Ali Savas

Percutaneous Controlled Radiofrequency Trigeminal Rhizotomy for the Treatment of Idiopathic Trigeminal Neuralgia: 25-year Experience with 1600 Patients

OBJECTIVEThe objective of this study was to evaluate the effectiveness of percutaneous, controlled radiofrequency trigeminal rhizotomy (RF-TR). The outcome of 1600 patients with idiopathic trigeminal neuralgia after RF-TR was analyzed after a follow-up period of 1 to 25 years. METHODSA total of 1600 patients with idiopathic trigeminal neuralgia underwent 2138 percutaneous radiofrequency rhizotomy procedures between 1974 and 1999. Sixty-seven patients had bilateral idiopathic trigeminal neuralgia, and 36 of them were treated with bilateral RF-TR; 1216 patients (76%) were successfully managed with a single procedure, and the remainder were treated with multiple procedures. Benzodiazepines and narcotic analgesics were used for anesthesia because patient cooperation during the procedures was essential so that the physician could create selective, controlled lesions. RESULTSThe average follow-up time was 68.1 ± 66.4 months (range, 12–300 mo). Acute pain relief was accomplished in 97.6% of patients. Complete pain relief was achieved at 5 years in 57.7% of the patients who underwent a single procedure. Pain relief was reported in 92% of patients with a single procedure or with multiple procedures 5 years after the first rhizotomy was performed. At 10-year follow-up, 52.3% of the patients who underwent a single procedure and 94.2% of the patients who underwent multiple procedures had experienced pain relief; at 20-year follow-up, 41 and 100% of these patients, respectively, had experienced pain relief. No mortalities occurred. After the first procedure was performed, early pain recurrence (<6 mo) was observed in 123 patients (7.7%) and late pain recurrence was observed in 278 patients (17.4%). Complications included diminished corneal reflex in 91 patients (5.7%), masseter weakness and paralysis in 66 (4.1%), dysesthesia in 16 (1%), anesthesia dolorosa in 12 (0.8%), keratitis in 10 (0.6%), and transient paralysis of Cranial Nerves III and VI in 12 (0.8%). Permanent Cranial Nerve VI palsy was observed in two patients, cerebrospinal fluid leakage in two, carotid-cavernous fistula in one, and aseptic meningitis in one. CONCLUSIONPercutaneous, controlled RF-TR represents a minimally invasive, low-risk technique with a high rate of efficacy. The procedure may safely be repeated if pain recurs.

Percutaneous Controlled Radiofrequency Rhizotomy in the Management of Patients with Trigeminal Neuralgia due to Multiple Sclerosis

Summary Between the years 1974 and 1999, 1,672 patients with medically intractable trigeminal neuralgia (TN) were treated by percutaneous controlled radiofrequency (RF) rhizotomy by the senior author and co-workers at the Department of Neurosurgery, Ankara University School of Medicine. Sixteen hundred cases (95.7%) were found to have idiopathic TN, while 72 cases (4.3%) were classified as symptomatic. In the latter group, TN was found to be caused by multiple sclerosis (MS) in 17 cases (23.6%), one of whom had bilateral TN. All patients having TN with MS (17 cases) underwent percutaneous controlled radiofrequency rhizotomy (25 procedures) as the procedure of choice. The MS patients were followed for an average of 60 months (range: 6–141 months). Complete pain relief was achieved with a single procedure in 12 of the 17 MS cases (70.6%). Early (less than 2 weeks) pain recurrence was seen in two patients (11.8%), while the overall recurrence rate was 29.4%. A second procedure was required to control TN in three cases (17.6%), a third in one (5.9%), and twice for each side for the case with bilateral TN (5.9%). Pain was completely relieved in 14 cases (82.4%) with single or multiple RF rhizotomies. In three cases (17.6%), partial pain control was achieved with RF rhizotomy, and the patients continued to receive adjunctive medical therapy. No complications were observed. All 17 patients (100%) were classified to have done well with RF rhizotomy. Satisfactory results and good long-term pain control were obtained in patients having TN due to MS with percutaneous controlled RF rhizotomy. The authors propose that RF rhizotomy may be a safe and effective procedure in the neurosurgical armamentarium for the treatment of patients having TN due to MS.

A simple method for reducing autotomy in rats after peripheral nerve lesions.

