Glossopharyngeal neuralgia with cardioinhibitory syncope: Is a permanent pacemaker required?

Glossopharyngeal neuralgia is a rare facial pain syndrome, which in more rare cases can be associated with syncope. We present the outcome of a case report that combines this rare association that received medical therapy with anti-epileptic medication and permanent dual chamber pacemaker implantation. In this case, syncope episodes were associated with both vasodepressor and cardioinhibitory reflex syncope types. The patient found relief from syncope, hypotension, and pain after initiation of anti-epileptic therapy. Although a dual chamber pacemaker was implanted, the pacemaker interrogation revealed no requirement for pacing at one-year follow-up. As far as we know, this is the first case that reports pacemaker interrogation during follow-up and, taking into account the absence of pacemaker activation at one-year follow-up, the device was not needed to prevent bradycardia and syncope episodes. This case report supports the current guidelines for pacing in neurocardiogenic syncope, by demonstrating a lack of requirement for pacing in the event of both cardioinhibitory and vasodepressor responses.

Chiari type I malformation discovered through a glossopharyngeal neuralgia

Glossopharyngeal neuralgia is a rare disease whose initial treatment is pharmacological. When medical therapy is not effective, different surgical options are available including stereotactic radiosurgery, microvascular decompression or nerve section. It is reported a case of a 26-year-old female with glossopharyngeal neuralgia and Chiari malformation. This rare type of neuralgia sometimes is associated with an abnormality of the cranio-cervical junction. It was performed a posterior fossa expansion with duraplasty and microvascular decompression. The patient showed a complete disappearance of the pain, with no need of tonsil resection.

Avellis syndrome with ipsilateral prosopalgia, glossopharyngeal neuralgia, and central post-stroke pain: A case report and literature review

RATIONALE

Avellis syndrome is a rare bulbar syndrome. The main lesions may involve nucleus ambiguus and the lateral spinothalamic tract. The typical reported clinical manifestations are hoarseness, dysphagia, pain, and temperature disturbance of contralateral body. The manifestations, however, may vary. We aim to report new manifestations of Avellis syndrome in this report.

PATIENT CONCERNS

A 47-year-old Chinese peasant woman who felt sudden dizziness, nausea when she was doing the laundry was referred to our department from other hospital. She vomited the stomach contents once and complained numbness of the left trunk and limbs as well as coughing while drinking. The patient presented with palatopharyngeal paralysis, Horner syndrome, and diminished pain as well as temperature sensation in the contralateral face, trunk, and limbs. She also presented with ipsilateral prosopalgia, glossopharyngeal neuralgia, and central poststroke pain.

DIAGNOSES

T2-weighted MRI images demonstrated a high-signal intensity lesion in the right medulla oblongata which indicated a banded infarction site. The patient was diagnosed with medulla oblongata infarction, Avellis syndrome, Horner syndrome, dysphagia, hemiparesthesia, ipsilateral prosopalgia, glossopharyngeal neuralgia, and central poststroke pain.

INTERVENTIONS

The patient was administrated aspirin to prevent the aggregation of platelet and rosuvastatin tablets to regulate lipids as well as to stabilize vascular plaque. She was injected with butylphthalide sodium chloride to improve nerve nutritional status and carbamazepine was prescribed to deal with prosopalgia and glossopharyngeal neuralgia. Gabapentin and pregabalin were administrated to deal with the central poststroke pain.

OUTCOMES

The symptoms of prosopalgia as well as glossopharyngeal neuralgia were gone, and dizziness, dysphagia, and Horner syndrome were significantly alleviated when she was discharged from the hospital while the interventions showed little effect on central poststroke pain.

LESSONS

We reported a case of Avellis syndrome who manifested as the typical reported manifestations. The patient, what's more, presented with ipsilateral trigeminal, glossopharyngeal neuralgia, and central poststroke pain which were described for the first time. It is of great significance for clinicians to recognize the typical as well as other manifestations which helps to make a clear diagnosis.

