Necessity of Magnetic Resonance Imaging (MRI) using an appropriate sequence for diagnosis of trigeminal neuralgia associated with intracranial tumor

doi:10.4236/ojst.2013.39084

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Open Journal of Stomatology, 2013, 3, 510-514 OJST

http://dx.doi.org/10.4236/ojst.2013.39084 Published Online December 2013 (http://www.scirp.org/journal/ojst/)

Necessity of Magnetic Resonance Imaging (MRI) using an

appropriate sequence for diagnosis of trigeminal neuralgia

associated with intracranial tumor

Yoko Yamazaki1*, Tomoko Niimi1, Yuko Ando1, Daisuke Tomizawa1, Masahiko Shimada2

1Orofacial Pain Clinic, Tokyo Medical and Dental University Dental Hospital, Tokyo, Japan

2Orofacial Pain Management, Oral Restitution, Oral Health Sciences, Graduate School of Medical and Dental Sciences, Tokyo

Medical and Dental University, Tokyo, Japan

Email:*[email protected]

Received 18 November 2013; revised 19 December 2013; accepted 28 December 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Aims: Trigeminal neuralgia is generally caused by

neurovascular compression. In rare cases intracranial

tumors may also lead to this condition. The present

study was conducted to identify clinical symptoms

and testing methods that are useful for early detection

of trigeminal neuralgia associated with intracranial

tumor. Methods: Five patients with trigeminal neu-

ralgia suspected to be due to intracranial tumor, who

visited our department for the first time during the

period between February 2007 and March 2009, were

examined. We analyzed the medical records and MRI

findings of these patients. The clinical symptoms of

subjects were compared to those presented at the In-

ternational Classification of Headache Disorders. Re-

sults: There were no feature symptoms to trigeminal

neuralgia caused by intracranial tumors compared

with trigeminal neuralgia in general. None of the pa-

tients complained of spontaneous headache and nau-

sea, which are clinical symptoms characteristic of

brain tumor. Head MRI at our hospital was the most

accurate method to detect intracranial tumors. Fi-

nally four of five patients received brain surgery to

remove tumors. Conclusion: Small tumors and roots

of the trigeminal nerve may not create accurate im-

ages by regular head MRI. Therefore, MRI using the

imaging sequence which enables accurate visualiza-

tion of roots of the trigeminal nerve is essential to

confirm the presence of tumors in patients with sus-

pected trigeminal neuralgia.

Keywords: Trigeminal Neuralgia; Intracranial Tumor;

Benign Tumor; MRI; Neurosurgery

1. INTRODUCTION

Trigeminal neuralgia is an excruciating type of pain that

occurs in the face and oral cavity. It greatly interferes

with daily activities of patients, including eating and face

washing. Neurovascular compression is a widely known

cause of trigeminal neuralgia [1]. In rare cases intra-

cranial tumors may also lead to this condition. For the

treatment of trigeminal neuralgia associated with intra-

cranial tumors, the tumors are often removed by neuro-

surgical procedures in order to eliminate pain [2]. How-

ever, the surgery must be performed early because com-

plete removal of the tumor may become impossible or

the surgery may damage other nerves as the size of the

tumor increases.

In trigeminal neuralgia pain arises in the areas of the

jaw, oral cavity and face; as a result some patients first

visit a dentist for treatment of the condition. If clinical

features or testing methods to identify trigeminal neural-

gia caused by tumors were known, dentists could easily

refer patients to neurosurgeons and this could contribute

to early detection of tumors.

The present study was conducted to identify clinical

symptoms and testing methods that are useful for early

detection of intracranial tumors. We retrospectively ex-

amined the clinical symptoms and imaging tests of pa-

tients with trigeminal neuralgia treated at the Orofacial

Pain Clinic, Tokyo Medical and Dental University Hos-

pital of Dentistry, whose neuralgia was speculated to be

caused by intracranial tumors.

2. METHODS

Five patients with trigeminal neuralgia suspected to be

due to intracranial tumor, who visited our department for

the first time during the period between February 2007

*Corresponding author.