Experiments using peripheral nerve lesions (crush or transection) in rats to study repair processes are hampered by the tendency for the animals to attack the limb in which the peripheral nerves are damaged (autotomy). In this paper we describe a simple method which significantly reduces the incidence of autotomy after peripheral nerve lesions. The method consists of painting the hind paws of operated rats with a commercially available non-toxic lotion, which is used to discourage nail-biting and thumb-sucking in humans. Although the method is not absolute, it was extremely beneficial in our experiments, since the number of animals that had to be taken out of the experiment due to severe autotomy was greatly reduced. We believe that this method may prove to be as beneficial to other investigators who are using experimental peripheral nerve lesions to study the regenerative aspects of the nervous system.

Computed Tomography-guided Trigeminal Tractotomy-Nucleotomy in the Management of Vagoglossopharyngeal and Geniculate Neuralgias

OBJECTIVE Vagoglossopharyngeal and geniculate neuralgias are less frequently seen types of cranial neuralgias. Their causes and symptomatology are similar to those of trigeminal neuralgia; however, the complex anatomic relationship between the intermedius, vagal, and glossopharyngeal nerves leads to difficulties in the diagnosis and management of neuralgias originating from these cranial nerves. Numerous procedures have been used to treat intractable neuralgias of the VIIth, IXth, and Xth cranial nerves: 1) extracranial sectioning of the cranial nerves, 2) percutaneous thermal rhizotomy, 3) intracranial glossopharyngeal and vagal rhizotomies, 4) microvascular decompression, and 5) percutaneous trigeminal tractotomy-nucleotomy (TR-NC) or nucleus caudalis dorsal root entry zone operation. We propose that computer-guided TR-NC may be the first-choice operation for patients with glossopharyngeal, vagal, or geniculate neuralgia. PATIENTS AND METHODS Nine patients suffering from idiopathic vagoglossopharyngeal neuralgia (six patients) and geniculate neuralgia (three patients) were managed at our clinic. Computed tomography-guided percutaneous trigeminal TR-NC was performed for these nine patients. RESULTS Excellent (six patients) or good (three patients) pain control was obtained in each patient. Complications included temporary ataxia in two patients after TR-NC. CONCLUSION The risk:benefit ratio should be evaluated individually to select the appropriate treatment procedure for patients with vagoglossopharyngeal and geniculate neuralgias. Computed tomography-guided percutaneous TR-NC is an effective and minimally invasive procedure for such patients.

Spinal Intradural-Intramedullary Cavernous Malformation

Cavernous angiomas or cavernomas are uncommon vascular malformations of the central nervous system and spinal involvement is much rarer especially in pediatric patients. We report a case of spinal intradural-intramedullary cavernous angioma in a 14-year-old male child. The cavernoma was located at the level of C6–C7 at the dorsal part of the spinal cord. The diagnosis was made with MRI and the patient underwent surgical treatment. The cavernoma was totally removed with laminotomy and microsurgical techniques. Somatosensory evoked potential monitoring was also used peroperatively. The clinical, radiological and surgical features of this rare case were presented and discussed with reference to the literature.

Unanticipated complication of percutaneous radiofrequency trigeminal rhizotomy: rhinorrhea: report of three cases and a cadaver study.

OBJECTIVE AND IMPORTANCE:Several neurosurgical procedures have been developed for the treatment of idiopathic trigeminal neuralgia: vascular decompression of the trigeminal root in the brainstem, percutaneous trigeminal ganglion procedures, and external beam radiosurgery. Percutaneous radiofrequency electrodes target the trigeminal fibers in the gasserian ganglion through the foramen ovale. Several complications of radiofrequency trigeminal rhizotomy (RF-TR) have been described, including puncture of the carotid artery, the cavernous sinus, and the cranial nerves. This study presents a very rare complication of percutaneous RF-TR, rhinorrhea, and attempts to define its mechanism. CLINICAL PRESENTATION:Of 2375 patients with idiopathic trigeminal neuralgia who underwent 2958 percutaneous RF-TR procedures, 3 developed subsequent rhinorrhea, which resolved spontaneously in 2 to 3 days. TECHNIQUE:Two formalin-fixed cadavers were dissected to demonstrate the relationship between the foramen ovale and the tuba auditiva and the mechanism of rhinorrhea. CONCLUSION:This article presents a very rare complication of RF-TR. Rhinorrhea and/or cerebrospinal fluid fistulae in the nasopharyngeal cavity are benign complications of RF-TR that result from puncturing both the membranous portion of the tuba auditiva (eustachian tube) and Meckels cave with the rhizotomy needle.

Chiari Type I malformation presenting as glossopharyngeal neuralgia: case report.

