[Trigeminal neuralgia. Diagnosis].
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Diagnosis, Differential↗
Biomedical subjects
M Sindou
Publications and source records attributed to M Sindou.
Cryptic angioma in the trochlear nerve. Excision of the invaded portion and successful repair with an autologous graft: case report.
Cryptic angiomas, which are intrinsic to cranial nerves, are uncommon. Such lesions involving the trochlear nerve have not been previously described. The authors have therefore found it interesting to report a case fortuitously discovered in a patient with trigeminal neuralgia who underwent a fifth nerve microvascular decompression through the supracerebellar space. The angioma was not responsible for the neuralgia, but because of its potential risk of bleeding, the lesion was treated by resection of the trochlear nerve in its invaded portion. Then, the nerve was successfully repaired with an autograft harvested from the distal part of the sural nerve.
Aged↗
Hearing prognosis and intraoperative guidance of brainstem auditory evoked potential in microvascular decompression.
Intraoperative monitoring of brainstem auditory evoked potential (BAEP) was done in 34 patients submitted to microvascular decompression (MVD). Seventeen of these patients had trigeminal neuralgia, and 17 had hemifacial spasm. Transitory postoperative hearing loss was observed in 6 (18%) of the patients, and permanent hearing loss was observed in 2 (6%) of the patients. Wave I-V interpeak latency (IPL) was calculated during each step of the MVD procedure in order to identify the dangerous steps of the surgery. Wave I-V IPL abnormalities occurred more frequently during cerebellar retraction. Of the 6 patients who had total loss of BAEP lasting throughout the surgery, 1 (17%) had definitive deafness. Ten of the 34 patients had an absence or partial diminution of BAEP without total normalization before the end of surgery. Among these 10 patients, 2 had transitory hearing loss and 1 had permanent hearing loss.
Adult↗
[Practical value of transcutaneous pressure adjustable valves (Sophy SU 8) in the treatment of hydrocephalus and arachnoid cysts in adults (75 cases)].
The authors report a series of 75 adults treated over the four last years for hydrocephalus (69 cases) or arachnoid cysts (6 cases) by using a transcutaneous pressure adjustable valve (sophy SU 8) the mechanism of which is recalled. The shunt was ventriculo-atrial 46 times, ventriculo-peritoneal 23 times and cysto-peritoneal 6 times. The opening pressure of the valve was initially adjusted 56 times in a medium, 9 times in a high, and 10 times in a low position, according to each particular patient's features. Following the evolution of the neurological status and/or the CT findings, the opening pressure was secondarily modified in 27 patients (i.e. in 36%), and in some of them several times. It was raised 16 times: 10 times because of subdural hydroma(s) (complicated with a subdural hematoma which required a surgical removal, in one case), and 6 times because of clinical symptoms of intracranial hypotension associated with hyper-drainage signs on CT. It was diminished 20 times because of the absence of clinical improvement and persistence of dilated ventricles on CT. In these 27 patients the Sophy SU 8 valve allowed modification of its opening pressure according to the clinical and CT evolution, without need for reoperation. It is concluded that the patients who can benefit the more from this valve system are patients with normal pressure hydrocephalus or with arachnoid cysts.
Adolescent↗
Cerebrospinal fluid dynamics in the tardive cauda equina syndrome of ankylosing spondylitis.
Typical cauda equina syndrome secondary to long-standing ankylosing spondylitis is reported in a 63-year-old man. Radionuclide cisternography demonstrated a resorption defect of cerebrospinal fluid in the enlarged lumbosacral dural sac. After transient symptomatic improvement with acetazolamide, a lumboperitoneal shunt was placed. The rate of cerebrospinal fluid, isotope resorption became normal. In the 5 years of follow-up, partial remission has been observed.
Cauda Equina↗
Does microsurgical vascular decompression for trigeminal neuralgia work through a neo-compressive mechanism? Anatomical-surgical evidence for a decompressive effect.
The positive effect of Microsurgical Vascular Decompression (MVD) on idiopathic trigeminal neuralgia still remains controversial between a decompressive mechanism and a "neo-compressive" one. This paper is a summary of a comparative study of the results on pain obtained with two technical modifications of the MVD procedure. The first consisted of interposition of a foreign material between the nerve and the transposed artery after dissection of the trigeminal nerve, whilst in the second the offending vessel(s) was dislodged without using any material touching the nerve. The two series of 60 patients in each were similar concerning the clinical features. Evaluation of results on neuralgia - with one year follow-up-in both series, shows that the technique used in the second group was not followed by a higher rate of recurrence than the technique used in the first group. On the contrary; 4.5% in the 2nd group compared to 10% in the first. This indicates that MVD would not act as a result of "neo-compression" of the nerve, but rather through a real decompressive mechanism.