Gradual aggravation of idiopathic glossopharyngeal neuralgia due to chronic tonsillitis: A case report

RATIONALE

Glossopharyngeal neuralgia (GPN) is a rare type of neuralgia. Depending on the cause, it is classified as idiopathic GPN and secondary GPN. Secondary GPN can also be caused by a mass effect or inflammation of the tonsils, the innervation area of glossopharyngeal nerve.

PATIENT CONCERNS

The patient was diagnosed idiopathic GPN 8 years ago. The patient had intermittent pain, but the pain was well controlled. From 5 months ago, the pain gradually worsened, the patient complained severe pain which impaired chewing and swallowing function.

DIAGNOSES

Idiopathic GPN, secondary GPN, chronic tonsillitis INTERVENTIONS:: Percutaneous glossopharyngeal nerve block, glossopharyngeal neurolysis, and pulsed radiofrequency neuromodulation of glossopharyngeal nerve were performed. After the diagnosis of tonsillitis, antibiotic therapy was performed OUTCOMES:: Two weeks after the antibiotic treatment, the pain decreased simultaneously with the patient's tonsillitis recovery.

LESSONS

In a Patient who had already been diagnosed with idiopathic GPN, both pain control and its cause should be considered when the pain is aggravated.

Vagoglossopharyngeal Neuralgia Occurred Concomitantly with Ipsilateral Hemifacial Spasm and Versive Seizure-Like Movement: A First Case Report

Vagoglossopharyngeal neuralgia (VGPN) is a very rare condition. VGPN with convulsive like attack is even rarer All of the cases had their head turned to the opposite side of facial pain. Hemifacial spasm occurring concurrently with VGPN has never been reported. Herein, we present the first case of VGPN that had ipsilateral hemifacial spasm and versive seizure-like movement to the same side of facial pain. We reported a 71-year-old man presenting with multiple episodes of intermittent sharp shooting pain arising on the right middle neck, followed by hemifacial spasm on right face. Then the patient became syncope while his head and gaze turned to the same side of the painful neck. Electrocardiography showed sinus arrest. Interictal Electroencephalography was normal. This patient initially responded to pregabalin for two weeks, then the symptoms became worse. Microvascular decompression and carbamazepine resulted in the complete remission of all symptoms after six months of follow-up. We could not explain the pathophysiology of unilateral versive seizure like movement.

Microvascular decompression in patients with coexistent trigeminal neuralgia, hemifacial spasm and glossopharyngeal neuralgia

BACKGROUND

Trigeminal neuralgia(TN), hemifacial spasm (HFS) and glossopharyngeal neuralgia (GPN) were referred to hyperactive dysfunction syndromes (HDSs) of the cranial nerves. These symptoms may occur synchronously or metachronously, but the combination of three diseases is extremely rare.

METHODS

From 2007 through 2013, six patients with coexistent GPN-HFS-TN were treated in our department. The combined symptoms occurred on the same side in three and on both sides in three. These patients underwent nine microvascular decompression (MVD) procedures in total. The clinical data including operative findings were respectively analyzed, and the etiological factors as well as treatment strategies were discussed.

RESULTS

Intraoperatively, in all the cases a small posterior fossa was found, which was crowded with cranial nerve roots and cerbellar vesels. Postoperatively, spasm was stopped immediately in four and within 3 months in two; the symptom of TN disappeared immediately in four and within 2 weeks in two; the symptom of GPN was relieved immediately in four and improved with medication in two. During the up to 77 months' follow-up, no changes, recurrence or any dysfunctions of cranial nerves were observed in any of the patients.

CONCLUSIONS

The combination of HFS-TN-GPN is extremely rare and is often associated with a looped VBA and a smaller posterior fossa. However, MVD is still a good choice for treatment. To achieve a safe and effective outcome, dissection of the caudal cranial nerves and proximal transposition of the vertebral artery before decompression of the affected nerve roots are strongly recommended.

