Trigeminal neuralgia as the sole neurological manifestation of COVID-19: A case report.

OBJECTIVE: To describe a case report of trigeminal neuralgia (TN) due to coronavirus disease-2019 (COVID-19). BACKGROUND: In March 2020, the World Health Organization declared COVID-19 as a pandemic. Respiratory system manifestations are dominant in this new disease. However, numerous case series and reviews have been published on the neurological manifestations, highlighting the potential neurotropism of the new coronavirus. METHODS: We describe a clinical case of TN during COVID-19 and we discuss the differential diagnosis and the potential pathogenic mechanism according to the literature. RESULTS: A 65-year-old man with general malaise and typical respiratory symptoms of COVID-19, who presented with paroxysmal lancinating pain in the right V1 trigeminal territory without other neurological symptoms. General blood test and neuroimaging study were normal. A rapid test showed positive IgG and IgM serologies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient was diagnosed with TN secondary to a viral infection by SARS-CoV-2. Facial pain resolved with the improvement of COVID-19. CONCLUSIONS: The new coronavirus SARS-CoV-2 is a possible etiology of secondary TN. Nevertheless, more studies are needed to elucidate the neuropathology of this viral infection.

Intracranial Leiomyoma Associated with Epstein-Barr Virus: A Cerebellopontine Angle Mass Presenting with Trigeminal Neuralgia.

BACKGROUND: Primary intracranial leiomyoma is a rare smooth muscle tumor often associated with Epstein-Barr virus (EBV), with <30 cases reported worldwide. These tumors commonly occur in patients with immunocompromised status, especially those with human immunodeficiency virus. In the present report, we have described the case of an EBV-associated leiomyoma at the cerebellopontine angle. The patient had presented with trigeminal neuralgia, which, to the best of our knowledge, is the first reported anatomical location and presentation for this tumor type. CASE DESCRIPTION: A 41-year-old male patient had presented with right-sided facial pain in the V1 and V2 dermatomes and previous workup and imaging studies. The patient had undergone treatment of a presumed right-side cerebellopontine angle meningioma as determined by the magnetic resonance imaging characteristics (no biopsy). The patient subsequently underwent right-sided retrosigmoid craniotomy and gross total resection of the tumor. The postoperative period was uneventful with resolution of the trigeminal neuralgia. Histopathologic examination revealed spindle cell neoplasm with histopathologic and immunohistochemical features consistent with leiomyoma. The tumor cells were positive for smooth muscle actin and desmin and were negative for S100, SOX-10, epithelial membrane antigen, glial fibrillary acidic protein, progesterone receptor, CD31, CD34, and E-cadherin. CONCLUSIONS: Primary intracranial leiomyomas are rare tumors associated with EBV infection that occur in immunocompromised patients. These lesions should be considered in the differential diagnosis for patients with known immunocompromised status (e.g., human immunodeficiency virus), and tissue biopsy should be considered.

High-Voltage, Long-Duration Pulsed Radiofrequency on Gasserian Ganglion Improves Acute/Subacute Zoster-Related Trigeminal Neuralgia: A Randomized, Double-Blinded, Controlled Trial.

BACKGROUND: Trigeminal postherpetic neuralgia is a severe neuropathic pain and often refractory to existing treatment, it develops secondary to herpes zoster-infected Gasserian ganglion. Therefore, it is important to prevent the transition of acute/subacute zoster-related pain to trigeminal postherpetic neuralgia. Despite numerous studies, the optimal intervention that reduces trigeminal postherpetic neuralgia incidence is still unknown. OBJECTIVES: This study aimed to evaluate the efficacy and safety of high-voltage, long-duration pulsed radiofrequency (PRF) on the Gasserian ganglion in patients with acute/subacute zoster-related trigeminal neuralgia. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Department of Pain Medicine, the First Affiliated Hospital of China Medical University. METHODS: Ninety-six patients with acute/subacute zoster-related trigeminal neuralgia were equally randomly assigned into 2 groups. The electrode needle punctured the Gasserian ganglion guided by computed tomography in every patient. High-voltage, long-duration PRF at 42°C for 900 seconds was applied in the PRF group (n = 48). It was also applied in the sham group (n = 48) without radiofrequency energy output. The therapeutic effects were evaluated using a visual analog scale (VAS) and the 36-Item Short Form Health Survey (SF-36) at different time points. The average dosage of pregabalin (mg/d) administrated within the first month after treatment was also recorded. RESULTS: The postprocedure VAS scores in the PRF group were significantly lower than those in the sham group at different time points after treatment (P < 0.01). The SF-36 scores, which included physical functioning, physical role, bodily pain, general health perceptions, vitality, social function, emotional role, and the mental health index, were significantly improved at the sixth month after treatment in the PRF group compared with the sham group (P < 0.01). The average dosage of pregabalin administered (mg/d) within the first month after treatment was also significantly reduced in the PRF group compared with the sham group (P < 0.01). There were no bleeding, infection, or other severe side effects in both groups. LIMITATIONS: Single center study, relatively small number of patients. CONCLUSIONS: High-voltage, long-duration PRF on the Gasserian ganglion is an effective and safe therapeutic alternative for patients with acute/subacute zoster-related trigeminal neuralgia. KEY WORDS: Pulsed radiofrequency, zoster-related trigeminal neuralgia, visual analog scale, 36-Item Short Form Health Survey.

