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Trigeminal neuralgia: New classification and diagnostic grading for practice and research.

Cruccu G, Finnerup NB, Jensen TS, Scholz J, Sindou M, Svensson P, Treede RD, Zakrzewska JM, Nurmikko T - Neurology (2016)

Bottom Line: Trigeminal neuralgia (TN) is an exemplary condition of neuropathic facial pain.Secondary TN is due to an identifiable underlying neurologic disease.TN of unknown etiology is labeled idiopathic.

View Article: PubMed Central - PubMed

Affiliation: From the Special Interest Group on Neuropathic Pain (NeuPSIG) of the International Association for the Study of Pain (G.C., N.B.F., T.S.J., J.S., R.-D.T., T.N.), Washington, DC; Scientific Panel Pain of the European Academy of Neurology (G.C., T.S.J., T.N.), Vienna, Austria; Department of Neurology and Psychiatry (G.C.), Sapienza University, Rome, Italy; Danish Pain Research Centre, Department of Clinical Medicine (N.B.F., T.S.J.), and Section of Orofacial Pain and Jaw Function, Department of Dentistry (P.S.), Aarhus University, Denmark; Departments of Anesthesiology and Pharmacology (J.S.), Columbia University Medical Center, New York, NY; Department of Neurosurgery (M.S.), Hôpital Neurologique "Pierre Wertheimer," University of Lyon 1, Lyon, France; Center for Biomedicine and Medical Technology Mannheim (CBTM) (R.-D.T.), Heidelberg University, Mannheim, Germany; Facial Pain Unit, University College London Hospitals NHS Foundation Trust (J.M.Z.); and Pain Relief (T.N.), Neuroscience Research Centre, The Walton Centre NHS Foundation Trust, Liverpool, UK.

No MeSH data available.


Related in: MedlinePlus

Neurovascular compression of the trigeminal root3D constructive interference in steady state MRI shows axial sections at the level of trigeminal nerve root entry into the pons. (A) Bilateral neurovascular contact without morphologic changes of the root in a patient with left trigeminal neuralgia (TN). Nerve (long arrows) and blood vessel (short arrows) appear hypointense surrounded by hyperintense CSF. Contact is seen at the root entry zone as well as mid-cisternal segment. (B, C) Morphologic changes exceeding mere neurovascular contact of the trigeminal nerve root are compatible with the diagnosis of classical TN. (B) Root atrophy in a patient with right TN. (C) Indentation and dislocation of the root in a patient with right TN (short arrow).
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Figure 3: Neurovascular compression of the trigeminal root3D constructive interference in steady state MRI shows axial sections at the level of trigeminal nerve root entry into the pons. (A) Bilateral neurovascular contact without morphologic changes of the root in a patient with left trigeminal neuralgia (TN). Nerve (long arrows) and blood vessel (short arrows) appear hypointense surrounded by hyperintense CSF. Contact is seen at the root entry zone as well as mid-cisternal segment. (B, C) Morphologic changes exceeding mere neurovascular contact of the trigeminal nerve root are compatible with the diagnosis of classical TN. (B) Root atrophy in a patient with right TN. (C) Indentation and dislocation of the root in a patient with right TN (short arrow).

Mentions: Classical TN is defined as a specific category of TN in which MRI demonstrates vascular compression with morphologic changes of the trigeminal nerve root (figure 3). Because of its sensitivity to detect pathologic processes involving brainstem and cranial nerves running through the base of the skull, MRI is widely seen as the method of choice to examine the trigeminal nerve and root. MRI may reveal neurovascular contact of the trigeminal nerve root, but the frequency of blood vessel contact with asymptomatic trigeminal nerve roots cautions against the implementation of contact alone as a diagnostic criterion. In a recent meta-analysis of 9 high-quality blinded and controlled studies, neurovascular contact was found in 471 out of 531 symptomatic nerves (89%) and 244 of 681 asymptomatic nerves (36%), indicating high sensitivity but poor specificity.35 Several authors have instead emphasized the importance of physical impact of the blood vessel on the nerve.36,37 Nerve dislocation or atrophy raised the specificity to 97%. Two prospective studies have corroborated these results.38,39 Location of the neurovascular contact also appears to be relevant. Compression of the trigeminal nerve root at its entry into the brainstem increased specificity and positive predictive value to 100%, with high interobserver consistency.35 The degree of morphologic root changes is therapeutically relevant. Long-term outcome after surgical revision of mere neurovascular contact is uncertain compared to the decompression of dislocated, distorted, or flattened nerve roots.37,40,41 Flattening and atrophy appear to be particularly sensitive signs of clinically relevant compression.36,41 Advanced MRI techniques further allow for visualization of structural changes within the root that are highly suggestive of physical alteration and provide high predictive value for pain relief after decompression.38 However, it is important to acknowledge that all cited studies relied on a clinical diagnosis of TN before MRI. MRI is a valuable diagnostic tool only if preceded by an evaluation of symptoms and signs that indicate probable TN.