[A patient with vertebral artery dissection who initially suffered from pharyngeal pain]

We have encountered a case of a patient with bilateral vertebral artery (VA) dissection who suffered from severe pharyngeal pain. A 61-year-old man, who initially visited a nearby hospital for investigation of mild headache, was pointed out to have a left VA aneurysm. The next morning, severe pharyngeal pain on the right side suddenly occurred. The cause was unknown even when consultation was made to an otolaryngology and oral and maxillofacial surgeon. Sore throat improved in two days. On the 12th day after pharyngeal pain, the patient entered our hospital with a diagnosis of VA dissection. Imaging studies indicated severe stenosis of the right VA and an aneurysm of the left VA which confirmed the diagnosis of bilateral VA dissection. After severe stenosis of the right VA improved a little, the trapping of the left VA aneurysm was performed with bypass surgery of the occipital artery to the posterior inferior cerebellar artery. Although there have been reports of glossopharyngeal neuralgia due to compression of dissective aneurysms of VA, no report exists in terms of a sore throat due to VA dissection without glossopharyngeal neuralgia. This symptom was considered to be involved in the referred pain.

Cranial neuralgias

This article describes the clinical findings of cranial neuralgias, such as trigeminal neuralgia, glossopharyngeal neuralgia, nervus intermedius neuralgia, and others, and postherpetic neuralgia. Pathophysiology of these neuralgias, diagnostic methods, and treatment are also discussed. This information will enable the dentist to diagnose patients who have these rare conditions.

[Vagoglossopharyngeal neuralgia treated with vascular decompression]

This case report describes a 63-year-old man referred with right-sided glossopharyngeal neuralgia. Magnetic resonance imaging (MRI) demonstrated asymmetry of the PICA vessels. A microvascular decompression was performed and complete remission of symptoms followed. After 14 months the neuralgia recurred, this time accompanied by sinus bradycardia/sinus arrest during attacks causing discomfort and syncopes. An MRI now demonstrated an arterial loop at the site of the vagoglossopharyngeal complex leaving the brainstem. After another microvascular decompression, complete remission of symptoms was observed.

[Glossopharyngeal neuralgia with MAS syndrome and complex partial seizures]

The authors present a 56-year-old-man with idiopathic glossopharyngeal neuralgia, complicated by cardiac disturbance with asystole and complex partial seizures. The mechanism of epileptic seizures was released due to transient brain ischaemia, which was caused by cardiac disturbance with asystole, during pain episodes. Pacemarker implantation completely abolished cardiac disturbance and complex partial seizures.

Laryngeal zoster with multiple cranial nerve palsies

A young immunocompetent patient is presented with a very rare presentation of a common viral illness: herpes zoster of the left hemilarynx with sensorial and motoric neuropathy of three ipsilateral lower cranial nerves: IX, X and XI. The mucosal lesions were discovered during upper gastrointestinal endoscopy. PCR of erosional exsudate confirmed the clinical diagnosis. Antiviral therapy and corticosteroids possibly contributed to the prosperous evolution with complete healing.

Loss of taste-induced hypertension--caveat for taste modulation as a therapeutic option in obesity

OBJECTIVE

Effective treatment of obesity is extremely difficult, and taste modulation has been suggested as a feasible option. We aim at presenting dangers associated with stroke-induced taste impairment.

METHODS

A case report is presented with clinical and laboratory findings. We review literature on the effect of taste modulation on body weight.