Prevention and management of trigeminal herpes zoster and postherpetic neuralgia.

Herpes zoster (HZ, also known as shingles) is caused by the reactivation of a dormant varicella zoster virus and can be a source of significant morbidity. Oral manifestations can include vesicular eruptions of the mucosa, osteonecrosis with tooth loss, and postherpetic neuralgia (PHN). This article discusses treatment for trigeminal nerve involvement with herpes zoster, as well as for the painful syndrome PHN.

Gasserian ganglion injected with Adriamycin successfully relieves intractable trigeminal nerve postherpetic neuralgia for an elderly patient: A case report.

RATIONALE: Effective treatments for trigeminal nerve postherpetic neuralgia (PHN) are limited. Adriamycin (doxorubicin) has been applied to the treatment of neuropathic pain. This study reports a new treatment: Adriamycin injected to Gasserian ganglion for an elderly patient with the intractable trigeminal nerve PHN. PATIENT CONCERNS: A 75-year-old man complained of lancing, burning pain in the right mandibular branch of the trigeminal nerve (V3) for 3 months after rash eruption. DIAGNOSES: Trigeminal nerve PHN. INTERVENTIONS: Approximately 0.5 mL of 0.25% Adriamycin and 20 mg methylprednisolone injected to Gasserian ganglion through the foramen ovale with computer tomography guidance. OUTCOMES: The visual analog scale was 10 of 100 throughout the 1-month follow-up, and oxcarbazepine had also been tapered. The patient remained free of pain at the 12-month follow-up. LESSONS: The treatment of Adriamycin injection to Gasserian ganglion is effective and safe, and may be considered as an alternative treatment for trigeminal nerve PHN. However, more research is needed to verify the validity.

Gamma knife surgery for refractory postherpetic trigeminal neuralgia: targeting in one session both the retrogasserian trigeminal nerve and the centromedian nucleus of the thalamus.

OBJECT: The authors tested the hypothesis that two targets are needed to treat postherpetic trigeminal neuralgia (TN): one in the trigeminal nerve for the direct sharp pain and one in the thalamus for the diffuse burning pain. METHODS: Three patients with refractory postherpetic TN were treated with gamma knife surgery (GKS) through a novel two-target approach. In a single treatment session, both the trigeminal nerve and centromedian nucleus were targeted. First, the trigeminal nerve, ipsilateral to the facial pain, was treated with 60 to 80 Gy. Second, the centromedian nucleus was localized using standard coordinates and by comparing magnetic resonance images with a stereotactic atlas. A single dose of 120 to 140 Gy was delivered to the target point with a single 4-mm isocenter. Patients were followed clinically and with neuroimaging studies. Pain relief was scored as excellent (75-100%), good (50-75%), poor (25-50%); or none (0-25%). Follow up ranged from 6 to 53 months. There were no GKS-related complications. Two patients died of unrelated medical illnesses but had good or excellent pain relief until death. One patient continues to survive with 44 months follow up and no decrease in pain intensity, but with a decreased area of pain. CONCLUSIONS: Combined GKS of the centromedian nucleus and trigeminal nerve in a single treatment session is feasible and safe, and the effect was promising. A larger study is required to confirm and expand these results.

Occurrence of Herpes Simplex Virus Reactivation Suggests a Mechanism of Trigeminal Neuralgia Surgical Efficacy.

