Retrogasserian trigeminal radiofrequency-thermorhizotmoy for trigeminal neuralgia.

Based on a personal experience of 4200 surgeries, radiofrequency thermocoagulation is useful lesional treatment for those trigeminal neuralgias (TNs) not amenable to microvascular decompression (idiopathic or secondary TNs). Introduced through the foramen ovale, behind the trigemnial ganglion in the triangular plexus, the needle is navigated by radiology and neurophysiological testing to target the retrogasserian fibers corresponding to the trigger zone. Heating to 55-75 °C can achieve hypoesthesia without anaesthesia dolorosa if properly controlled. Depth of anaesthesia varies dynamically sedation for cannulation and lesioning, and awareness during neurophysiologic navigation. Proper technique ensures long-lasting results in more than 75% of patients.

Morphologic and Morphometric Measurements of the Foramen Ovale: Comparing Digitized Measurements Performed on Dried Human Crania With Computed Tomographic Imaging. An Observational Anatomic Study.

The foramen ovale (FO) of the sphenoid bone is clinically important for the interventional treatment of trigeminal neuralgia. Percutaneous procedures applied to treat the chronic pain condition typically involve the cannulation of this oval-like foramen located at the base of the skull. Anatomic variations of the FO have been reported to contribute to difficulties in the cannulation of this structure. Computed tomography (CT) can help the surgeon improve the accuracy and safety of the intervention. However, even with navigation technology, unsuccessful cannulation of the FO has been reported. The aim of this observational anatomic study was to define morphometric and morphologic data of the FO and to investigate for potential differences between measurements taken on dried human crania and digitized measurements of the FO measured on CT images. One hundred eighteen FOs were evaluated. Twenty FOs underwent CT scanning. The mean length of the foramen was 7.41±1.3 mm on the left side and 7.57±1.07 mm on the right. The mean width of the foramen was 4.63±0.86 mm on the left side and 4.33±0.99 on the right. The mean area on the left side was 27.11±7.58 and 25.73±6.64 mm 2 on the right. No significant left-right differences were found for any of these dimensions. The most important conclusion that we can draw is that the measurements can indeed be performed on CT images to obtain an accurate picture of the morphology. Considering the surgical importance of the FO and taking into consideration the limitations this study added to scientific knowledge, this study was constructive as far as neurosurgeons and anatomists are concerned.

Percutaneous Balloon Compression for Treatment of Trigeminal Neuralgia Assisted by O-Arm O2-Based Navigation: Case Series and Review of the Literature.

BACKGROUND: Percutaneous cannulation of foramen ovale (FO) for treatment of trigeminal neuralgia, classically performed according to empirical landmarks and under fluoroscopic guide, may be difficult, time-consuming, and burdened with vascular or neurological complications related to close anatomic relationships. OBJECTIVE: To investigate cannulation of FO for treatment of trigeminal neuralgia assisted by O-Arm O2-based navigation, to assess safety and accuracy. METHODS: Nineteen patients underwent percutaneous balloon compression of Gasserian ganglion assisted by navigation provided by O-Arm O2 and StealthStation. Clinical outcomes according to Barrow Neurological Institute Pain Score, time of recurrence, side effects, and complications, as well as technical aspects as time of the procedure and number of tracks were investigated and evaluated. Obtained data were compared with current literature in a systematic review. RESULTS: The median time for procedure was 46 minutes; cannulation of the FO was performed in a median of 3 minutes and 47 seconds, in a single track in 16 patients, while 3 cases required a further O-Arm acquisition to check the needle position. No complications were observed. Onset of facial hypoesthesia was recorded in 10 patients and dysesthesia in 5. Although at a median follow-up of 12.7 months 7 patients had recurrence after an average pain-free period of 7.3 months, all but 2 patients had improvement in pain score. CONCLUSION: Advantages powered by navigation should be addressed in accuracy, lower complication rate, and success of cannulation even in case of previous treatments or anatomic variations, rather than in effective reduction of surgical time.

Presurgical video-EEG monitoring with foramen ovale and epidural peg electrodes: a 25-year perspective.