RESULTS

Eight months after suffering stroke, a 63-year old obese woman with a nine year-old history of type 2 diabetes reported headache and poor general feeling. Physical examination revealed significantly elevated blood pressure of 190/110 mmHg. The patient had never had elevated blood pressure before nor ever been taking any antihypertensive medication. However, stroke resulted in severe persisting dysgeusia. We found out that she had been using up to 110 g of salt daily to make her meals palatable. Standard gustatory tests confirmed severe taste impairment, reflecting the lesion of the glossopharyngeal nerve. Taste loss was not associated with body weight reduction. Limiting daily salt intake to 5 g within 4 weeks resulted in lowering blood pressure to 120/70 mmHg.

CONCLUSION

Stroke-induced dysgeusia may lead to increased salt intake in a type 2 diabetes patient, which caused development of severe hypertension. The taste loss did not yield any weight reduction. We suggest that aiming at reducing body weight by means of taste modulation should be done with caution. Physicians must be aware that patients may try to overcome dysgeusia by additional salt intake, if not adequately informed of the risk thereof.

Mixed cranial nerve neuroma revealing itself as baroreflex failure

We report here the first case of baroreflex failure due to a mixed cranial nerve neuroma in which the clinical manifestations (recurrent severe hypertensive crisis, hypotension) due to baroreflex arc impairment preceded the clinical diagnosis of brain tumour and neurosurgery by a few months. Given the clinical suspicion of baroreflex failure, even in the absence of iatrogenic clues, we propose that the patient's study should include neuroradiologic evaluation of the ponto-cerebellar angulus.

Síncope cardíaca reflexa por "nevralgia" do glossofaríngeo: rara apresentação dessa doença

The first description of severe pain in the distribution of the glossopharyngeal nerve is credited to Weisenberg, in 1910, in a patient with cerebellopontine angle tumor. However, it was Harris, in 1926, who coined the term glossopharyngeal neuralgia to describe this rare condition characterized by paroxysms of excruciating pain located laterally at the back of the tongue, soft palate, throat, and lateral and posterior pharynx, radiating to the ear. Swallowing, coughing, yawning or chewing may trigger pain, which usually lasts from seconds to minutes. The association between glossopharyngeal neuralgia and syncope is very rare, being identified by brief episodes of bradycardia, asystole, and hypotension. Such an association, with this same pathophysiology, was first described by Riley et al in 1942.

Traumatic dissection of the internal maxillary artery associated with isolated glossopharyngeal nerve palsy: case report

OBJECTIVE AND IMPORTANCE

Spontaneous or traumatic dissection of the internal carotid artery with resultant lower cranial nerve palsies is well documented. However, dissection of the external carotid artery with lower cranial palsies has not been reported previously.

CLINICAL PRESENTATION

A 42-year-old man experienced an epidural hematoma as the result of a fall and underwent a craniotomy and hematoma removal. Subsequently, he developed dysgeusia and difficulty in swallowing. Brain magnetic resonance imaging showed a dilated linear structure, with isosignal intensity on T1-weighted images and hyperintense signal intensity on T2-weighted images. Strong enhancement was seen on postcontrast T1-weighted images, indicating a dissected internal maxillary artery. This was confirmed on selective angiography of the left common carotid artery.

INTERVENTION

Guglielmi detachable coils were introduced into the false lumen of the dissected artery. Subsequently, 0.5 ml of glue mixed with Lipiodol (Lafayette Pharmacal, Lafayette, IN) was packed into the remnant of the false lumen. Repeat angiograms demonstrated complete occlusion of the dissected vessel. The patient's postoperative course was uneventful, and the neurological deficits gradually improved.

CONCLUSION

We describe the first reported case of internal maxillary artery dissection and pseudoaneurysm presenting with isolated glossopharyngeal nerve palsy. The association between cranial nerve palsy and dissection of the external carotid artery branch may be the result of a compressive mechanism, as suggested by its anatomic relationships, the characteristics of the dissection, and the good prognosis. Endovascular embolization of the external carotid artery dissection and pseudoaneurysm is suggested as an effective therapeutic method for improving or alleviating neurological deficits produced by mass effect.

