCLUSIONS

Until now, there had been no reports on the effectiveness of MVD performed before the age of 18 to treat TN. These preliminary results suggest MVD may be performed with good pain relief and minimal side effects in the pediatric population.

Trigeminal neuralgia in young adults

OBJECT

Trigeminal neuralgia (TN) is a form of facial pain that can be debilitating if left untreated. It typically affects elderly adults and is thought to be related to neurovascular compression. It is uncommon in people younger than 30 years of age, with only 1% of cases reportedly occurring in those younger than 20 years of age. The most common cause of compression in young adults is thought to be venous nerve compression either alone or in association with arterial nerve compression. The objective of this study was to review data in cases of TN in which patients were 25 years of age or younger and to identify TN disease characteristics, demographics, clinical features, operative findings, and outcome.

METHODS

The authors retrospectively reviewed the clinical records, surgical treatment, and long-term outcome in patients 25 years of age or younger with TN who underwent surgery performed by the senior author (K.J.B.) at Oregon Health & Science University between 1995 and 2008.

RESULTS

Seven patients (2 males and 5 females) met the inclusion criteria. The average age at symptom onset was 19.6 ± 3.4 years (± SD) and the average age at surgery was 22.9 ± 1.7 years. Six patients had right-sided symptoms and 1 had left-sided symptoms. Pain distribution was the V2 in 3 cases, V2-3 in 3 cases, and V3 in 1 case, with no cases of V1 affliction. A total of 11 procedures were performed in 7 patients, and 4 patients underwent a second procedure. Surgery and imaging revealed venous compression in all cases. The average follow-up period was 35.5 ± 39.9 months (median 12 months). Three patients reported a good outcome (no pain with or without medications) and 4 reported a poor outcome (either no pain relief or mild pain relief after surgery).

CONCLUSIONS

Trigeminal neuralgia is uncommon in young adults. Patients tend to present with symptoms similar to those in adults: long periods of pain and venous compression, but outcome unfortunately is not as good as that reported in the older population.

Neuropathic pain in children: Special considerations

Neuropathic pain is relatively uncommon in children. Although some syndromes closely resemble those found in adults, the incidence and course of the condition can vary substantially in children, depending on developmental status and contextual factors. There are some neuropathic pain syndromes that are rare and relatively unique to the pediatric population. This article discusses the array of neuropathic pain conditions in children and available treatment strategies. Data are limited by small numbers and few randomized controlled trials. Research and clinical implications are discussed.

A case of trigeminal neuralgia complicated by ipsilateral temporal arteritis

Trigeminal neuralgia (TN) complicated with temporal arteritis (TA) is not a common disease, but it is a very important syndrome to consider for diagnosing facial pain in individuals older than 50 years. We therefore report on a rare case of TN with TA that occurred simultaneously on the same side with each symptom responding to specific treatment.

Trigeminal neuralgia due to anterior inferior cerebellar artery loop: a case report

Trigeminal neuralgia is uncommon in children. Idiopathic type is less often seen than the secondary or symptomatic type. We report a 6-year-old girl with trigeminal neuralgia. Magnetic resonance imaging revealed an arterial loop at the exit of the trigeminal nerve.

Unilateral hypoglossal nerve palsy due to neurovascular conflict in a child

A neurovascular conflict (NC) consists of a pathological contact between a vessel, generally an artery, and the root entry zone of a cranial nerve close to the brainstem. Even if NC of the V, VII and IX cranial nerve have been rarely described, to the best of our knowledge there is no report about the XII cranial nerve NC in the paediatric age. A three-year-old girl presented with right-sided tongue atrophy and fasciculation, of one-year-duration, consistent with a peripheral lesion of the right XII cranial nerve. Brain MRI and MRA documented a marked tortuosity of the vertebrobasilar arteries compressing the brainstem at the emergency of the XII cranial nerve, while the CT disclosed a concomitant osseous malformation of the cranio-cervical junction. The differential diagnosis of a peripheral unilateral cranial nerve palsy should include, even if rare in children, a neurovascular conflict. In this case a complete neuroimaging study is indicated.

Microvascular decompression for intractable singultus: technical case report

OBJECTIVE

Intractable singultus is a rare but significantly disruptive clinical phenomenon that often accompanies other diseases but can present in isolation due entirely to intracranial pathology. We report a case of intractable singultus that improved after microvascular decompression and present a comprehensive review of singultus by discussing its similarity to other cases of microvascular decompression, its history and etiology, and its evolutionary basis.