OBJECTIVE AND IMPORTANCE Chiari Type I malformation is an important pathological state in which the brainstem is compressed by the cerebellar tonsil. We present a case of glossopharyngeal neuralgia caused by Chiari Type I malformation. CLINICAL PRESENTATION A 50-year-old male patient was admitted with glossopharyngeal neuralgia. Magnetic resonance imaging studies revealed caudal displacement of the left cerebellar tonsil. INTERVENTION Small occipital craniectomy and C1 laminectomy were performed. The left cerebellar tonsil was resected. CONCLUSION This glossopharyngeal neuralgia was caused by compression of the lower cranial nerves and brainstem by the displaced left cerebellar tonsil. Decompression and pain relief were obtained with resection of the cerebellar tonsil. The patient was pain-free 30 weeks after the operation.

Intracavitary Chemotherapy of Polycystic Craniopharyngioma with Bleomycin

Craniopharyngiomas are the most common intracranial primary tumours of nonglial origin in children. Despite recent advances in aggressive and conservative approaches to these tumours and their benign histological nature, they are associated with signi®cant morbidity and mortality. The best management of craniopharyngioma continues to be a controversial topic among neurosurgeons, with proponents of radical microsurgical excision, stereotactic biopsy or partial excision plus radiotherapy, radiosurgery, or a combination of these techniques [1, 3]. We report a case with polycystic craniopharyngioma who was treated with stereotactic insertion of a catheter-reservoir system, drainage and intracavitary use of bleomycin.

Surgical treatment of intracranial cavernous angiomas

We present a surgical series of 35 patients (25 males and 10 females) with histopathologically verified intracranial cavernous angiomas. The 35 malformations were located as follows: 21 were in the cerebral hemispheres; 4 in the lateral ventricles, 4 in the brain stem; and 6 in the cerebellum. Seizures and focal neurological deficits were the main clinical features observed in patients with intracranial cavernous angiomas. A number of these vascular malformations were misdiagnosed by computerized tomography. In the last 10 years, magnetic resonance imaging has been the most sensitive method for detecting these lesions. Thirty-five cavernous angiomas were treated surgically; in 33 patients a complete excision, and in 2 patients subtotal excision were obtained. One of the patients died one year after the operation. The overall outcome was good in all of the 34 remaining patients, resulting in improved seizure control or neurological deficit. The rationale for neurologic differential diagnosis and surgical treatment and follow up results are discussed.

Differential diagnosis of idiopathic inflammatory trigeminal sensory neuropathy from neuroma with a biopsy: case report.

OBJECTIVE AND IMPORTANCE Idiopathic inflammatory trigeminal sensory neuropathy (IITSN) is a disorder with the dominant clinical features of trigeminal sensory disturbance; this idiopathic condition follows a benign course in most cases. Recent reports have shown that transient abnormalities, which may mimic those of trigeminal neuromas, can be observed in magnetic resonance imaging scans. Presented here is a case of IITSN that was diagnosed, with cytological and histopathological verification, during the active inflammatory phase of the disease (the first such attempt, to our knowledge). CLINICAL PRESENTATION A 20-year-old female patient was referred to our hospital with a 2-month history of numbness of the left side of her face, headache, and hemifacial pain attacks. Cranial magnetic resonance imaging scans revealed a mass above and below the foramen ovale, extending into the cavernous sinus. INTERVENTION A percutaneous biopsy procedure through the foramen ovale was performed; the pathological examination revealed lymphocytes, macrophages, and endothelial cells but no evidence of neoplastic cells. A few days later, the patient was surgically treated using a cranial base approach, the gasserian ganglion was exposed, and the lesion was removed. Pathological examination of the specimens revealed inflammatory changes and fibrosis of the nerve fibers and ganglion cells. Disruption of the myelin around the nerve bundles was detected. Therefore, IITSN was pathologically confirmed during the early stage of the disease. During 3 months of follow-up monitoring, the patient experienced no serious clinical problems. CONCLUSION IITSN should be suspected in cases of tumors involving the cavernous sinus, and a percutaneous biopsy through the foramen ovale should be performed as part of the differential diagnosis in such cases. This procedure might obviate unnecessary aggressive surgery. In the current case, no neoplastic cells were observed during the examination; only lymphocytes, macrophages, and endothelial cells were observed, on a background of erythrocytes. Lymphocyte-dominant inflammatory infiltration, fibrotic changes, and demyelinization are cardinal histopathological findings observed during the active phase of IITSN.