Arteries↗
Somatosensory function following dorsal root entry zone lesions in patients with neurogenic pain or spasticity.
The goal of this study was to assess the effects of the dorsal root entry zone (DREZ) lesioning procedure, microsurgical DREZ-otomy (MDT), on spinal cord somatosensory function based on peri- and intraoperative clinical and electrophysiological data. The study was performed prospectively on a series of 20 patients suffering from either chronic neurogenic pain or spasticity. Physiological observations were made of the intraoperative evoked electrospinographic recordings as collected from the surface of the spinal cord. The MDT procedure produced analgesia or severe hypalgesia, moderate hypesthesia, and only slight deficits in proprioception and cutaneous spatial discrimination on the body segments operated on. These clinical data correlated well with evoked electrospinographic recordings, which showed a moderate effect of MDT on presynaptic compound action potentials recorded from the spinal cord (N11 and N21), a partial or even reversible effect on the cortical postcentral N20 wave, a more marked effect on the postsynaptic dorsal horn waves N13 and N24 related to large primary afferent fibers, and a disappearance of dorsal horn waves related to finer afferents (N2 and possibly N3). These data provide evidence for an acceptably selective action of MDT on spinal cord nociceptive mechanisms, and for a partial, often slight, involvement of the other somatosensory domains. The presence of abnormal evoked electrospinographic waves is discussed in relation to the mechanisms of neurogenic pain and spasticity. The hypothesis of a "retuning" of the dorsal horn as the mode of action of MDT is presented.
Action Potentials↗
[Peroperative monitoring of early auditory evoked potentials in microsurgical vascular decompression for trigeminal neuralgia or hemifacial spasm].
Intra-operative B.A.E.P. monitoring have been performed in two series of patients who underwent Microsurgical Vascular Decompression (M.V.D.) of the Vth and VIIth cranial nerves in the posterior fossa. The first series consisted of 17 patients among the 400 operated on for Trigeminal Neuralgia (T.N.), the second one also of 17 patients among the 25 treated for Hemifacial spasm (H.S.), over the last four years. The equal number of recorded patients in the two groups is totally fortuitous. The aim of the work was to correlate the electrophysiological changes: 1) to the surgical manoeuvres potentially responsible for B.A.E.P. alterations, in order to modify the M.V.D. technique, so as to minimize the risks of hearing loss, 2) to the eventual post-operative auditory disturbances, in order to define prognostic criteria from B.A.E.P. monitoring. I. Intra-operative B.A.E.P. modifications were graded into 4 categories, according to their degree of severity (table II): minimal changes (category 1), increase in latency returning to normal (2) or without normalization (2a) before end of surgery, abolition or partial decrease of responses returning to normal (3) or without complete normalization (3a) before end of surgery, total B.A.E.P. loss lasting through the entire procedure (4). Patients operated on for H.S. had more often significant B.A.E.P. changes than those with T.N., respectively 10 and 6 for categories 3a and 4 together. Auditory function was at risk mainly during cerebellar retraction (especially if cerebello-pontine angle was approached laterally) and during vascular manipulation of the labyrinthine artery (which can generat vasospasm).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Idiopathic neuralgia of the glossopharyngeal nerve. Study of a series of 14 cases and review of the literature].
The authors report 14 cases of idiopathic glossopharyngeal neuralgias surgically treated and followed over a mean 3.5 year period. The series consisted of 7 females and 7 males, 66 years old on average. The pain was located on the left side in 13 out of the 14 cases. A trigeminal neuralgia was associated to the glossopharyngeal pain (on the same side) in 4 cases. The vertebral angiogram evidenced a megadolicho-artery in 6 cases and was considered normal in 8 cases. The surgical treatment was a percutaneous thermocoagulation of the Andersh ganglion in 3 case (the thermolesion could not be completed in one of these cases due to the onset of coronarian ischemia). A microsurgical vascular decompression was carried out 9 times, alone in 8 cases, associated with a radicotomy in one case. A mere radicotomy was performed in 2 other cases, because of no finding vascular compression. Total pain relief was achieved in the 2 cases of completed thermocoagulation and in all the 11 cases of direct approach. The thermocoagulations, as well as the radicotomies, of the IX and anterior rootlets of the X produced in each case permanent deficits in the IX and X territories, whilst the side-effects of the decompression procedure were only mild or transient. Therefore microsurgical vascular decompression is preferred by the authors everytime the age, general conditions and the patient's acceptance authorize it.