Common to the types of surgery that are effective for the treatment of trigeminal neuralgia (TN) is reactivation of herpes simplex virus (HSV). It is likely that such HSV reactivation following surgery indicates altered trigeminal ganglion neuron function, which was caused by the surgery. It is not thought that HSV infection is related to the cause of TN or that HSV reactivation is important for surgical treatment efficacy. Rather, it is thought that HSV reactivation is a marker of altered trigeminal ganglion neuron function resulting from the TN surgery. It is suggested that HSV reactivation is a surrogate marker of ganglion neuron injury. The correlation between effective types of surgery and evidence that they alter ganglion neuron function suggests that altered trigeminal ganglion neuron function may be the basis of the surgical efficacy.

Trigeminal neuralgia: mechanisms of treatment.

BACKGROUND: Mechanisms of the surgical treatment of trigeminal neuralgia are considered. RESULTS: Trigeminal neuralgia is effectively treated by microvascular decompression (MVD) and other surgical procedures. These procedures often cause reactivation of herpes simplex virus (HSV), which is latent in trigeminal ganglion neurons. CONCLUSION: MVD and other surgical procedures alter ganglion neuron transcription, as indicated by HSV reactivation. Controlled injury of the trigeminal root-ganglion probably occurs with the disparate surgical procedures, and this is likely the means of their effectiveness.

Severity of skin lesions of herpes zoster at the worst phase rather than age and involved region most influences the duration of acute herpetic pain.

Duration of acute herpetic pain (AHP) in 1431 patients for whom treatment was begun within 14 days after the onset of herpes zoster (HZ) was analyzed with respect to age, involved region, and severity of skin lesions. All patients were treated with repeated sympathetic nerve blocks until their pain was almost nil. Severity of the skin lesions at the worst phase was defined as mild when they covered less than one-quarter of the primary dermatome, as severe when they covered more than three-quarters of the primary dermatome, and moderate if they were between mild and severe. Without taking into account the severity of skin lesions, the duration of AHP for those aged 60 years or over and for those with trigeminal involvement was significantly longer than for patients aged under 40 years (P < 0.01 and P < 0.001) and for patients with thoracic (P < 0.001) and lumbosacral (P < 0.01) involvement, respectively. However, duration of AHP was significantly longer with increase in the severity of skin lesions in all age groups (the mild group versus the moderate group, P < 0.01 and P < 0.001; the moderate group versus the severe group, P < 0.01 and P < 0.001). The mean duration of AHP for patients aged 60 years or over with mild skin lesions ranged from 17.4 to 22.9 days, while that for patients aged 30-59 years with severe skin lesions ranged from 37.2 to 50.1 days. In addition, duration of AHP was significantly longer with increase in the severity of skin lesions in all regions (the mild group versus the moderate group, P < 0.01 and P < 0.001; the moderate group versus the severe group, P < 0.05 and P < 0.001). The mean duration of AHP for those with trigeminal involvement with mild skin lesions was 19.5 days, while the range was from 51.3 to 55.0 days for patients with severe skin lesions involving regions other than the trigeminal area. The frequency of severe skin lesions was significantly higher (P < 0.001) in patients aged 60 years or over and in those with trigeminal involvement. Multiple stepwise regression analysis revealed that the most important factors influencing the duration of AHP were the severity of skin lesions of HZ at the worst phase (r = 0.412), age (r = 0.277) and the involved region (r = -0.101). Thus, AHP in the elderly and in cases of trigeminal involvement is longer because of higher frequencies of severe HZ in the elderly and in trigeminal involvement rather than "being aged' and "trigeminal involvement' itself. We propose that one needs to analyze the results of treatment of AHP with respect to the severity of skin lesions at the worst phase.

Are latent, immediate-early genes of herpes simplex virus-1 essential in causing trigeminal neuralgia?

The etiology and pathogenesis of major trigeminal neuralgia remain largely unknown, but are believed to result from an irritative lesion near the semilunar ganglion. We suggest that its primary cause is a single, active DNA sequence in the persistent but non-integrated genome of latent herpes simplex virus type 1 commonly observed in a few infected A-delta nerve fibers of the cheek. Facial pain occurs as a result of herpes virus reactivation and when supplies of neurotrophins controlling normal transport functions of axolemmal ion channels become depleted.

[Herpes zoster of the trigeminal nerve: a case report and review of the literature]. / Herpes zoster del nervo trigemino. Revisione della letteratura e caso clinico.