BACKGROUND: Epilepsy surgery cases are becoming more complex and increasingly require invasive video-EEG monitoring (VEM) with intracranial subdural or intracerebral electrodes, exposing patients to substantial risks. We assessed the utility and safety of using foramen ovale (FO) and epidural peg electrodes (FOP) as a next step diagnostic approach following scalp VEM. METHODS: We analyzed clinical, electrophysiological, and imaging characteristics of 180 consecutive patients that underwent FOP VEM between 1996 and 2021. Multivariate logistic regression was used to assess predictors of clinical and electrophysiological outcomes. RESULTS: FOP VEM allowed for immediate resection recommendation in 36 patients (20.0%) and excluded this option in 85 (47.2%). Fifty-nine (32.8%) patients required additional invasive EEG investigations; however, only eight with bilateral recordings. FOP VEM identified the ictal onset in 137 patients, compared to 96 during prior scalp VEM, p = .004. Predictors for determination of ictal onset were temporal lobe epilepsy (OR 2.9, p = .03) and lesional imaging (OR 3.1, p = .01). Predictors for surgery recommendation were temporal lobe epilepsy (OR 6.8, p < .001), FO seizure onset (OR 6.1, p = .002), and unilateral interictal epileptic activity (OR 3.8, p = .02). One-year postsurgical seizure freedom (53.3% of patients) was predicted by FO ictal onset (OR 5.8, p = .01). Two patients experienced intracerebral bleeding without persisting neurologic sequelae. CONCLUSION: FOP VEM adds clinically significant electrophysiological information leading to treatment decisions in two-thirds of cases with a good benefit-risk profile. Predictors identified for electrophysiological and clinical outcome can assist in optimally selecting patients for this safe diagnostic approach.

Percutaneous balloon compression for trigeminal neuralgia: a how I do it.

BACKGROUND: Surgical treatments for trigeminal neuralgia may include percutaneous techniques including the balloon compression technique. We present here a simple, effective, and safe adaptation of the historical technique described by Mullan in 1978. METHOD: Our procedure is performed in a bi-plane neuro-radiology room. During general anesthesia, 14-G needle is guided under radioscopy to foramen ovale. The 3-F embolectomy catheter is then inserted and inflated with contrast for a period of 2 min 15 s. CONCLUSION: Our technique, performed entirely under bi-plane fluoroscopy, allows a quicker and more precise surgery and avoids errors in guiding the catheter that can result serious injury.

A Simple Method for Foramen Ovale Puncture Based on Preoperative Image Simulation in Percutaneous Microcompression of the Trigeminal Ganglion.

BACKGROUND: The classic puncture method of percutaneous microcompression using fluoroscopy might be difficult to precisely locate and visualize the foramen ovale. Various new surgical tools to increase the accuracy of finding the foramen ovale location have been introduced. However, all of these systems require some complicated operating steps and/or advanced devices to complete the work. OBJECTIVE: To describe the use of a simple method for foramen ovale puncture by percutaneous microcompression based on preoperative image simulation. METHODS: Forty-five patients were included in the study. All patients underwent a computed tomography examination. Among them, the simulated preoperative puncture pathway was reconstructed on the basis of computed tomography scan examination for 22 patients. Procedures were performed by 2 surgeons: one experienced surgeon and another young surgeon with surgical qualification. The puncturing time and cumulative radiation exposure dose, from start of the puncturing until reaching the foramen ovale, were recorded. Postoperative pain relief, facial hypoesthesia, masticatory muscle weakness, and other complications were recorded. RESULTS: In all cases, the procedure of cannulation was completed successfully. The puncturing time for both the experienced and young surgeon with the use of preoperative image simulation seemed to be time-saving. The young surgeon had less cumulative radiation exposure with the use of preoperative image simulation. Moreover, the intraoperative puncture pathways were almost consistent with the preoperative simulated images. The rest of the process went smoothly. Short-term outcomes of all the 45 patients were satisfactory. CONCLUSION: Based on our preliminary experience, the preoperative image simulation-guided technique is useful during these cases.

Comparison of Efficacy and Safety of CT-Guided Radiofrequency Thermocoagulation Through Foramen Rotundum Versus Foramen Ovale for V2 Primary Trigeminal Neuralgia.