Adult↗
[Prognostic factors in ruptured intracranial aneurysm. Significance of the temperature curve].
This report concerns 130 consecutive patients admitted as emergencies for ruptured intracranial aneurysms. The poorer the patient's clinical condition, the longer the time elapsed before surgery (14 days on average). While awaiting surgery, 4.6 per cent of the patients rebled and 5.4 per cent deteriorated due to vasospasm. The 14 patients who had shown no symptom since the rupture remained asymptomatic until surgery, while the clinical status of the other 116 patients improved in 36.3 per cent, remained unchanged in 53.4 per cent and deteriorated in 10.3 per cent (3 per cent of whom died). After a one year follow-up, 58 per cent of the 126 patients operated upon had resumed all their previous activities; 10.3 per cent were autonomous but had been unable to resume their professional activities normally; 8.7 per cent were dependent and 20.5 per cent had died of neurological complications and/or sequelae (2.4 per cent had died of intercurrent diseases). An analysis of prognostic factors showed that the outcome was not significantly influenced by the site of the aneurysms, the patient's sex or age, or a past history of systemic arterial hypertension, but it was narrowly dependent (P less than 0.001) upon the clinical status at the time of surgery, the amount of extravasated blood at CT or the degree of vasospasm at angiography. The greater the size of the haematoma and the degree of vasosplasm, the more the clinical status was affected (P less than 0.01). In addition, the clinical status was found to be particularly poor when hyperthermia was present (P less than 0.01), and the outcome was worse in patients who were operated upon during the ascending phase of fever (P less than 0.05). Thus, a careful examination of the temperature curve might be of help in the choice of the optimal time for surgery.
Adolescent↗
Fronto-temporal approach with orbito-zygomatic removal. Surgical anatomy.
Removal of the orbital rim and the zygomatic arch can be associated with fronto-temporal craniotomy to gain additional space, so as to decrease cerebral retraction. In order to quantify the gain provided by this enlarged approach, the authors underwent anatomical studies comparing the field view angle of various intracranial targets with and without orbito-zygomatic removal, in 11 fresh human cadavers with the brain in situ. The field view angle was increased, thanks to orbito-zygomatic removal, on average, by 75% in the sub-frontal approach, 46% in the pterional approach, and 86% in the sub-temporal approach. Such approaches can be very useful for access to difficult lesions located in the vicinity of the skull base. In the last 3 years 21 patients were operated upon using this technique, with excellent results.
Cadaver↗
Ablative neurosurgical procedures for the treatment of chronic pain.
This article is devoted to ablative neurosurgical procedures used for the treatment of chronic pain. The authors detail only those procedures that are currently performed. The procedures are classified as those directed to the peripheral nerves, spinal roots and cranial nerves; the dorsal root entry zone; the ascending extra-lemniscal pathways. The authors have analyzed the results of their own series and those published in the literature. They concentrate on the rationale and neurophysiological effects of the operations.
Chronic Disease↗
Intraoperative electrophysiological recordings during microsurgical DREZ-tomies in man.
Spinal cord surface evoked potentials were studied during surgery in 20 patients operated upon for pain and spasticity using microsurgical DREZ-tomy (MDT). The goal was to collect data on spinal cord physiology and analyze the effects of MDT. Thanks to a simplified floating tungsten microelectrode, intraoperative unit recordings were obtained from the dorsal horn of 3 spastic and 2 neurogenic pain patients.
Afferent Pathways↗
Microsurgical ablative procedures in the peripheral nerves and dorsal root entry zone for relief of focal spasticity in the limbs.
When spasticity is harmful and localized in the limb(s), ablative procedures in the peripheral nerves or the dorsal root entry zone (DREZ) can be useful. The authors report on the long-term results of (1) selective tibial neurotomy in a series of 62 spastic feet, and (2) microsurgical DREZ-tomy in a series of 69 patients affected with hyperspasticity in the entire upper or lower limb(s).
Follow-Up Studies↗
[Intraoperative brainstem auditory evoked potential in the microvascular decompression of the 5th and 7th cranial nerves].