Trigeminal and concurrent glossopharyngeal neuralgia secondary to lateral medullary infarction

A 69-year-old woman developed acute pain in the left trigeminal and glossopharyngeal nerve distributions. MR imaging demonstrated a left lateral medullary infarction (LMI) involving the left spinotrigeminal nucleus and tract, nucleus ambiguus, and solitary nucleus. Most patients presenting with trigeminal neuralgia will have disease involving the trigeminal nerve or ganglion or the primary sensory nucleus in the pons. We discuss the unusual finding of LMI associated with concurrent trigeminal and glossopharyngeal neuralgia.

Epidemiology of typical and atypical craniofacial neuralgias

Trigeminal neuralgia (TN) has a prevalence of 0.1-0.2 per thousand and an incidence ranging from about 4-5/100,000/year up to 20/100,000/year after age 60. The female-to-male ratio is about 3:2. A review of several case series shows that pain is more predominant on the right side, but the difference is not statistically significant. TN is significantly associated with arterial hypertension, Charcot-Marie-Tooth neuropathy, glossopharyngeal neuralgia (GN) and multiple sclerosis. GN has an incidence of 0.7/100,000/year and epidemiological studies have shown it to be less severe than previously thought. Post-herpetic neuralgia has a comparable incidence to idiopathic TN. The epidemiology of the central causes of facial pain is still unclear, but it is known that persistent idiopathic facial pain is a widespread, not easily manageable problem.

Orofacial Pain—Part I

Orofacial pain is a common complaint, affecting the lives of millions of people around the world. Chronic orofacial pain often constitutes a challenging diagnostic problem that can be complicated by psychosocial factors and typically requires multidisciplinary treatment approaches. The fundamental prerequisite for successful management of orofacial pain is an accurate diagnosis. Generating a differential diagnosis, which will ultimately lead to a definite diagnosis, requires thorough knowledge of the diagnostic range of orofacial pain. There is a vast array of orofacial pain categories including: (1) musculoskeletal, (2) neuropathic, (3) vascular, (4) neurovascular, (5) idiopathic, (6) pain caused by local, distant, or systemic pathology, and (7) psychogenic. This article presents the salient clinical features and the therapeutic approaches for the various subtypes of musculoskeletal and neuropathic pain. Musculoskeletal pain is the most prevalent orofacial pain, with temporomandibular disorders and tension-type headache being the main examples. Neuropathic pain develops secondary to neural injury and/or irritation and can be distinguished into episodic, including trigeminal neuralgia and glossopharyngeal neuralgia, as well as continuous, such as herpetic and postherpetic neuralgia, traumatic neuralgia, and Eagle's syndrome.

A case of Collet-Sicard syndrome associated with traumatic atlas fractures and congenital basilar invagination

An 18 year old man with congenital basilar invagination developed multiple lower cranial nerve (CN) palsies including CN IX to XII after a traffic accident. Computed tomography of his skull base revealed a two part atlas Jefferson fracture. Normally, lower cranial nerves (CN IX-XII) pass through a space between the styloid process and the atlas transverse process. Atlas burst fractures rarely cause neurological deficits because of a greater transverse and sagittal diameter of the spinal canal at the atlas, and a tendency of the lateral masses to slide away from the cord after injury. However, when associated with a rare condition-congenital basilar invagination-atlas fractures can compromise the space and make CN IX-XII more vulnerable to compression injury. This report discusses the correlation between the anatomical lesions and clinical features of this patient.

