Acta Neurochirurgica

, Volume 150, Issue 11, pp 1157–1161 | Cite as

Typical trigeminal neuralgia associated with brainstem white matter lesions on MRI in patients without criteria of multiple sclerosis

  • Ignacio Arrese
  • Alfonso Lagares
  • Rafael Alday
  • Ana Ramos
  • Juan J. Rivas
  • Ramiro D. Lobato
Clinical Article



Although compression of the trigeminal nerve by a vascular loop is thought to be the most common cause of trigeminal neuralgia (TN), other aetiologies, such as multiple sclerosis or brainstem infarction may be associated with this disorder. MRI may detect lesions different from vascular loop compression of the trigeminal nerve that may be related to TN.

Patients and methods

The pre-operative MRIs of 68 patients without the diagnosis of multiple sclerosis who were operated for typical TN between 1998 and 2003 were retrospectively reviewed Four of these showed hyperintense lesions in the pons on T2 MRI sequences. No patient had prior surgery. These four patients underwent different operations for the control of pain but in two of them only ablative procedures were effective


Although it is uncertain whether the occurrence of TN in our patients may be attributed to the brainstem abnormalities seen on MRI, the presence of these lesions appears to be the most convincing explanation for the occurrence of pain. We believe that, in the presence of such imaging changes, a destructive procedure should be regarded as the elective surgical treatment in patients presenting with typical TN with or without apparent vascular loop compression of the trigeminal root.


Cerebral infarction Multiple sclerosis Brainstem lesions Trigeminal neuralgia Magnetic resonance 



This study was supported by a grant from Fundación Alfonso Martín Escudero.