OPEN ACCESS

Y. Yamazaki et al. / Open Journal of Stomatology 3 (2013) 510-514 511

and March 2009, were examined. The medical records

and MR images of each patient were retrospectively

analyzed. Data obtained from the medical record in-

cluded sex, age, duration of disease before the first visit,

past and current medical history, characteristics of pain

and the diagnosis and treatment provided at our depart-

ment and the Department of Neurosurgery. The clinical

symptoms of subjects were compared to those of classi-

cal trigeminal neuralgia presented at the International

Classification of Headache Disorders.

3. RESULTS

3.1. Background of Patients

All the patients were females. There was no particular

tendency in their characteristics, such as age, duration of

disease before the first visit to our department and past

history (Table 1).

3.2. Clinical Symptoms

The clinical symptoms of trigeminal neuralgia reported

by the subjects of this study were compared to those of

classical trigeminal neuralgia presented at the Interna-

tional Classification of Headache Disorders (Table 2).

There was no feature unique to trigeminal neuralgia

caused by intracranial tumors in the factors that induce

pain as well as character and duration of pain. This con-

dition did not greatly differ from trigeminal neuralgia in

general. None of the patients complained of spontaneous

headache or nausea, which are clinical symptoms char-

acteristic of brain tumor. Only one patient reported diz-

ziness.

All the patients also visited the Department of Neuro-

surgery, Tokyo Medical and Dental University Hospital

of Medicine and were diagnosed with intracranial tumor.

The diagnoses made at our department and at the De-

partment of Neurosurgery are shown in Table 3. None of

the subjects had clinical symptoms of brain stem tumor,

such as hemiplegia and hearing loss.

3.3. Effect of Drugs

All five patients had received the prescription for car-

bamazepine, which was effective. However, in 4 cases

the dose could not be increased due to adverse reactions,

making it difficult to eliminate pain with this drug

(Table 4).

Table 1. Background of patients.

Age Sex Duration of disease Past history

Case 1 24 female About 3 weeks −

Case 2 67 female About 3 years

Transient ischemic attack

Drug eruption

(carbamazepine)

Case 3 40 female About 2 years −

Case 4 71 female About 7 months

Temporomandibular joint disorder

Osteoporosis

Glaucoma

Rheumatism

Case 5 63 female About 3 months

Uterine myoma

Ischemic colitis

Hypertension

−: nothing particular.

Table 2. The comparixon between clinical symptoms of trigeminal neuralgia caused by intracranial tumors and classical trigeminal

neuralgia.

Trigeminal neuralgia caused by intracranial tumors Classical trigeminal neuralgia

Pain inducing factor

 Eating (5 cases)

 Talking (4 cases)

 Washing the face (2 cases)

 Brushing the teeth (2 cases)

Trivial stimuli including washing, shaving, smoking, talking

and/or brushing the teeth (trigger factors)

Character of pain

 Unilateral location

 The first, second and/or third division of the trigeminal

nerve

 Intense, electric shock-like pain, shooting, stabbing

 Unilateral disorder

 The distribution of one or more divisions of the trigeminal

nerve

 Brief electric shock-like pains

 Intense, sharp, superficial or stabbing

Duration of pain  Flashing (4 cases)

 2 - 3 minutes (1 cases) Fraction of a second to 2 minutes

Spontaneous pain Aching pain (2 cases) Dull background pain may persist in some long-standing cases

Y. Yamazaki et al. / Open Journal of Stomatology 3 (2013) 510-514

512

Table 3. Diagnosis at first visit, preoperative and postoperative diagnosis.

Diagnosis (first visit) Diagnosis (neurosurgery) Operation Diagnosis (postoperative)

Case 1 Left trigeminal neuralgia (V1) Schwannoma − −

Case 2 Left trigeminal neuralgia (V2) Epidermoid ○ Epidermoid

Case 3  Left trigeminal neuralgia (V3)

 Left persistent idiopathic facial pain

Petrous bone

meningioma ○ Meningioma

Case 4  Left trigeminal neuralgia (V3)

 Left glossopharyngeal neuralgia Cerebellopontine angle tumor ○ Meningioma

Case 5  Right trigeminal neuralgia (V3)

 Glossodynia Tumor nearby facial and trigeminal nerve○ Apophysis

In Case 1, operation was not performed. Thus, postoperative diagnosis was unknown.

Table 4. Medication and effect of drugs.