CLINICAL PRESENTATION

The patient exhibited intractable singultus for 15 years, resistant to multiple medical regimens.

INTERVENTION

Microvascular decompression to relieve pressure on the tenth cranial nerve and medulla oblongata resulted in near total resolution of the singultus.

CONCLUSION

Neurovascular compression should be considered a potentially reversible cause of intractable singultus, a significantly disabling clinical phenomenon.

Unusual headache syndromes in children

Headaches represent one of the most common reasons why children and adolescents seek medical attention and are the primary reason that they are referred to pediatric neurology practices. The most common headache syndromes diagnosed are migraine, tension-type, and chronic daily headache, and the bulk of recent medical literature regarding headache in children has focused on these clinical entities. Children are prone to have unusual headache syndromes, most of which fall under the category of "primary headache," most notably as manifestations of migraine with aura. Included within this group are basilar-type and hemiplegic migraine. The most intriguing subset included in the International Headache Society's classification system is the so-called "periodic syndromes of childhood that are precursors to migraine." These syndromes, quite peculiar to children, present a wide variety of episodic symptoms, including movement disorders, vomiting, ataxia, and vertigo, and may not include headache at all. This article provides an overview of some of the more unusual headache syndromes in children and adolescents.

Analgesic action of gabapentin on chronic pain in the masticatory muscles: a randomized controlled trial

Chronic masticatory myalgia (CMM) can be defined as constant pain in the masticatory muscles for more than 6 months and is influenced by the central nervous system. The antiepileptic agent gabapentin acts centrally and is used for managing different types of chronic pain conditions. The objective of this study was to evaluate the analgesic action of gabapentin on CMM. In this 12-week randomized controlled clinical trial 50 patients were randomly allocated into two study groups: 25 received gabapentin and 25 received placebo. The outcome measures utilized were pain reported on a VAS (VAS-pain), Palpation Index (PI) and impact of CMM on daily functioning reported on a VAS (VAS-function). Thirty-six patients completed the study. Gabapentin showed to be clinically and statistically superior to placebo in reducing pain reported by patients (gabapentin=51.04%; placebo=24.30%; P=0.037), masticatory muscle hyperalgesia (gabapentin=67.03%; placebo=14.37%; P=0.001) and impact of CMM on daily functioning (gabapentin=57.70%; placebo=16.92%; P=0.022). It can be concluded from this study that gabapentin is effective for the management of CMM.

The "other" primary headaches in children and adolescents

Headache represents one of the most common reasons why children and adolescents are referred to pediatric neurology practices where the most common headache syndromes diagnosed are migraine and its variants, and chronic daily headache. The bulk of recent literature regarding headache in children has focused on these two clinical entities even though large epidemiologic studies have demonstrated that tension-type headache may be two to three times more common in children. Why has so little attention been given to these other disorders? The purpose of this review is to examine the "other" primary headache disorders in children and adolescents.

Headache and facial pain in children and adolescents

Headaches commonly affect children and adolescents. Proper diagnosis and management is dependent on thorough history taking and a comprehensive physical and neurological examination. Additional diagnostic testing is indicated in some cases. The second edition of the headache classification system by the International Headache Society has recently become available. The classification system is primarily based on adults, but we discussed the subtle distinctions made regarding children. In addition to the primary headache types of migraine, tension-type, and cluster headaches, we discussed selected symptomatic headaches. Emphasis was placed on migraine and tension-type headaches because these are the most common pediatric headache types. We briefly discussed genetic aspects of headaches. Genetic factors have been hypothesized for chronic tension headache and other forms of migraine, but genetic linkage has only been established for familial hemiplegic migraine. We reviewed the nonpharmacologic and pharmacologic therapies, including abortive and prophylactic medications for various age groups. Unlike headaches, facial neuralgias are rare in otherwise healthy children. Facial pain may be neurological, vascular, or dental in origin. We focused on trigeminal neuralgia, glossopharyngeal neuralgia, occipital neuralgia, and Bell's palsy as neurological causes of facial pain in children.

Cranial neuralgias and headaches associated with cranial vascular disorders

This article discusses various cranial neuralgias and headaches linked to vascular disorders, including trigeminal neuralgia, intracerebral hemorrhage, temporal arteritis, and central nervous system angiitis. Also discussed are diagnostic methods, treatment options, and pain management.

Trigeminal neuralgia in children: two case reports

Trigeminal neuralgia in children is extremely rare, and current options for the management of it are not very well defined. We present here two children with trigeminal neuralgia reaching the second branch, one of whom has a true painful state and treatment difficulties.