  1. 1.
    Balestrino M, Leandri M (1997) Trigeminal neuralgia in pontine ischaemia. J Neurol Neurosurg Psychiatry 62:297–298PubMedGoogle Scholar
  2. 2.
    Boecher-Schwarz HG, Bruehl K, Kessel G, Guenthner M, Perneczky A, Stoeter P (1998) Sensitivity and specificity of MRA in the diagnosis of neurovascular compression in patients with trigeminal neuralgia. Neuroradiology 40:88–95PubMedCrossRefGoogle Scholar
  3. 3.
    Broggi G, Ferroli P, Franzini A, Nazzi V, Farina L, La Mantia L, Milanese C (2004) Operative findings and outcomes of microvascular decompression for trigeminal neuralgia in 35 patients affected by multiple sclerosis. Neurosurgery 55:830–838PubMedCrossRefGoogle Scholar
  4. 4.
    Chang JW, Choy JY, Yoon YS, Park YG (2002) Unusual causes of trigeminal neuralgia treated by gamma knife radiosurgery-Report of two cases. J Neurosurg 97:533–535PubMedGoogle Scholar
  5. 5.
    Delitala A, Brunori A, Chiappetta F (1999) Trigeminal neuralgia resulting from infarction of the root entry zone of the trigeminal nerve: case report. Neurosurgery 45:202PubMedCrossRefGoogle Scholar
  6. 6.
    Devor M, Amir R, Rappaport ZH (2002) Pathophysiology of trigeminal neuralgia: The ignition hypothesis. Clin J Pain 18:4–13PubMedCrossRefGoogle Scholar
  7. 7.
    Eldridge PR, Sinha AK, Javadpour M, Littlechild P, Varma TR (2003) Microvascular decompression for trigeminal neuralgia in patients with multiple sclerosis. Stereotact Funct Neurosurg 81:57–64PubMedCrossRefGoogle Scholar
  8. 8.
    Fromm GH, Terrence CF, Maroon JC (1984) Trigeminal neuralgia: current concepts regarding aetiology and pathogenesis. Arch Neurol 41:1204–1207PubMedGoogle Scholar
  9. 9.
    Gass A, Kitchen N, MacManus DG, Moseley IF, Hennerici MG, Miller DH (1997) Trigeminal neuralgia in patients with multiple sclerosis: lesion localization with magnetic resonance imaging. Neurology 49:1142–1144PubMedGoogle Scholar
  10. 10.
    Golby AJ, Norbash A, Silverberg GD (1998) Trigeminal neuralgia resulting from infarction of the root entry zone of the trigeminal nerve. Neurosurgery 43:620–622PubMedCrossRefGoogle Scholar
  11. 11.
    Jawahar A, Kondziolka D, Kanal E, Bissonette DJ, Lunsford LD (2001) Imaging the trigeminal nerve and pons before and after surgical intervention for trigeminal neuralgia. Neurosurgery 48:101–106PubMedCrossRefGoogle Scholar
  12. 12.
    Jensen TS, Rasmussen P, Riske-Nielsen E (1982) Association of trigeminal neuralgia with multiple sclerosis: Clinical and pathological features. Acta Neurol Scand 65:182–189PubMedCrossRefGoogle Scholar
  13. 13.
    Kanpolat Y, Berk C, Savas A, Bekar A (2000) Percutaneous controlled radiofrequency rhizotomy in the management of patients with trigeminal neuralgia due to multiple sclerosis. Acta Neurochir (Wien) 142:685–689CrossRefGoogle Scholar
  14. 14.
    Kerr FW (1967) Evidence for a peripheral aetiology of trigeminal neuralgia. J Neurosurg 26:168–174PubMedGoogle Scholar
  15. 15.
    Kerr FW, Miller RH (1966) The pathology of trigeminal neuralgia. Electron microscopic studies. Arch Neurol 15:308–319PubMedGoogle Scholar
  16. 16.
    Kim JS, Kang JH, Lee MC (1998) Trigeminal neuralgia after pontine infarction. Neurology 51:1511–1512PubMedGoogle Scholar
  17. 17.
    King RB (1967) Evidence for a central aetiology of tic douloureux. J Neurosurg 26:175–180PubMedCrossRefGoogle Scholar
  18. 18.
    Love S, Coakham HB (2001) Trigeminal neuralgia: pathology and pathogenesis. Brain 124:2347–2360PubMedCrossRefGoogle Scholar
  19. 19.
    McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, McFarland HF, Paty DW, Polmar CH, Reingold SC, Sandberg-Wolheim M, Sibley W, Thomson A, van der Noort S, Weinshenker BY, Wolinsky JS (2001) Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis. Ann Neurol 50:121–127PubMedCrossRefGoogle Scholar
  20. 20.
    Peker S, Akansel G, Sun I, Pamir NM (2004) Trigeminal neuralgia due to pontine infarction. Headache 44:1043–1045PubMedCrossRefGoogle Scholar
  21. 21.
    Schaltenbrand G, Wahren W (1977) Scheme of transverse sections of the brainstem and cerebellum. In: Atlas for Stereotaxy of the Human Brain. Thieme Stuttgart, pp 58Google Scholar
  22. 22.
    Sweet WH (1998) The pathophysiology of trigeminal neuralgia. In: Gildemberg PL, Tasker RR (eds) Texbook of stereotactic and functional neurosurgery. McGraw-Hill, New York, pp 1667–1682Google Scholar
  23. 23.
    Young RF (1990) The trigeminal nerve and its central pathways. In: Rovit RL, Murali R, Jannetta PJ (eds) Trigeminal neuralgia. Williams & Wilkins, Baltimore, pp 27–52Google Scholar
  24. 24.
    Zurita-Cueva B (2002) Pre-pontine rhizotomy for therapy of trigeminal neuralgia secondary to a brainstem infarction. Revista Ecuatoriana de Neurocirugía 11:76–78Google Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Ignacio Arrese
    • 2
  • Alfonso Lagares
    • 2
  • Rafael Alday
    • 2
  • Ana Ramos
    • 1
  • Juan J. Rivas
    • 2
  • Ramiro D. Lobato
    • 2
  1. 1.Departamento de NeurorradiologíaHospital 12 de OctubreMadridSpain
  2. 2.Servicio de Neurocirugía, Hospital 12 de OctubreMadridSpain

Personalised recommendations