Tentorial dural arteriovenous malformation manifesting as trigeminal neuralgia treated by stereotactic radiosurgery: a case report

doi:10.1016/j.surneu.2006.01.022

Surgical Neurology

Volume 66, Issue 5, November 2006, Pages 519-523

https://doi.org/10.1016/j.surneu.2006.01.022 Get rights and content

Abstract

Background

Tentorial dAVMs as a cause of trigeminal neuralgia are extremely rare. Consensus exists that radical treatment of such high-flow dAVMs should be considered because of their high risk of bleeding. The authors present a case of a 50-year-old man who presented with symptoms of tic douloureux caused by tentorial dAVM, which was treated successfully by SRS.

Case Description

The patient consulted us with a 1-month history of harboring right trigeminal neuralgia. The cerebral angiography revealed a dAVM in the petrotentorial region and the MRI demonstrated a dilated petrosal venous varix compressing the root entry zone of the right trigeminal nerve. Gamma knife surgery was performed with a marginal dose of 18 Gy and a maximum dose of 30 Gy in a volume of 0.3 mL. The target point of the radiosurgery for this patient was a fistula identified by superselective angiography, enhanced computed tomography, and MRI. Follow-up MRI, 1 year after GKS, showed a thrombosed lesion, and the patient was able to end medication. There was no evidence of recurrence or adverse effects in the 3-year follow-up.

Conclusion

Stereotactic radiosurgery can play an effective role as a treatment modality for such unusual dAVMs.

Introduction

Tentorial dAVMs as a cause of trigeminal neuralgia are extremely rare. Only 7 cases have been reported in the available literature [3], [9], [10], [11], [16], [17], [19], [24]. Treatment strategy of tentorial dAVMs is still debated because of the rich variety of their flow types and the surgical difficulty for such deeply seated lesions. Most tentorial dAVMs are classified into Borden type II or III, which are usually related to a high risk of hemorrhagic phenomena [1], [3], [6]. The tentorial arteriovenous malformations (AVMs) associated with sinus thrombosis, retrograde leptomeningeal venous drainage, and venous varix have a much higher probability of hemorrhage [1], [4]. We report the case of a patient with a tentorial dural AVM manifesting as trigeminal neuralgia, associated with leptomeningeal venous return and venous aneurysm. We also discuss the feasibility of SRS as one of the treatment modalities for tentorial dAVMs.

Section snippets

Case report

A 50-year-old man presented with a 1-month history of facial pain in the second and third divisions of the right trigeminal nerve. The patient consulted us for further evaluation and treatment. Neurologic examination revealed hypesthesia and lancinating pain in the second and third division of the right trigeminal nerve. Magnetic resonance imaging revealed that the right petrosal vein with venous varix was causing compression at the root entry zone of the right trigeminal nerve (Fig. 1A).

Discussion

Tentorial dAVMs are relatively rare, accounting for only 8.4% of 377 dAVMs reviewed in a retrospective meta-analysis of the literature and clinical experience [1]. Most of them manifest hemorrhagic stroke; tentorial AVMs as a cause of trigeminal neuralgia are extremely uncommon. This has rarely been reported, and only 7 cases are described in the available literature [3], [9], [10], [11], [16], [17], [19], [24]. In summary, according to precise records, including those of our case, 3 males and

Conclusions

The authors report an unusual case of dAVM manifesting as trigeminal neuralgia. The patient was treated by SRS, resulting in complete resolution of the trigeminal neuralgia. Stereotactic radiosurgery may be effective for tentorial AVMs within the limitations of smaller-sized AVMs or low-flow shunts.