BACKGROUND: Primary trigeminal neuralgia (TN) is one of the most severe facial pain syndromes. TN affects patients' quality of life and, when severe, can lead to depression and increase social burden. OBJECTIVES: This retrospective study aimed to compare efficacy and safety of computed tomographic (CT)-guided percutaneous radiofrequency thermocoagulation (RFT) through the foramen rotundum (FR) versus through the foramen ovale (FO) for treatment of maxillary division (V2) TN. STUDY DESIGN: A prospective study. SETTING: Shengjing Hospital of China Medical University. METHODS: Seventy patients with V2 TN were randomly assigned to 2 groups: RFT-FR group (n = 35) and RFT-FO group (n = 35). Visual Analog Scale (VAS), the Medical Outcomes Study 36-Item Short-Form Health Survey, the total efficacy, complications, and recurrence rate were assessed before and after surgery at different time points. RESULTS: Compared with the preoperative VAS, the postoperative VAS in the RFT-FR and RFT-FO groups both decreased significantly (P < 0.05). There was no significant difference in VAS between the 2 groups (P > 0.05); in both groups quality of life improved to varying degrees after RFT. In the RFT-FO group, the physical component summary (PCS) and mental component summary (MCS) were significantly lower than in the RFT-FR group at 1 week, 2 weeks and 1 month (P < 0.05). After 3 months, the PCS and MCS of the RFT-FO group gradually increased, so the 2 groups no longer differed significantly (P > 0.05). The total incidence of complications in the RFT-FR and RFT-FO groups was 20.0% (7/35) and 62.9% (22/35), respectively, and differed significantly (P < 0.05). LIMITATIONS: This study cohort size is small, but we will gradually increase the number of patients later. Second, there may be acquiescence bias or response bias. Third, the punctures under the more commonly used C-arm imaging guidance deserve to be evaluated in the future. CONCLUSIONS: CT-guided RFT through the FR and FO are both an effective, minimally invasive treatments for V2 TN that can relieve pain effectively.

A Segmentation Method of Foramen Ovale Based on Multiatlas.

Trigeminal neuralgia is a neurological disease. It is often treated by puncturing the trigeminal nerve through the skin and the oval foramen of the skull to selectively destroy the pain nerve. The process of puncture operation is difficult because the morphology of the foramen ovale in the skull base is varied and the surrounding anatomical structure is complex. Computer-aided puncture guidance technology is extremely valuable for the treatment of trigeminal neuralgia. Computer-aided guidance can help doctors determine the puncture target by accurately locating the foramen ovale in the skull base. Foramen ovale segmentation is a prerequisite for locating but is a tedious and error-prone task if done manually. In this paper, we present an image segmentation solution based on the multiatlas method that automatically segments the foramen ovale. We developed a data set of 30 CT scans containing 20 foramen ovale atlas and 10 CT scans for testing. Our approach can perform foramen ovale segmentation in puncture operation scenarios based solely on limited data. We propose to utilize this method as an enabler in clinical work.

Peroral Trigeminal Rhizotomy Using a Novel 3-Dimensional Printed Patient-Specific Guidance Tool.

BACKGROUND: Ganglion Gasseri rhizotomy is a viable therapeutic option for trigeminal pain (TP). For this neurosurgical procedure, different potential operative and technical nuances exist. OBJECTIVE: To evaluate a novel peroral trigeminal rhizotomy method and 3-dimensional printed patient-specific guidance tool (3D-PSGT) with respect to their applicability and safety. METHODS: Between March 2018 and February 2021, 20 peroral balloon compression rhizotomy procedures with a 3D-PSGT were performed in 18 consecutive TP patients (13 female, mean age 58 yr). We registered the procedure duration, side effects, complications, and trigeminal function. The therapeutic effect was gauged from reduction of TP and use of analgesics. RESULTS: All catheter insertions and rhizotomy procedures were successful at the first attempt. Apart from fluoroscopy, no auxiliary material was necessary. The average length of surgery was 19 min (range, 11-27 min). In total, 8 patients indicated complete analgesia and 6 patients pain relief; in 4 patients, persistence of TP was observed during follow-up examinations of up to 20 mo. In total, 6 patients reported of new mild to moderate facial hypesthesia affecting the trigeminal branches V2, V3, or V1-3. No masticatory musculature or corneal affections and device-related complications occurred. CONCLUSION: The peroral 3D-PSGT trigeminal rhizotomy is straightforward for the neurosurgeon. This operative approach allows for rapid, safe, and simple foramen ovale cannulation in TP patients and reduces the use of additional equipment, radiation exposure, and procedure time.

Localization of Foramen Ovale According to Bone Landmarks of the Splanchnocranium: Help for Transforaminal Surgical Approach to Trigeminal Neuralgia.

