Presentation
Right side trigeminal neuralgia for six years. No other complaint.
Patient Data
The root of the right trigeminal nerve is close to the superior cerebellar artery, with intra-substance low T1 signal intensity changes and atrophy when compared to the normal left side.
Punctate and some confluent T2/FLAIR hyperintense lesions in the periventricular and deep white matter probably from chronic small vessel ischemic disease. Enlarged sella and partially empty.
Case Discussion
Trigeminal neuralgia is a clinical diagnosis. MRI plays a role in identifying causes of trigeminal neuralgia such as tumor, neurovascular compression, and multiple sclerosis.
The patient has long-standing trigeminal neuralgia. The presence of a vascular loop close to the trigeminal nerve might be the most likely cause of the patient's presentation, as it probably contacted the nerve before it was in its present form, atrophic. Moreover, neurovascular compression is the most common cause of trigeminal neuralgia.
Multiple sclerosis could be the other possible cause of trigeminal neuralgia. The presence of periventricular and deep white matter changes, that are not appropriate for age might beg attention. However, the lack of clinical symptoms of multiple sclerosis and not typical white matter changes for multiple sclerosis plaques fall short of the diagnosis.
Neurovascular compression in trigeminal neuralgia has been graded from I to III. Grade I is mere contact with the trigeminal nerve, grade II is displacement or distortion of the root, and grade III is marked indentation of the nerve by a vascular loop1. The degree of nerve atrophy is often proportional to the degree of neurovascular compression. Moreover, microvascular decompression demonstrated better long term out come with highest grade of neurovascular compression. Meaning, the highest the grade of compression with resultant greater nerve atrophy and good clinical outcome after decompression2. In our case, the degree of compression was most likely grade I and it is not clear whether decompression would result in clinical improvement.
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