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Stereotactic radiosurgery (SRS) is effectively used for treating various cerebrovascular diseases, including arteriovenous malformations. As image-based surgery is the gold standard technique in SRS, the quality of stereotactic angiography images greatly influences the surgical approach for cerebrovascular diseases. Despite several studies in the relevant literature, research on auxiliary devices, including angiography indicators used for cerebrovascular disease surgeries, is limited. Thus, the development of angiographic indicators may provide meaningful data for stereotactic surgery.
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Citation Excerpt :
In the first there was a petrotentorial fistula with a vein compressing the adjacent trigeminal nerve. The prescription dose was 18 Gy (Matsushige et al., 2006) and the patient became pain free. The other case was a right sided DAVF surrounding the right trigeminal nerve.
Spontaneous Trigeminal Neuralgia is a painful condition of the face which may require interventional treatment if medicines fail to control the pain. These include microvascular decompression (MVD) and GKNS. The former is moderately more effective but GKNS has become accepted both as an alternative to MVD or as an adjunct. Like all treatments of the condition, it is successful in a majority of patients but by no means all. Repeat treatments are possible.
When Trigeminal Neuralgia is secondary to other conditions the response to GKNS is different. With AVMs, Dural Arteriovenous Fistulae and Epidermoids, the dose to treat the visible lesion usually cures the neuralgia. With meningiomas it is necessary to treat the neuralgia as a separate entity with a neuralgia dose focused on the nerve. GKNS does not improve the rare neuralgia associated with Vestibular Schwannomas. It works with Multiple Sclerosis but not as well as with the spontaneous illness. There is some evidence that GKNS can be useful with the rare Glossopharyngeal and Sphenopalatine Neuralgias.
Cognard Grade IV Tentorial Dural Arteriovenous Fistula Presenting as Trigeminal Neuralgia: Endovascular Management
2020, World Neurosurgery
Tentorial dural arteriovenous fistulas have an increased risk of rupture and hemorrhage, and therefore require urgent treatment to occlude the fistula and proximal venous drainage. This is usually accomplished via endovascular treatment. We present a case of a Cognard grade IV dural arteriovenous fistula that presented as trigeminal neuralgia. This video showcases the angiographic vascular composition of the lesion with main feeders coming from the middle meningeal artery and the tentorial artery of Bernasconi and Cassinari. Details, benefits, and risks of the procedure were thoroughly discussed with the patient and consent was obtained prior to the procedure. We performed endovascular Onyx embolization through a distal branch of the right middle meningeal artery. We were able to successfully occlude the lesion using Onyx embolization and the patient had significant improvement of her pretreatment trigeminal neuralgia.
Dural Arteriovenous Fistula Presenting as Trigeminal Neuralgia: 2 Case Reports and Review of the Literature
2020, World Neurosurgery
Dural arteriovenous fistulae (dAVFs) can sporadically compress the root entry zone of the trigeminal nerve or the Gasserian ganglion and therefore be a rare cause of isolated or complicated trigeminal neuralgia (TN).
We describe 2 cases of TN related to dAVF treated similarly with transarterial embolization but with divergent outcomes. Further, we completed a comprehensive literature review of previously reported cases to date. A sparse but growing literature with regards to this specific and rare but salient cause of TN was noted. The type of dAVF most commonly found to cause TN was that of a tentorial nidus, a lesion generally accepted to be at high risk of hemorrhage and in need of urgent treatment. This warrants imaging for new TN presentations to ensure that a dangerous lesion does not represent the underlying cause, especially when the TN symptoms are comorbid with other symptoms such as a bruit. Treatments pursued span the range of open surgery, endovascular treatment, and radiosurgery with great success in treating both the TN symptoms, as well as the rupture risk of the dAVF itself in most cases. Indeed, endovascular approaches are becoming more widely employed for these cases over time, often resolving the abnormality on first treatment attempt. Other cases reach resolution after employing a combination of treatment modalities.
This work highlights that dAVFs, particularly the tentorial type, are capable of causing TN symptomatically identical to that of other etiologies and that treatment of the dAVF itself is often sufficient.
Resolution of Trigeminal Neuralgia After Surgical Disconnection of a Foramen Magnum Dural Arteriovenous Fistula
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Trigeminal neuralgia (TN) resulting from dural arteriovenous fistulas (DAVFs) is rare. TN caused by a foramen magnum DAVF has not been reported yet. We report a patient with TN caused by a foramen magnum DAVF treated with surgical disconnection.
A 35-year-old man was admitted to our hospital with a right TN. Magnetic resonance imaging showed an abnormal flow void in the posterior fossa and a vascular structure next to the root entry zone of the right trigeminal nerve. Digital subtraction angiography showed a Cognard type IV DAVF located at the foramen magnum. The fistula was disconnected surgically. The patient was rendered completely pain-free, and the fistula did not recur during 4-year follow-up.
DAVF is a rare cause of TN. Surgical disconnection is an effective treatment method for TN caused by a foramen magnum DAVF.
Trigeminal Neuralgia Caused by Dural Arteriovenous Fistula in Meckel Cave Treated with Gamma Knife Radiosurgery
2019, World Neurosurgery
Citation Excerpt :
However, it is unclear if these findings can be extrapolated to TGN caused by DAVF. Options for treatment for typical DAVF include observation,13 embolization,11,14,15 stereotactic surgery,3,16 surgical obliteration,17 or combinations of the aforementioned techniques.10,18 Although complete surgical resection is an ideal option for patients with a history of hemorrhage, complete surgical resection may be limited because of the risks associated with certain locations of the fistula.6,19
Classic trigeminal neuralgia is an often debilitating condition that frequently results from vascular compression at the root entry zone of the trigeminal nerve. We report a case of dural arteriovenous fistula surrounding the trigeminal nerve from near the root entry zone extending as far ventral as the Meckel cave treated solely with Gamma Knife radiosurgery.
A 71-year-old woman presented with a history of persistent attacks of right facial pain after failed conservative management. Magnetic resonance imaging of the brain demonstrated dilated vasculature in the right cerebellopontine angle, and diagnostic cerebral angiography revealed a dural arteriovenous fistula surrounding the right trigeminal nerve. Stereotactic radiosurgery using Gamma Knife was performed. At 6-month follow-up, she was symptom-free with decreased caliber of abnormal vascularity surrounding the trigeminal nerve on magnetic resonance imaging.
This case suggests that trigeminal neuralgia associated with dural arteriovenous fistula can potentially be treated with Gamma Knife radiosurgery; however, more extensive studies and long-term follow-up to evaluate vessel patency will be necessary to elucidate further the role of stereotactic radiosurgery alone in treating this entity.