ABSTRACT: Trigeminal neuralgia is a painful condition, usually treated through surgical procedures focusing on the foramen ovale (FO). A detailed localization of FO relative to reference landmarks is therefore crucial to avoid possible complications.The present study aims at assessing the position of FO according to the surrounding bone structures: 100 CT-scans of patients, equally divided between sexes, aged between 18 and 86 years were examined. From each subject, the 3D models of FO and the maxillary bones, the zygomatic bones and the zygomatic process of the temporal bones were segmented through ITK-SNAP software. The distance between the center of the FO and subnasale, zygion, and the upper edge of the zygomatic bone at the origin of the frontal process were measured on 3D models. On CT-scans three cranial measurements were taken as well (distance between anterior and posterior nasal spine, upper facial height and bizygomatic breadth).Statistically significant differences in the three distances according to side and sex were assessed through two-way ANCOVA test, using the three cranial measurements (ANS-PNS, NP, ZZ) as covariates (P < 0.05).Distances between the centre of FO and subnasale, zygion and the upper edge of the zygomatic bone were on average 82.3 ±â€Š3.4 mm, 41.9 ±â€Š2.6 mm and 48.8 ±â€Š3.5 mm in males, 77.3 ±â€Š3.9 mm, 38.2 ±â€Š2.5 mm and 45.5 ±â€Š3.1 mm in females, with a significant difference according to sex (P < 0.05).Results provide innovative data for the localization of FO and will be useful for the management of transforaminal procedures in case of trigeminal neuralgia.

Tooth-supported personalized template-assisted foramen ovale puncture system for trigeminal neuralgia treatment.

PURPOSE: To introduce a tooth-supported personalized template-assisted foramen ovale (FO) puncture system for trigeminal neuralgia (TN) treatment, analyze its advantages, and review other previously reported methods. METHODS: Sixty-seven patients were included. According to the preoperative digital design, the personalized puncture path was determined. Then, a tooth-supported personalized template was designed and manufactured. Finally, surgery (radiofrequency thermocoagulation or balloon compression) was carried out with the assistance of the template. The puncture effect and puncture-associated complications were evaluated, and the related literature was reviewed. RESULTS: The FO was successfully punctured in one attempt in all patients. The procedure was completed in 15 s in 35 (52.24%) patients and in 15-30 s in 28 (41.79%) patients. The required position was accurately reached in all patients, and the center point error range was within 1 mm. No complications associated with puncture occurred. CONCLUSION: The tooth-supported personalized template-assisted FO puncture system reported in this paper is an exceedingly simple, highly effective and safe FO puncture method that is worth popularizing.

Techniques to Improve the Efficacy of Percutaneous Biopsy Procedures for Cavernous Sinus Lesions.

BACKGROUND: The cavernous sinus can be affected by pathologies with profound clinical implications. Therefore, obtaining an accurate diagnosis with minimal disruption of native tissue is needed. Percutaneous needle aspiration biopsy through the foramen ovale using the Härtel corridor is one option. The diagnostic yield is around 86%, typically failing in cases where the tissue is firm. OBJECTIVE: This work describes a new method of percutaneous biopsy to increase the diagnostic yield in cases where the tissue is firm and not deliverable into the biopsy needle via a suction device. METHODS: Under general anesthetic, a percutaneous approach through the foramen ovale was performed. A k-wire was then placed and the needle was removed. A 14-ga angiocatheter was then placed using the over-the-wire technique. Once the K-wire was removed, endoscopic graspers were used to biopsy the lesion through the angiocatheter, providing reasonably sized biopsy specimens. RESULTS: This technique was applied when fine needle aspiration failed and resulted in successful pathologic diagnosis. CONCLUSION: This technique for minimally invasive biopsy of the cavernous sinus is potentially safe and can be performed when fine needle aspiration is unsuccessful or larger samples are required for definitive diagnosis.

Cross-sectional Survey of Nickel Allergy Management in the Context of Intracardiac Device Implantation.