Herpes zoster (shingles) is caused when the varicella zoster virus that has remained latent since an earlier varicella infection (chicken-pox) is reactivated. Herpes Zoster is a less common and endemic disease than varicella: factors causing reactivation are still not well known, but it occurs in older and/or immunocompromised individuals. Following reactivation, centrifugal migration of herpes zoster virus (HZV) occurs along sensory nerves to produce a characteristic painful cutaneous or mucocutaneous vesicular eruption that is generally limited to the single affected dermatome. Herpes zoster may affect any sensory ganglia and its cutaneous nerve: the most common sites affected are thoracic dermatomes (56%), followed by cranial nerves (13%) and lumbar (13%), cervical (11%) and sacral nerves (4%). Among cranial nerves, the trigeminal and facial nerves are the most affected due to reactivation of HZV latent in gasserian and geniculated ganglia. The 1st division of the trigeminal nerve is commonly affected, whereas the 2nd and the 3rd are rarely involved. During the prodromal stage, the only presenting symptom may be odontalgia, which may prove to be a diagnostic challenge for the dentist, since many diseases can cause orofacial pain, and the diagnosis must be established before final treatment. A literature review of herpes zoster of the trigeminal nerve is presented and the clinical presentation, differential diagnosis and treatment modalities are underlined. A case report is presented.

Tooth exfoliation, osteonecrosis and neuralgia following herpes zoster of trigeminal nerve.

A case of herpes zoster of the trigeminal nerve with complications of osteonecrosis and neuralgia in the absence of local or systemic predisposing factors is presented. The literature is reviewed and the role of varicella zoster virus in the pathology of tooth exfoliation and osteonecrosis is discussed.

Unusual trigeminal autonomic pain heralding hemichorea due to zoster sine Herpete vasculopathy.

BACKGROUND: Varicella zoster virus primary infection is responsible for chickenpox, whereas secondary infection or reactivation can lead to a variety of clinical scenarios. If latent infection is established in trigeminal ganglion, the reactivation can determine viral migration to cerebral arteries, which causes a cerebral vasculopathy and subsequently an ischemic stroke. PATIENTS: Here we report on a child experiencing recurrent episodes of headache mimicking a trigeminal autonomic cephalalgia, in the absence of any skin rash, which were followed by the occurrence of an ipsilateral hemiparesis associated with a choreic movement disorder a month later. RESULTS: Magnetic resonance angiography showed evidence of a right-sided infarction of basal ganglia and anterior limb of the internal capsule, corresponding to the vascular territory of the recurrent artery of Heubner, as a consequence of a focal varicella zoster virus arteriopathy. CONCLUSIONS: We suggest that the recognition of this prodromal manifestation, which can be interpreted as a zoster sine herpete, could provide clinicians an extremely useful time window to start promptly with a prophylactic treatment.

Herpes zoster of trigeminal nerve after dental extraction.

Herpes zoster is an uncommon acute viral infection caused by reactivation of varicella zoster virus. During the prodromal stage, the only presenting symptom may be odontalgia, which may prove to be a diagnostic challenge for the dentist. Practicing dentist may carry out emergency treatment that might result in irreversible damage or may delay the appropriate treatment. With an ever-increasing number of elderly and immunocompromised patients reporting to the dentist, the dental profession can expect to encounter an increased number of herpes zoster patients. Dentist must be familiar with the presenting signs and symptoms of patients experiencing the prodromal manifestations of herpes zoster of the trigeminal nerve. This article focuses on the difficulties in management of such cases, and one such case is reported here.

Successful vascular decompression in an 11-year-old patient with trigeminal neuralgia.

CASE REPORT: We present the case of an 11-year-old boy who was suffering distinct trigeminal neuralgia. At the age of 3 years, the patient had contracted a severe Epstein-Barr virus infection and developed mild meningoencephalitis. Magnetic resonance imaging scans showed a slight enhancement in the pontomesencephalic cistern as well as a neurovascular conflict at the right trigeminal nerve. Intraoperatively, thickened fibrous tissue was found that was attached to both the trigeminal nerve and the superior cerebellar artery. Microvascular decompression using Gore Tex as tissue implant brought immediate relief. DISCUSSION: Trigeminal neuralgia in pediatric patients is very rare. We present a case of typical trigeminal neuralgia in a child, demonstrating the pathogenesis of the neurovascular conflict due to subarachnoidal adhesions after meningoencephalitis.