Shanker Rachyl M, Kim Miri, Verducci Chloe, Rezaii Elhaum G, Steed Kerry, Mallik Atul K, Anderson Douglas E
Departments of Neurological Surgery and.
Radiology, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois.
J Neurosurg Case Lessons. 2021 Jun 28;1(26):CASE21109. doi: 10.3171/CASE21109.
While cases of trigeminal neuralgia induced by a brainstem infarct have been reported, the neurosurgical literature lacks clear treatment recommendations in this subpopulation.
The authors present the first case report of infarct-related trigeminal neuralgia treated with pontine descending tractotomy that resulted in durable pain relief after multiple failed surgical interventions, including previous microvascular decompressions and stereotactic radiosurgery. A neuronavigated pontine descending tractotomy of the spinal trigeminal tract was performed and resulted in successful pain relief for a 50-month follow-up period.
While many cases of ischemic brainstem lesions are caused by acute stroke, the authors assert that cerebral small vessel disease also plays a role in certain cases and that the relationship between these chronic ischemic brainstem lesions and trigeminal neuralgia is more likely to be overlooked. Furthermore, neurovascular compression may obscure the causative mechanism of infarct-related trigeminal neuralgia, leading to unsuccessful decompressive surgeries in cases in which neurovascular compression may be noncontributory to pain symptomatology. Pontine descending tractotomy may be beneficial in select patients and can be performed either alone or concurrently with microvascular decompression in cases in which the interplay between ischemic lesion and neurovascular compression in the pathophysiology of disease is not clear.
虽然已有脑干梗死诱发三叉神经痛的病例报道，但神经外科文献中缺乏针对这一亚群的明确治疗建议。
作者报告了首例采用脑桥下行束切断术治疗梗死相关性三叉神经痛的病例，该患者在包括先前的微血管减压术和立体定向放射外科手术等多次手术干预失败后，疼痛得到了持久缓解。进行了神经导航下的脊髓三叉神经束脑桥下行束切断术，术后50个月的随访期内疼痛成功缓解。
虽然许多缺血性脑干病变病例是由急性中风引起的，但作者认为，脑小血管疾病在某些情况下也起作用，而且这些慢性缺血性脑干病变与三叉神经痛之间的关系更有可能被忽视。此外，神经血管压迫可能掩盖梗死相关性三叉神经痛的致病机制，导致在神经血管压迫可能与疼痛症状无关的情况下减压手术失败。脑桥下行束切断术可能对特定患者有益，在疾病病理生理学中缺血性病变与神经血管压迫之间的相互作用不明确的情况下，可以单独进行，也可以与微血管减压术同时进行。