BACKGROUND: The occlusion devices used for repair of atrial septal defect and patent foramen ovale commonly contain nitinol, an alloy containing nickel. There are reports of nickel allergy in the context of intracardiac device implantation. Type IV delayed-type reactions likely predominate in intracardiac metal hypersensitivity, but there are potentially other mechanisms such as cytotoxic or innate immunity. Based on available literature to date, the significance of nickel allergy in intracardiac occluders remains unclear. OBJECTIVE: The aim of the study was to investigate nickel allergy management strategies in intracardiac occluders. METHODS: The American Contact Dermatitis Society facilitated distribution of a survey via e-mail to the members of its association, which included dermatologists and allergists/immunologists. A total of 70 individuals answered the survey. CONCLUSIONS: There was no consensus regarding the ability of patch testing to accurately determine allergic reactions within cardiac tissue. There was also no agreement on the criteria for patch testing in patients undergoing intracardiac implantation. However, most would inquire about a history of contact sensitivity to previously implanted devices. With a positive patch test, nickel-based intracardiac devices should be avoided, or the decision should be left to the discretion of the cardiologist.

ioCT-guided percutaneous radiofrequency ablation for trigeminal neuralgia: how I do it.

BACKGROUND: Percutaneous trigeminal nerve rhizotomy is usually performed by free-handed puncture of the foramen ovale under radiographic control with the patient kept semiconscious. The procedure has thus been reported to be highly uncomfortable for both the patient and surgeon. To our knowledge, this is the first description of a technique that includes precise navigated, CT-guided puncture of the foramen with the patient in general anesthesia and confirmation of needle placement by intraoperative CT. METHOD: Radiofrequency ablation of the trigeminal nerve was guided by intraoperative CT navigation with neuromonitoring of trigeminal nerve function. The patient was kept under general anesthesia during the procedure. CONCLUSION: CT-guided percutaneous trigeminal nerve rhizotomy is a safe and efficient treatment strategy for the management of trigeminal neuralgia without the need of the patient being in a semiconscious state.

An Infratemporal Dermoid Cyst That Expanded the Foramen Ovale: A Case Report.

BACKGROUND: Dermoid cysts are rare tumors usually seen in the midline structure of the brain but rarely arise in the petrous apex and cavernous sinus. There have been very few reports of dermoid cysts arising in the infratemporal fossa, with scarce anatomic descriptions. Here we report the case of a patient with a dermoid cyst in the left infratemporal fossa. CASE DESCRIPTION: The patient was a 43-year-old female with complaints of nonspecific headaches. A computed tomography (CT) scan revealed a cystic lesion measuring 25 × 18 × 15 mm in the left infratemporal fossa that had expanded the foramen ovale. The same lesion was observed as a high-intensity area on T1-weighted magnetic resonance imaging (MRI) with fat saturation. Diffusion-weighted MRI showed no restriction, unlike in cases of epidermoid cysts. A left fronto-temporo-sphenoidal craniotomy with a detachment of the zygoma was performed to approach the lesion. The tumor wall was continuously attached to the dura, although the tumor itself was entirely extradural in location. The V3 branch of the trigeminal nerve was firmly attached around the tumor. The tumor was cystic, and it shrunk after the fatty yellowish contents were suctioned. Complete resection was achieved without complications. A pathological analysis enabled the diagnosis of a dermoid cyst. No tumor recurrences or associated complications were observed at the 1-year follow-up. CONCLUSIONS: Dermoid cysts in the infratemporal fossa are extremely rare. However, tumor resections can be performed safely and efficaciously using anatomically detailed preoperative planning.

New method to predict need for Rashkind procedure in fetuses with dextro-transposition of the great arteries.