Trigeminal neuralgia: New classification and diagnostic grading for practice and research.

Cruccu G, Finnerup NB, Jensen TS, Scholz J, Sindou M, Svensson P, Treede RD, Zakrzewska JM, Nurmikko T - Neurology (2016)

Neurovascular compression of the trigeminal root3D constructive interference in steady state MRI shows axial sections at the level of trigeminal nerve root entry into the pons. (A) Bilateral neurovascular contact without morphologic changes of the root in a patient with left trigeminal neuralgia (TN). Nerve (long arrows) and blood vessel (short arrows) appear hypointense surrounded by hyperintense CSF. Contact is seen at the root entry zone as well as mid-cisternal segment. (B, C) Morphologic changes exceeding mere neurovascular contact of the trigeminal nerve root are compatible with the diagnosis of classical TN. (B) Root atrophy in a patient with right TN. (C) Indentation and dislocation of the root in a patient with right TN (short arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4940067&req=5

Figure 3: Neurovascular compression of the trigeminal root3D constructive interference in steady state MRI shows axial sections at the level of trigeminal nerve root entry into the pons. (A) Bilateral neurovascular contact without morphologic changes of the root in a patient with left trigeminal neuralgia (TN). Nerve (long arrows) and blood vessel (short arrows) appear hypointense surrounded by hyperintense CSF. Contact is seen at the root entry zone as well as mid-cisternal segment. (B, C) Morphologic changes exceeding mere neurovascular contact of the trigeminal nerve root are compatible with the diagnosis of classical TN. (B) Root atrophy in a patient with right TN. (C) Indentation and dislocation of the root in a patient with right TN (short arrow).
Mentions: Classical TN is defined as a specific category of TN in which MRI demonstrates vascular compression with morphologic changes of the trigeminal nerve root (figure 3). Because of its sensitivity to detect pathologic processes involving brainstem and cranial nerves running through the base of the skull, MRI is widely seen as the method of choice to examine the trigeminal nerve and root. MRI may reveal neurovascular contact of the trigeminal nerve root, but the frequency of blood vessel contact with asymptomatic trigeminal nerve roots cautions against the implementation of contact alone as a diagnostic criterion. In a recent meta-analysis of 9 high-quality blinded and controlled studies, neurovascular contact was found in 471 out of 531 symptomatic nerves (89%) and 244 of 681 asymptomatic nerves (36%), indicating high sensitivity but poor specificity.35 Several authors have instead emphasized the importance of physical impact of the blood vessel on the nerve.36,37 Nerve dislocation or atrophy raised the specificity to 97%. Two prospective studies have corroborated these results.38,39 Location of the neurovascular contact also appears to be relevant. Compression of the trigeminal nerve root at its entry into the brainstem increased specificity and positive predictive value to 100%, with high interobserver consistency.35 The degree of morphologic root changes is therapeutically relevant. Long-term outcome after surgical revision of mere neurovascular contact is uncertain compared to the decompression of dislocated, distorted, or flattened nerve roots.37,40,41 Flattening and atrophy appear to be particularly sensitive signs of clinically relevant compression.36,41 Advanced MRI techniques further allow for visualization of structural changes within the root that are highly suggestive of physical alteration and provide high predictive value for pain relief after decompression.38 However, it is important to acknowledge that all cited studies relied on a clinical diagnosis of TN before MRI. MRI is a valuable diagnostic tool only if preceded by an evaluation of symptoms and signs that indicate probable TN.

Bottom Line: Trigeminal neuralgia (TN) is an exemplary condition of neuropathic facial pain.Secondary TN is due to an identifiable underlying neurologic disease.TN of unknown etiology is labeled idiopathic.

View Article: PubMed Central - PubMed

Affiliation: From the Special Interest Group on Neuropathic Pain (NeuPSIG) of the International Association for the Study of Pain (G.C., N.B.F., T.S.J., J.S., R.-D.T., T.N.), Washington, DC; Scientific Panel Pain of the European Academy of Neurology (G.C., T.S.J., T.N.), Vienna, Austria; Department of Neurology and Psychiatry (G.C.), Sapienza University, Rome, Italy; Danish Pain Research Centre, Department of Clinical Medicine (N.B.F., T.S.J.), and Section of Orofacial Pain and Jaw Function, Department of Dentistry (P.S.), Aarhus University, Denmark; Departments of Anesthesiology and Pharmacology (J.S.), Columbia University Medical Center, New York, NY; Department of Neurosurgery (M.S.), Hôpital Neurologique "Pierre Wertheimer," University of Lyon 1, Lyon, France; Center for Biomedicine and Medical Technology Mannheim (CBTM) (R.-D.T.), Heidelberg University, Mannheim, Germany; Facial Pain Unit, University College London Hospitals NHS Foundation Trust (J.M.Z.); and Pain Relief (T.N.), Neuroscience Research Centre, The Walton Centre NHS Foundation Trust, Liverpool, UK.

No MeSH data available.


Related in: MedlinePlus