Microvascular decompression techniques are rational surgical procedures for treating trigeminal neuralgia and facial hemispasm, with results ranging from good to excellent in 90% of cases. Among the most frequent complications recorded in the literature concerning these decompressions, impairment of the facial nerve and auditory nerve account for 5% to 10% due to mechanical traction and/or vascular injury. The peroperative use of early brain-stem evoked potentials (BAEP) was performed on 17 patients in a series of 325 decompressions of the trigeminal nerve, and on 17 patients in a series of 25 decompressions for facial hemispasm. Such peroperative monitoring is considered to be most important in the surgical technique. The author reports on his experience and results.
Adult↗
[Orbital and/or zygomatic removal in an approach to lesions near the cranial base. Surgical technic, anatomic study and analysis of a series of 24 cases].
The authors describe the technique of removal of the orbital rim, the zygomatic arch and the combination of both, i.e., the orbito-zygomatic arch. Then they give the summary of an anatomical study in human cadavers (13 approaches), measuring the field view angle (F.V.A.) of various intra-cranial targets in the vicinity of the skull base after orbital and/or zygomatic removal associated to fronto-temporal craniotomy. Thanks to orbital and/or zygomatic removal, F.V.A. was increased on average, by 75% in the sub-frontal approach, 46% in the pterional approach, and 86% in the sub-temporal approach. Finally the authors illustrate the usefulness of these combined approaches in a series of 24 cases of various difficult lesions located in the vicinity of the skull base, operated on during the last 3 years.
Brain↗
[Microsurgical vascular decompression in trigeminal neuralgia. Comparison of 2 technical modalities and physiopathologic deductions. A study of 120 cases].
Since 1972, 1,000 patients were operated upon for trigeminal neuralgia, 816 percutaneously using thermocoagulation and 184 through a direct approach at the cerebello-pontive angle. This article deals with the microvascular decompression (MVD) procedure, stressing on the influence (on morbidity and results) of different technical modalities. This work compares: 1. a series of 60 patients operated upon in the sitting position, with a wide opening of the cerebellopontine-angle, and using an interposed foreign body to protect the nerve from the conflicting artery (Group I, 1984-1986) and 2. a series of 60 other patients who underwent MVD in the lateral position, with a restricted approach and transposition of the conflicting artery without interposition of synthetic material (Group II, 1986-1988). Both series were fortuitously comparable concerning sex, age and clinical features. Comparison of results in the two series shows that: 1. Duration of the anesthetic induction, surgery and awakening, were all shorter (70 mm, 2 h 47 mn, 1 h 38 mn, respectively) in group II than in group I (110 mn, 3 h 12 mn, 2 h 38 mn). 2. Complications related both to anesthesia and surgery were significantly less frequent in group II than in group I, excepted for rhinorrhea due to C.S.F. leak through the mastoid cells. 3. Trigeminal neuralgia was completely relieved--without any hypoesthesia and/or dysesthesias--in 75% of group I patients (mean follow-up: 41 months) and in 83.3% of group II (mean follow-up: 16 months). Evaluation of results on pain, after one year, in both series shows that the technique used in the second series: transposition of the conflicting vessel without foreign body touching the nerve was not followed by a higher rate of recurrences than in the first series, on the contrary: 4.5% versus 10%. This indicates that MDV would not act by creating a neocompression of the nerve, but in fact by a real decompression mechanism.
Adult↗
Clinical use of nociceptive flexion reflex recording in the evaluation of functional neurosurgical procedures.
Nociceptive flexion reflexes (RIII) obtained by stimulation of sural nerve were studied in patients with intractable chronic pain before and after functional neurosurgery, either dorsal column stimulation (DCS, n = 15) or posterior selective rhizotomy in the dorsal root entry zone (DREZ, n = 5). Dynamic study of RIII at supraliminal levels provided direct, quantitative and replicable evidence of the inhibition of nociceptive spinal reflexes by DSC. The effects of DSC on the RIII were highly correlated with subjective pain relief. In non-collaborative patients it was still possible to select the best DCS parameters (frequency, intensity) as those providing maximal RIII depression. After posterior selective rhizotomy in the DREZ involving S1-S2 root levels postoperative evidence of selective extralemniscal lesioning could be assessed by the abolition or strong attenuation of nociceptive RIII, whereas preservation of the lemniscal pathways was evidenced by somatosensory evoked potentials. Routine recording of nociceptive reflexes in man proved to be a useful tool for the objective evaluation of anatomo-physiological effects of functional neurosurgical procedures.
Electric Stimulation↗