Trigeminal neuropathy: evaluation with MR imaging.

Neuropathy of the trigeminal nerve can involve its full course, from its nuclei in the brain stem to its peripheral branches. The nerve can be divided into four segments--brain stem, cistern, the Meckel cave and cavernous sinus, and extracranial--and consideration of the pathologic entities by these locations simplifies the differential diagnosis. Multiple sclerosis, infarct, and glioma are the most common abnormalities in the brain stem leading to trigeminal neuropathy. The most common cisternal cause is neurovascular compression, followed by acoustic and trigeminal schwannomas, meningiomas, epidermoid cysts, lipomas, and metastases. Trigeminal neuropathy arising from the Meckel cave and cavernous sinus is frequently due to meningiomas, trigeminal schwannomas, epidermoid cysts, metastases, pituitary adenomas, and aneurysms. Malignant tumors, which may demonstrate perineural tumor spread, are the most common extracranial cause. Because the clinical findings do not permit accurate lesion localization, magnetic resonance imaging must be used to visualize the entire course of the fifth cranial nerve. The standard study should include T2-weighted images of the whole brain and high-resolution axial and coronal T1-weighted images of the skull base obtained with and without contrast material enhancement.

Internal mammary artery and vein supercharge in TRAM flap breast reconstruction.

To improve the blood supply of the pedicled flap we have performed an additional microvascular augmentation to this type of breast reconstruction procedure since 1991. The ipsilateral deep inferior epigastric pedicle is anastomosed to the internal mammary artery and vein (IMAV supercharge). In 19 of 20 patients this technique proved to be feasible. For the venous anastomoses the 3M microvascular anastomosis system facilitated the procedure. In one patient the venous anastomosis failed due to the small calibre of two internal mammary veins. In a majority of the cases rapid improvement of flap perfusion could be observed as the direct result of the supercharging. The IMAV supercharged flap is quite comparable with the free flap as regards to the operative procedure. Disadvantages are a slightly more extensive dissection and less freedom in positioning the flap due to the presence of the superior muscular pedicle. The main advantage is that the supercharge procedure minimises the risk of total flap loss. Further technical improvement may be obtained by the use of a contralateral vascular pedicle dissected with muscle-sparing techniques.