[Heart arrest during fibro-bronchoscopic intubation in a patient with parapharyngeal space neoplasia]

A 37-year-old woman a diagnosis of squamous carcinoma of the tongue and a history of partial/hemiglossectomy with cervical lymphadenectomy and postoperative radiotherapy was scheduled for biopsy under general anesthesia given the suspicion of local recurrence. She underwent routine preparation for intubation with a fiberoptic bronchoscope with topical anesthesia of mucosal tissue without sedation. Syncope and asystole presented suddenly during intubation and external cardiopulmonary resuscitation and difficult ventilation through a face mask were necessary. She was finally intubated using a retrograde technique and recovered heartbeat after 20 minutes. No neurological sequelae were observed over the next few days. The etiologic diagnosis of this rare complication was later based on the appearance of the characteristic clinical profile of glossopharyngeal neuralgia-asystole syndrome in combination with parapharyngeal space lesion syncope syndrome; magnetic resonance findings of extensive neoplastic invasion of the space confirmed the diagnosis. Endotracheal intubation with a fiberoptic bronchoscope plays an important role in the management of the anticipated difficult airway. It is safe in the awake patient and facilitates the identification of structures, particularly when there are anatomical alterations due to neoplastic invasion, surgery, or radiotherapy. In the patient we describe, however, stimulation caused asystole.

Glossopharyngeal neuralgia with cardiac syncope treated by glossopharyngeal rhizotomy and microvascular decompression

A glossopharyngeal neuralgia case with cardiac asystole is presented. The sinus mode dysfunction and subsequent syncope with pain appears to be the most important life-threatening symptom in the late period of the disease. Because of cardiac symptoms induced by intense vagal stimulation, this case was considered to be vagoglossopharyngeal neuralgia. Several medical and surgical alternatives have been proposed for its treatment. In the presented case the cause of disease was compression of lower cranial nerves in the right cerebello-pontine angle (CPA) by the vertebro-basilar arterial system. Carbamazepine and pacing were determined ineffective, so the patient was treated surgically by cutting the glossopharyngeal nerve and by decompression of the vagal nerve at the CPA. The sinus arrest and paroxysmal pain attacks disappeared and the patient's life returned to normal.

Hemiparálisis velopalatina idiopática

Idiopathic velopalatine palsy is a condition of unknown etiology and is rarely seen in childhood. Consequently, diagnosis requires a high degree of suspicion. We report a case of sudden onset dysfunction of the lower cranial pairs (IX and X) in a 5-year-old girl who was previously asymptomatic. The clinical course was favorable and the results of complementary investigations were normal and the patient was diagnosed with velopalatine palsy. Based on this case, we aim to report our experience of this condition and provide a review of the literature. This disease should be suspected in patients aged between 5 and 15 years old who present a palsy of the IX and X cranial nerves of sudden onset and without any other symptoms in order to rationalize diagnostic and therapeutic tools. Treatment is based on support measures. The prognosis is excellent, with a high percentage of complete recovery and absence of recurrences.

[Gabapentin treatment of glossopharyngeal neuralgia with cardiac syncope]

A 61-year-old man with glossopharyngeal neuralgia (GPN) associated with cardiac syncope was successfully treated with gabapentin. The treatment of GPN with the antiepileptics is discussed with focus on gabapentin, because of its few side effects in comparison with other anticonvulsants.

Long-term results after microvascular decompression in essential hypertension

BACKGROUND AND PURPOSE

In 1998, 8 patients with severe, intractable arterial hypertension and MR tomography-demonstrated neurovascular contact of a looping artery at the root entry zone of cranial nerves IX and X, causing neurovascular compression, underwent neurosurgical decompression. The short-term results showed a normalization of blood pressure with a markedly reduced antihypertensive drug regimen in 7 patients. To determine the longer-term outcome concerning blood pressure and secondary organ damage after neurovascular decompression, we studied these 8 operated patients prospectively for a mean follow-up of 3.5 years after surgical intervention.

METHODS

Eight hypertensive patients who had undergone microsurgical decompression were monitored every 6 months after surgery to assess blood pressure (by 24-hour ambulatory pressure readings) and the need for antihypertensive medication. To evaluate secondary organ damage, echocardiographic assessment of left ventricular hypertrophy, fundoscopic assessment of hypertensive lesions, and analysis of renal function and proteinuria were done.

