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|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 5 | Page : 1451-1453
Contralateral Trigeminal Neuralgia Due to Left Petroclival Meningioma an Extremely Rare Presentation: A Case Report
Nilesh Jain, Jitendra Tadghare
Department of Neurosurgery, Sri Aurobindo Medical College and P.G. Institute, Indore, Madhya Pradesh, India
|Date of Submission||16-Apr-2018|
|Date of Decision||27-Nov-2019|
|Date of Acceptance||15-May-2021|
|Date of Web Publication||30-Oct-2021|
Department of Neurosurgery, Sri Aurobindo Medical College and P.G. Institute, Indore - 453 555, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jain N, Tadghare J. Contralateral Trigeminal Neuralgia Due to Left Petroclival Meningioma an Extremely Rare Presentation: A Case Report. Neurol India 2021;69:1451-3
Meningioma is a benign tumor that presents with ipsilateral disturbances of trigeminal and other lower cranial nerves. Contralateral trigeminal neuralgia has been mentioned as a false localizing sign but that due to petroclival meningioma is not found in the literature.
A 55-year lady presented with sudden paroxysmal episodes of sharp shooting lancinating severe right facial pain, increasing on touching and chewing for 4 months. Tenderness of right face for touch in distribution of V1–V2 segment of trigeminal nerve was noted. Rest of the examination was normal. MRI and CT scan brain with angiography showed well-defined rounded homogeneous extra-axial solid peripherally calcified lesion of 2.4 × 2.4 × 2.5 cm in left petroclival and ambient cistern, broad based to the tentoria with minimal homogeneous post contrast enhancement and no obvious diffusion restriction, causing mass effect over midbrain and pons [Figure 1] and [Figure 2]. Mid and top of basilar artery was displaced towards right by the lesion. The left trigeminal nerve was seen as separate at its origin from the mass anteriorly. The two vascular loops were noted in close proximity to right trigeminal nerve; however, no mass effect was noted over the nerve. Anteriorly, the lesion was seen in close proximity to Meckel's cave[Figure 3]. During surgery, left-sided retrosigmoid suboccipital craniectomy was done. The cistern magna was opened to drain cerebrospinal fluid. A globular tumor with its capsule was visualized and internal debulking was done, and its capsule was partially removed to avoid inadvertent injury to adjacent neurovascular structures. Histopathology confirmed meningothelial meningioma [Figure 4]. Patient showed immediate complete relief from pain and even after 1 year of follow up. Immediate postoperative CT scan showed near total excision of tumor with some regression of mass effect on brainstem [Figure 5].
|Figure 1: CT scan brain with angiography showed well defined extra-axial lesion in left petroclival region with minimal contrast enhancement. Basilar artery was seen displaced towards right and left PCA seen coursing along the superior aspect of the lesion|
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|Figure 2: MRI brain showed well defined extra-axial lesion in left half of perimesencephalic cistern and left CPA cistern with homogenous contrast enhancement and no obvious diffusion restriction causing mass effect over midbrain and pons region|
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|Figure 3: MRI FIESTA showed left trigeminal nerve separate at its origin from the mass anteriorly in close proximity to meckel's cave. The two vascular loops were noted in close proximity to right trigeminal nerve without any mass effect.|
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|Figure 4: Histopathological examination showed pieces of tumor tissue composed of spindle cells with eosinophilic cytoplasm forming syncytial sheets and whorls. Many psammoma bodies were seen.|
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|Figure 5: Post operative CT scan showed excision of cyst with small residual capsule in situ and regression of mass effect on brainstem|
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Ipsilateral trigeminal neuralgia results from cross-compression or distortion of trigeminal root entry zone by the tumors and elongated loop of vessels like superior cerebellar and anterior inferior cerebellar arteries,, whereas the pathophysiology of contralateral trigeminal neuralgia is not well understood. Only few cases are found in the literature other than petroclival meningioma [Table 1]., The trigeminal sensory root is compressed between temporal bone or edge of tentorium and brainstem. The distortion of brainstem make the sharp angulation entry of trigeminal nerve at the meckel's cave., The CPA tumors rotate the anterior surface of brainstem, and the ventrally directed trigeminal nerve is stretched at its dural foramen. An alternate explanation is the presence of a cross-compression by contralateral vascular structure like the basilar or superior cerebellar artery that may be displaced by the mass and forms an “arterial loop” in conflict with trigeminal nerve root.,,,,,,,,,
|Table 1: Previous reports of contralateral trigeminal neuralgia noted in the literature|
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Thus, the anatomical factors responsible are: 1) dimensions and nature of the mass, 2) shape and size of CP angle region, and 3) direction of the cranial nerve. The pathological factors responsible are: 1) displacement and rotation of the brainstem, 2) stretching of the nerve, 3) compression of the nerve against the dura or bone by the brainstem, 4) vascular cross-compression, and 5) arachnoid adhesion and disturbances of CSF flow. The optimal strategy for the treatment of contralateral trigeminal neuralgia is the safe complete excision of the tumor along with its capsule and allow the structures of CPA and petroclival region to return to its normal position and providing complete relief from pain. If the symptoms are not relieved, then microvascular decompression of contralateral trigeminal nerve can be done. Postoperative complications like aseptic meningitis, cranial nerve palsies, and the tumor recurrence are reported.
In conclusion, the pathology behind such atypical symptom should be thoroughly investigated and managed further. Most cases have an excellent prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]