Drugs Effect

Case 1 Carbamazepine (600 mg)

 No change of pain intensity

 Reduction of pain frequency

 Drug eruption

Case 2 Zonisamide (100 mg)

Carbamazepine (100 - 200 mg)

 Zonisamide failed to control of pain

 Carbamazepine made pain reduction

 Drug eruption (Carbamazepine)

Case 3 Carbamazepine (800 mg)

Zonisamide (400 mg)

 Zonisamide failed to control of pain

 Carbamazepine made pain reduction

 Leukopenia (Carbamazepine)

Case 4 Goreisan (TJ-17) (7.5 g)

Carbamazepine (100 - 200 mg)

 Goreisan failed to control of pain

 Carbamazepine made pain reduction

Case 5

Carbamazepine (400 mg)

Goreisan (TJ-17) (7.5 g)

Zonisamide (200 mg)

Gabapentin (1200 mg)

 Carbamazepine made pain reduction

 Hepatic insufficiency (Carbamazepine)

 Zonisamide failed to control of pain

 Gabapentin made pain reduction

Goreisan (TJ-17) is Kampo: traditional Japanese herbal medicine.

In Case 1 administration of carbamazepine was dis-

continued due to drug eruption, but the relief from pain

was obtained immediately after discontinuation and fur-

ther drug therapy became unnecessary. In Cases 2, 3 and

5 the dose of carbamazepine could not be increased be-

yond the reported levels because of adverse reactions.

Zonisamide was used instead of carbamazepine, but pain

could not be adequately alleviated. Gabapentin was fi-

nally effective in Case 5, still this drug was impossible to

eliminate the patient’s pain. One patient (Case 4) refused

to take carbamazepine prescribed at our department and

therefore pain control by Goreisan (TJ-17) was started.

Subsequently, when the patient was referred to the De-

partment of Neurosurgery, carbamazepine was pre-

scribed and the patient agreed to take it.

3.4. Past Treatments and Imaging Tests

Some patients underwent treatment at other healthcare

facilities before visiting our department. These patients

had received dental treatment, such as occlusal adjust-

ment, root canal treatment of teeth in the area where pain

occurred and extraction of the teeth was performed.

Moreover medical treatment such as infraorbital nerve

block as well as head CT or MRI were execued. Patients

were prescribed antimicrobial agents, antiinflammatory

agents and carbamazepine. Although some patients un-

derwent imaging tests, the results did not reveal any tu-

mors. Two patients were diagnosed with trigeminal neu-

ralgia, but they were treated with medication or nerve

block without performing head MRI. In all patients in-

tracranial tumors were detected for the first time when

MRI was performed at our hospital.

3.5. Neurosurgeries

As a result of examination at the Department of Neuro-

surgery, brain surgery to remove tumors was performed

in all cases except Case 1. The diagnoses after the sur-

geries are shown in Table 3. In Case 5 craniotomy re-

vealed that the object suspected to be a tumor was an

apophysis, which was impossible to remove. After the

surgeries pain disappeared in Cases 2, 3 and 4. Case 1

was followed up without surgery. In Case 5, pain was

alleviated but did not disappear because neurovascular

compression was slightly resolved; however, the apophy-

Y. Yamazaki et al. / Open Journal of Stomatology 3 (2013) 510-514 513

sis could not be removed.

4. DISCUSSION

Trigeminal neuralgia is one of the most painful afflic-

tions of humanity [3], which substantially lowers the

patient’s quality of life. It is roughly divided into classi-

cal and symptomatic trigeminal neuralgia [4]. Trigeminal

neuralgia caused by tumors as examined in this study is a

rare type of symptomatic trigeminal neuralgia and its

overall incidence is low [5]. Ono et al. reported that

among 243 patients with trigeminal neuralgia, pain was

attributed to pontine angle tumors in 25 patients (10.3%)

[6]. Other studies reported that about 10% of trigeminal

neuralgia cases were caused by brain tumors [2,7]. At

our department about 2.9% of trigeminal neuralgia cases

were caused by brain tumors during the study period.

All five patients examined in this study visited the

Department of Neurosurgery and four of them later un-

derwent craniotomy. After the tumors were removed, the

pain disappeared in three patients, indicating that pain

control in trigeminal neuralgia caused by intracranial

tumors requires tumor resection. On the other hand, in

Case 5 with a bony prominence compressing nerves, pain

was alleviated but not eliminated after the surgery. The

compression of the trigeminal nerve remained, because

the bony prominence could not be resection.

