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Trigeminal Neuralgia: Evaluation of Neuralgic Manifestation and Site of Neurovascular Compression with 3D CISS MR Imaging and MR Angiography¹

¹ From the Departments of Oral and Maxillofacial Radiology (N.Y., A.T., T.K., E.H., S.N., T.S.), Neurosurgery (H.A., T.N.), and Diagnostic Radiology and Oncology (I.Y.), Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan. Received April 15, 2002; revision requested June 17; final revision received November 12; accepted December 19. Address correspondence to N.Y. (e-mail: norio.orad@tmd.ac.jp).

View larger version (19K): [in a new window]   Figure 1. Schematic demonstrates the classification of the position of a blood vessel that compresses the trigeminal nerve on its cross section. When the blood vessel has compressed the trigeminal nerve at the position shown in this schematic, it is classified as a medial site.

View larger version (110K): [in a new window]   Figure 2a. Images in a 69-year-old woman. (a) Transverse 3D CISS MR image (12.25/5.9, 70° flip angle) depicts the blood vessel (short arrow) and the nerve (long arrows) as low-signal-intensity structures and the cerebrospinal fluid () as a high-signal-intensity structure, thus providing high contrast resolution between the structures. (b) Transverse MR angiographic image (39/6.5, 20° flip angle) depicts the artery (short arrow) as a high-signal-intensity structure, the nerve (long arrows) as an intermediate-signal-intensity structure, and the cerebrospinal fluid () as a low-signal-intensity structure.

View larger version (96K): [in a new window]   Figure 2b. Images in a 69-year-old woman. (a) Transverse 3D CISS MR image (12.25/5.9, 70° flip angle) depicts the blood vessel (short arrow) and the nerve (long arrows) as low-signal-intensity structures and the cerebrospinal fluid () as a high-signal-intensity structure, thus providing high contrast resolution between the structures. (b) Transverse MR angiographic image (39/6.5, 20° flip angle) depicts the artery (short arrow) as a high-signal-intensity structure, the nerve (long arrows) as an intermediate-signal-intensity structure, and the cerebrospinal fluid () as a low-signal-intensity structure.

View larger version (106K): [in a new window]   Figure 3a. Images in a 63-year-old man with trigeminal neuralgia, with NVC caused by the superior cerebellar artery. (a, b) Two adjacent transverse 3D CISS MR images (12.25/5.9, 70° flip angle) show that the superior cerebellar artery (short arrow) has compressed the REZ of the right trigeminal nerve (long arrow) at the medial site. (c, d) Reformatted (c) coronal and (d) sagittal 3D CISS MR images (12.25/5.9, 70° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (e, f) Two adjacent transverse MR angiographic images (39/6.5, 20° flip angle) show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (g, h) Reformatted (g) coronal and (h) sagittal MR angiographic images (39/6.5, 20° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site.

View larger version (107K): [in a new window]   Figure 3b. Images in a 63-year-old man with trigeminal neuralgia, with NVC caused by the superior cerebellar artery. (a, b) Two adjacent transverse 3D CISS MR images (12.25/5.9, 70° flip angle) show that the superior cerebellar artery (short arrow) has compressed the REZ of the right trigeminal nerve (long arrow) at the medial site. (c, d) Reformatted (c) coronal and (d) sagittal 3D CISS MR images (12.25/5.9, 70° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (e, f) Two adjacent transverse MR angiographic images (39/6.5, 20° flip angle) show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (g, h) Reformatted (g) coronal and (h) sagittal MR angiographic images (39/6.5, 20° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site.

View larger version (43K): [in a new window]   Figure 3c. Images in a 63-year-old man with trigeminal neuralgia, with NVC caused by the superior cerebellar artery. (a, b) Two adjacent transverse 3D CISS MR images (12.25/5.9, 70° flip angle) show that the superior cerebellar artery (short arrow) has compressed the REZ of the right trigeminal nerve (long arrow) at the medial site. (c, d) Reformatted (c) coronal and (d) sagittal 3D CISS MR images (12.25/5.9, 70° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (e, f) Two adjacent transverse MR angiographic images (39/6.5, 20° flip angle) show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (g, h) Reformatted (g) coronal and (h) sagittal MR angiographic images (39/6.5, 20° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site.

View larger version (48K): [in a new window]   Figure 3d. Images in a 63-year-old man with trigeminal neuralgia, with NVC caused by the superior cerebellar artery. (a, b) Two adjacent transverse 3D CISS MR images (12.25/5.9, 70° flip angle) show that the superior cerebellar artery (short arrow) has compressed the REZ of the right trigeminal nerve (long arrow) at the medial site. (c, d) Reformatted (c) coronal and (d) sagittal 3D CISS MR images (12.25/5.9, 70° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (e, f) Two adjacent transverse MR angiographic images (39/6.5, 20° flip angle) show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (g, h) Reformatted (g) coronal and (h) sagittal MR angiographic images (39/6.5, 20° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site.