RESULTS

Three of the 8 operated patients remained normotensive in the long-term period with decreased antihypertensive medication. Two patients required gradual increases of antihypertensive medication after the first postoperative year, after which arterial blood pressure levels were 10% to 15% lower than preoperative levels. Three patients suffered serious cardiovascular and renal complications, with the incidence of lethal intracerebral hemorrhage in 1 patient and end-stage renal disease in 2 patients, of whom 1 experienced sudden cardiac death.

CONCLUSIONS

The long-term results verify that microsurgical decompression is a successful alternative therapy in a certain subgroup of patients with arterial hypertension due to neurovascular compression. However, the relevance of the looping artery in the other cases, who did not improve, is not clear. Prospective studies to elucidate the pathophysiological role of neurovascular abnormalities and arterial hypertension are needed.

Serotonin mediated cluster headache, trigeminal neuralgia, glossopharyngeal neuralgia, and superior laryngeal neuralgia with SAD chronicity

Cluster headache is a rare and severe pain syndrome with elusive pathophysiology. Serotonin pathways within the brainstem may be implicated in cluster headache with seasonal affective disorder and a subset of cranial nerve neuralgias. We describe and chronicle a syndrome consisting of cluster headache, seasonal affective disorder, with associated trigeminal, glossopharyngeal, superior laryngeal neuralgias in an 11-year-old female. Pharmacologic interventions for this patient were examined in conjunction with current classification, location and function of serotonin receptors. Etiology is postulated as mixed cranial nerve excitation via endogenous 5-HT (agonist) activity of 5-HT3 receptors within the nucleus tractus solitarius and trigeminal tract nucleus.

Glossopharyngeal neuralgia and MS

Glossopharyngeal neuralgia (GPN) is characterized by a severe lancing pain in the posterior pharynx, tonsillar fossa, and base of the tongue. It is induced frequently by swallowing and yawning. GPN has not been described previously in MS patients. The authors report four MS patients with GPN. Three responded to carbamazepine and one resolved during treatment with adrenocorticotrophin hormone (ACTH) and cyclophosphamide. Withdrawal of carbamazepine after 1 week in one patient resulted in recurrence of pain. GPN may be associated with MS and responds to carbamazepine.

Neurogenic hypertension. A new MRI protocol for the evaluation of neurovascular compression of the cranial nerves IX and X root-entry zone

OBJECTIVE

Neurovascular compression of the rostral ventrolateral medulla (RVLM) has been implicated in the pathogenesis of essential hypertension. Although MRI has been widely used to evaluate the morphologic relation of structures in this region, spatial resolution of the previously used techniques was limited. This article describes the use of a new MRI protocol that combines two sequences with improved spatial resolution and complementary image information as well as a set of defined criteria for image analysis.

METHODS

MRI of the brain stem was performed in 60 hypertensive and 50 normotensive subjects using a 3D-CISS and a 3D-FISP-MRA sequence. Neurovascular contact in the RVLM was independently assessed by four readers using predefined criteria and compared with a consensus finding. Agreement was expressed by kappa statistics on a 0 to 1 scale.

RESULTS

Left-sided neurovascular contact within the RVLM was found in 13 (22%) hypertensive and 6 (12%) control subjects. The inter-reader agreement for positive and negative findings ranged from 0.47 to 0.79; agreement to the consensus finding ranged from 0.65 to 0.90.

CONCLUSIONS

The combination of 3D-CISS and arterial flow-sensitive 3D-FISP, together with the evaluation criteria defined in this study, can be used for describing the finer anatomic features of the brain stem, and in particular for investigation of neurovascular contact of the IX/X cranial nerve root-entry zone. The high quality of images and the substantial or almost perfect reader-consensus agreement should make this protocol useful for future investigations of the neurovascular compression syndrome in patients with essential hypertension and possibly in other neurovascular compression syndromes, such as trigeminal neuralgia and hemifacial spasm.