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RadiosurgeryTentorial dural arteriovenous malformation manifesting as trigeminal neuralgia treated by stereotactic radiosurgery: a case report

Abstract

Background

Case Description

Conclusion

Introduction

Section snippets

Case report

Discussion

Conclusions

Surg Neurol

Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course

J Neurosurg

Radiosurgical treatment of low flow carotid-cavernous fistulae

Acta Neurochir Suppl (Wien)

A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment

J Neurosurg

Intracranial dural arteriovenous fistulae: angiographic predictors of intracranial hemorrhage and clinical outcome in nonsurgical patients

J Neurosurg

Successful radiosurgical treatment of a dural arteriovenous malformation: case report

Neurosurgery

The validity of classification for the clinical presentation of intracranial dural arteriovenous fistulas

J Neurosurg

Surgical treatment of tentorial arteriovenous malformations draining into the subarachnoid space. Report of four cases

J Neurosurg

Histopathological aspects of dural arteriovenous fistulas in the transverse-sigmoid sinus region in nine patients

Neurosurgery

Dural AV malformation of the lateral and sigmoid sinuses as possible cause of trigeminal neuralgia. Case report

Acta Neurochir (Wien)

Surgical interruption of draining vein or dural sinus: treatment for petrotentorial dural arteriovenous malformation

No Shinkei Geka (Jpn)

Percutaneous transvenous coil embolization of a Djindjian type 4 tentorial dural arteriovenous malformation

AJNR Am J Neuroradiol

Radiosurgery
Tentorial dural arteriovenous malformation manifesting as trigeminal neuralgia treated by stereotactic radiosurgery: a case report