Tumors that cause trigeminal neuralgia include sch-

wannoma, meningioma and epidermoid cyst, which are

mostly benign [8]. Because benign tumors grow slowly

and are unlikely to cause intracranial hypertension, clini-

cal symptoms such as nausea and dizziness do not de-

velop so often [9]. However, when tumors grow and oc-

cupy a large volume in the vicinity of brain stem, they

can not only affect the trigeminal nerve but also influ-

ence activities of daily life. Moreover, when tumors in-

crease in size, complete resection would be difficult be-

cause of the possibility of damaging various nerves dur-

ing the surgery. Therefore, it could be essential that early

detection of intracranial tumors is performed and a con-

tinuous follow-up is necessary.

There were no characteristic clinical symptoms in this

study. Other investigators reported that there was no

clinical feature characteristic of trigeminal neuralgia

caused by tumors [9]. Some reports suggest that vascular

compression or tumoral compression produces the same

pathologic findings.

Therefore, the present study indicates that it is difficult

to speculate about the presence or absence of tumors

based only on clinical symptoms.

The present study demonstrated that head MRI was

the most accurate method to detect tumors. In the algo-

rithm for diagnosis of trigeminal neuralgia proposed by

Kleef et al., MRI is given high priority in the diagnostic

procedure [10]. There is also a report suggesting that

MRI was useful in diagnosis of symptomatic trigeminal

neuralgia [11,12].

In our department head MRI is performed for almost

all patients with suspected trigeminal neuralgia. The

MRI device used in Tokyo Medical and Dental Univer-

sity Hospital (Magnetom Vision; Siemens, Erlangen,

Germany) creates images with a magnetic force of 1.5

Tesla. Because early-stage tumors are small and roots of

the trigeminal nerve occupy a very limited area, regular

head MRI may not create accurate images. Therefore,

MRI using an imaging sequence that allows for accurate

visualization of roots of the trigeminal nerve would be

necessary. We use fast imaging with steady-state preci-

sion (FISP) and constructive interference in steady state

(CISS) as well as T1 and T2-weighted images. These

imaging sequences use the following paramaters; FISP:

39/6.5 (repetition time msec/echo time msec), 20˚ flip

angle, CISS: 12.25/5.9, 70˚ flip angle on CISS. In par-

ticular CISS enables visualization of not only arteries but

also veins [13]. In FISP and CISS we enlarge the image

of the area of pons and visualize it with a slice width of 1

mm. By doing so, we can see the details of the area of

roots of the trigeminal nerve (Figure 1). Therefore, small

tumors that cannot be confirmed by regular MRI could

be detected using this method, so head MRI would be the

most accurate method to detect intracranial tumors at our

hospital whether or not patients are examined with regu-

lar MRI at other hospitals.

Figure 1. This image is MRI using an imaging sequence of

CISS in Case 2. The arrow is an epidermoid tumor in the left

cerebellopontine angle. On CISS imaging, the blood vessel and

the nerve were shown as structures with a low signal intensity,

and the cerebrospinal fluid was shown as a structure with a

high signal intensity. The structures were clearly visualized.

Y. Yamazaki et al. / Open Journal of Stomatology 3 (2013) 510-514

514

[7] Nomura, T., Ikezaki, K., Matsushima, T. and Fukui, M.

(1994) Trigeminal neuralgia: Differentiation between in-

tracranial mass lesions and ordinary vascular compres-

sion as causative lesions. Neurosurgical Review, 17, 51-

57. http://dx.doi.org/10.1007/BF00309988

Thus, MRI using an appropriate imaging sequence

seems to be indispensable for the detection of tumors.

5. ACKNOWLEDGEMENTS

[8] Love, S. and Coakham, H.B. (2001) Trigeminal neuralgia:

Pathology and pathogenesis. Brain, 124, 2347-2360.

http://dx.doi.org/10.1093/brain/124.12.2347

The authors thank the Department of oral and maxillofacial radiology,

Tokyo Medical and Dental Hospital of dentistry for presenting details

of MRI.

[9] Cirak, B., Kiymaz, N. and Arslanoglu. A. (2004) Trige-

minal neuralgia caused by intracranial epidermoid tumor:

Report of a case and review of the different therapeutic

modalities. Pain Physician, 7, 129-132.

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