View larger version (88K): [in a new window]   Figure 3e. Images in a 63-year-old man with trigeminal neuralgia, with NVC caused by the superior cerebellar artery. (a, b) Two adjacent transverse 3D CISS MR images (12.25/5.9, 70° flip angle) show that the superior cerebellar artery (short arrow) has compressed the REZ of the right trigeminal nerve (long arrow) at the medial site. (c, d) Reformatted (c) coronal and (d) sagittal 3D CISS MR images (12.25/5.9, 70° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (e, f) Two adjacent transverse MR angiographic images (39/6.5, 20° flip angle) show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (g, h) Reformatted (g) coronal and (h) sagittal MR angiographic images (39/6.5, 20° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site.

View larger version (83K): [in a new window]   Figure 3f. Images in a 63-year-old man with trigeminal neuralgia, with NVC caused by the superior cerebellar artery. (a, b) Two adjacent transverse 3D CISS MR images (12.25/5.9, 70° flip angle) show that the superior cerebellar artery (short arrow) has compressed the REZ of the right trigeminal nerve (long arrow) at the medial site. (c, d) Reformatted (c) coronal and (d) sagittal 3D CISS MR images (12.25/5.9, 70° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (e, f) Two adjacent transverse MR angiographic images (39/6.5, 20° flip angle) show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (g, h) Reformatted (g) coronal and (h) sagittal MR angiographic images (39/6.5, 20° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site.

View larger version (76K): [in a new window]   Figure 3g. Images in a 63-year-old man with trigeminal neuralgia, with NVC caused by the superior cerebellar artery. (a, b) Two adjacent transverse 3D CISS MR images (12.25/5.9, 70° flip angle) show that the superior cerebellar artery (short arrow) has compressed the REZ of the right trigeminal nerve (long arrow) at the medial site. (c, d) Reformatted (c) coronal and (d) sagittal 3D CISS MR images (12.25/5.9, 70° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (e, f) Two adjacent transverse MR angiographic images (39/6.5, 20° flip angle) show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (g, h) Reformatted (g) coronal and (h) sagittal MR angiographic images (39/6.5, 20° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site.

View larger version (67K): [in a new window]   Figure 3h. Images in a 63-year-old man with trigeminal neuralgia, with NVC caused by the superior cerebellar artery. (a, b) Two adjacent transverse 3D CISS MR images (12.25/5.9, 70° flip angle) show that the superior cerebellar artery (short arrow) has compressed the REZ of the right trigeminal nerve (long arrow) at the medial site. (c, d) Reformatted (c) coronal and (d) sagittal 3D CISS MR images (12.25/5.9, 70° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (e, f) Two adjacent transverse MR angiographic images (39/6.5, 20° flip angle) show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site. (g, h) Reformatted (g) coronal and (h) sagittal MR angiographic images (39/6.5, 20° flip angle) also show that the superior cerebellar artery (short arrow) has compressed the right trigeminal nerve (long arrow) at the medial site.

View larger version (119K): [in a new window]   Figure 4a. Images in a 55-year-old woman with trigeminal neuralgia, with NVC caused by both the vein and anterior inferior cerebellar artery. (a) Transverse 3D CISS MR image (12.25/5.9, 70° flip angle) shows that both the vein (curved arrow) and the anterior inferior cerebellar artery (short straight arrow) have compressed the left trigeminal nerve (long straight arrow) at the REZ. This finding was confirmed at surgery. (b) Transverse MR angiographic image (39/6.5, 20° flip angle) does not depict the vein, although it shows the anterior inferior cerebellar artery (short arrow) that has compressed the REZ of the left trigeminal nerve (long arrow). This was insufficient information at surgery.

View larger version (100K): [in a new window]   Figure 4b. Images in a 55-year-old woman with trigeminal neuralgia, with NVC caused by both the vein and anterior inferior cerebellar artery. (a) Transverse 3D CISS MR image (12.25/5.9, 70° flip angle) shows that both the vein (curved arrow) and the anterior inferior cerebellar artery (short straight arrow) have compressed the left trigeminal nerve (long straight arrow) at the REZ. This finding was confirmed at surgery. (b) Transverse MR angiographic image (39/6.5, 20° flip angle) does not depict the vein, although it shows the anterior inferior cerebellar artery (short arrow) that has compressed the REZ of the left trigeminal nerve (long arrow). This was insufficient information at surgery.

View larger version (18K): [in a new window]   Figure 5. Schematic of the trigeminal nerve fiber array at the REZ. The nerve fibers of the second branch (V2) are widely distributed medially, those of the third branch (V3) are widely distributed laterally, and those of the first branch (V1) are distributed cranially.