OBJECTIVE: Prenatal congenital heart disease classification systems distinguish between critical dextro-transposition of the great arteries (d-TGA) with restriction of the foramen ovale (FO) (which requires a Rashkind procedure within the first 24 h following delivery) and d-TGA for which surgery is planned (after prostaglandin perfusion or Rashkind procedure later than 24 h after delivery). However, current prenatal diagnostic criteria for postnatal FO restriction in d-TGA are inadequate, resulting in a high false-negative rate. We aimed to identify echocardiographic features to predict the urgent need for Rashkind procedure. METHODS: We identified retrospectively 98 patients with singleton pregnancy diagnosed prenatally with fetal d-TGA at two European centers from 2006 to 2013. Two groups were compared: (1) those in whom the Rashkind procedure was performed within the first 24 h postnatally; and (2) those who did not undergo a Rashkind procedure before cardiac surgery. Exclusion criteria were: (1) no fetal echocardiography within 3 weeks prior to delivery (n = 18); (2) delivery before 37 weeks of gestation (n = 6); (3) improper or lack of measurement of pulmonary vein maximum flow velocity (n = 10); (4) lack of neonatal follow-up data (n = 9); (5) Rashkind procedure performed more than 24 h after delivery (n = 4). RESULTS: Fifty-one patients met the inclusion criteria: 29 who underwent the Rashkind procedure and 22 who did not. There were no differences between these two study groups in terms of maternal age, gestational age at time of fetal echocardiography, fetal biometric measurements, estimated fetal weight, rate of Cesarean delivery, newborn weight or Apgar score at 1 min. There were also no differences during prenatal life between the two groups in terms of fetal cardiac size (heart area/chest area ratio), rate of disproportion between left and right ventricle, FO diameter and maximum velocity of flow through the FO. However, the pulmonary vein maximum velocity was significantly higher in the group requiring a Rashkind procedure (47.62 ± 7.48 vs 32.21 ± 5.47 cm/s; P < 0.001). The cut-off value of 41 cm/s provided maximum specificity (100%) and positive predictive value (100%) at only a slight cost of sensitivity (82%) and NPV (86%). The prenatal appearance of the FO also differed between the groups, the FO valve being flat in 52% of those requiring a Rashkind procedure. CONCLUSIONS: In fetuses with d-TGA, prenatal sonographic findings of increased pulmonary venous blood flow and flattened FO valve were associated with the need for a Rashkind procedure within the first 24 h postnatally; these echocardiographic features could be used to predict prenatally a need for the procedure following delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Trigeminal neuropathy associated with an enlarging arachnoid cyst in Meckel's cave: case report, management strategy and review of the literature.

We describe a rare case and novel management strategy of painful trigeminal neuropathy caused by an arachnoid cyst confined to Meckel's cave. A 57-year-old female presented with several years of progressive trigeminal pain and signs of trigeminal deafferentation, including sensory loss, corneal anesthesia and mastication muscle atrophy. Medical treatment with carbamazepine provided partial and temporary pain control. Surgical treatment was eventually performed by aspiration of the arachnoid cyst through the foramen ovale using a percutaneous approach. The patient experienced relief of pain and improvement of numbness and muscle strength. To our knowledge, this is the first case description of a percutaneous drainage of a Meckel's cave arachnoid cyst.

Alternative option for osteogenesis imperfecta and trigeminal neuralgia / Opção alternativa em tratamento da neuralgia do trigêmeo com osteogênese imperfeita

Summary Osteogenesis imperfecta (OI) is a bone disorder that can lead to skull base deformities such as basilar invagination, which can cause compression of cranial nerves, including the trigeminal nerve. Trigeminal neuralgia in such cases remains a challenge, given distorted anatomy and deformities. We present an alternative option, consisting in cannulation of the foramen ovale and classical percutaneous treatment. Percutaneous balloon microcompression was performed in a 28 year-old woman with OI and severe trigeminal neuralgia using computed tomography (CT) and radiographic-guided cannulation of the Gasserian ganglion without neuronavigation or stereotactic devices. The patient developed hypoesthesia on the left V1, V2 and V3 segments with good pain control. This alternative technique with a CT-guided puncture, using angiosuite without the need of any Mayfield clamp, neuronavigation systems, frame or frameless stereotactic devices can be a useful, safe and efficient alternative for patients with trigeminal neuralgia with other bone deforming diseases that severely affect the skull base.

Resumo Osteogênese imperfeita (OI) é uma doença óssea que pode levar a deformidades de base de crânio, como invaginação basilar que pode provocar compressão de nervo craniano, incluindo o nervo trigêmeo. Nestes casos, a neuralgia do trigêmeo permanece como um desafio, pela anatomia distorcida e pelas deformidades. Apresentamos uma alternativa que consiste na canulação do forame oval e no tratamento percutâneo clássico. A microcompressão percutânea por balão foi realizada em uma paciente de 28 anos apresentando OI e grave neuralgia do trigêmeo, sendo realizadas tomografia computadorizada (CT) e canulação guiadas do gânglio gasseriano sem neuronavegação ou dispositivos estereotáxicos. A paciente apresentou hipoestesia à esquerda dos segmentos V1, V2 e V3, com bom controle da dor. Essa técnica alternativa com punção orientada por CT utilizando o angiosuite sem a necessidade de qualquer grampo de Mayfield, sistemas de neuronavegação, ou dispositivos com ou sem arcos estereotáxicos, pode ser uma opção útil, segura e eficiente para pacientes com neuralgia do trigêmeo cursando com outras doenças deformativas que afetem a base craniana de modo grave.