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Glossopharyngeal neuralgia due to ectatic anterior inferior cerebellar artery Sir, Glossopharyngeal neuralgia is a rare condition with neuralgic sharp pain in the pharyngeal and auricular region with a reported incidence of 0.2-0.7 per 100,000 population.[1]
Figure 2: Histopathological examination of the lesion shows a cyst wall lined by stratified squamous epithelium with overlying lamellated keratin suggestive of epidermoid cyst (H and E, × 200)
the cystic appearance and the unusual location as seen in the present case bring other lesions such as an oligodendroglioma and ganglioglioma into the differential consideration, these tumors have not been described to have a hyperintense signal on DW imaging. MRI findings, in the absence of DWI, are not specific and these intracerebral lesions are often mistaken for lowgrade astrocytoma or oligodendroglioma.
Sukhdeep S. Jhawar, Sarvpreet S. Garewal, Raghav Wadhwa, Toshi Nandi Shadangi, Pranshu Bhargava Department of Neurosurgery, Christian Medical College and Hospital, Ludhiana - 141008, Punjab, India E-mail:
[email protected]
References 1. Conley FK. Epidermoid and dermoid tumors: Clinical features and surgical management. In: Wilkins RH, Rengachary SS, editors. Neurosugery. New York: McGraw-Hill; 1996. p. 971-6. 2. Russell DS, Rubinstein LJ. Tumors and tumor like lesions of maldevelopment origin. In: Russell DS, Rubinstein LJ, editors. Pathology of Tumors of the Nervous System. London: Edward Arnold; 1989. p. 693-9. 3. Netsky MG. Epidermoid tumors. Review of literature. Surg Neurol 1988;29:477-83. 4. Kaido T, Okazaki A, Kurokawa S, Tsukamoto M. Pathogenesis of intraparenchymal epidermoid cyst in the brain: A case report and review of the literature. Surg Neurol 2003;59:211-6. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.100730
Received: 11-06-2012 Review completed: 11-06-2012 Accepted: 24-06-2012 442
A 46-year-old female presented with history of paroxysms of severe pain at the base of tongue extending up to pinna on right side of 4 years duration. Initially, the pain subsided with carbamazepime, but started to experience severe pain not responding to increased dose of carbamazepime since 4 months. She had difficulty in taking even liquid diet due to the severity of pain. In addition to routine magnetic resonance imaging (MR) study, 3D constructive interference in steady state (CISS) sequence and 3D time of flight MR angiography (MRA) of intracranial vessels was performed. These imaging sequences showed ectasia of basilar artery with a large tortous right anterior inferior cerebellar artery (AICA) in contact with right glossopharyngeal nerve at the supraolivary fossette [Figures 1 and 2]. Endoscopeassisted microvascular decompression (MVD) was done in supine position with head turned to left and fixed in sugita head frame, by retrosigmoid suboccipital approach. Endoscopic visualization of ectatic right AICA vessel confirmed the preoperative radiological findings. AICA was seen adherent to the ninth and tenth cranial nerves [Figure 3]. Arachnoid adhesions between AICA and glossopharyngeal and vagus nerves were divided. AICA was separated from the cranial nerves, and Teflon felt was inserted between the vessel and the nerve. Patient had immediate relief of pain following surgery. There were no postoperative complications. Patient did not have dysphonia, dysphagia, or dysarthria during the perioperative period. There was no recurrence of pain at 6 months of follow-up. Glossopharyngeal neuralgia is characterized by repeated episodes of severe pain in the tongue, throat, ear, and tonsils, which can last from a few seconds to a few minutes. The pain can also be felt in the areas innervated by the auricular and pharyngeal branches of the vagus nerve, thus also described as “vagoglossopharyneal neuralgia.”[2] It is commonly provoked by swallowing, talking, and coughing. It can rarely be life-threatening as a result of associated cardiovascular consequences like syncope, bradycardia, and hypotension.[3] Classical glossopharyngeal neuralgia is caused by neurovascular compression at the root Neurology India | Jul-Aug 2012 | Vol 60 | Issue 4
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entry zone of the nerve.[1] The primary goal of diagnostic procedures is to rule out symptomatic glossopharyngeal neuralgia. Three-dimensional CISS and MRA are
Figure 1: Source image from 3D TOF MRA showing right AICA and right vertebral artery relation
Figure 2: MRI image showing contact between right AICA and right glossopharyngeal nerve on 3D CISS axial images
helpful in visualizing the offending artery in contact with the glossopharyngeal nerve in supraolivary rosette.[4] The supraolivary fossette is the most medial portion of the cerebellopontomedullary angle and the rootlet of the glossopharyngeal nerve is located at this fossette.[4,5] As reported in literature, the posterior inferior cereberllar artery (PICA) is the most frequent causative vessel, which compressed the root entry zone of the glossopharyngeal nerve, followed by vertebral artery and AICA.[4] Glossopharyngeal neuralgia due to neurovascular compression by AICA is rare and accounts for only 5 to 10% of cases.[1,6] AICA as offending vessel is rare and imaging of such neurovascular conflict was reported in very few case reports.[4] Surgery in glossopharyngeal neuralgia is considered when initial medical treatment fails or when unacceptable side effects occur with medical treatment. Surgery, MVD, for glossopharyngeal neuralgia can be approached either by retromastoid suboccipital approach [7] or by transcondylar fossa (supracondylar transjugular tubercle) approach. [8] The offending vessel is separated from the nerve, and further contact of the vessel with the nerve can be prevented by either a Teflon felt or by stitched sling retraction technique.[8] Endoscope-a ssisted MVD helps in better visualization of the anatomy than with microscopy. [9] Glossopharyngeal rhizotomy along with MVD has also been reported.[6] Postoperative complications include common risks of anesthesia, bleeding, infection, hearing loss, hoarseness, and difficulties in swallowing. MVD has been standard surgical treatment for trigeminal neuralgia as reported previously in our series.[10] MVD of the glossopharyngeal nerve is an effective treatment of patients with glossopharyngeal neuralgia. In the present case, patient had immediate and persisting relief of pain following surgery. Other treatment modalities for glossopharyngeal neuralgia include percutaneous radiofrequency rhizotomy for glossopharyngeal nerve and gamma knife radiosurgery.
Rajesh K. Ghanta, Vivekanand Kattimani1, Vamsipani Koneru2, Srinivas Dandamudi3 Department of Neurosurgery, Suraksha Hospital, 2Department of Oral and Maxillofacial Surgery, Family Dental Hospital, 3 Department of Radiology, Suraksha Hospital, Vijayawada, Andhra Pradesh, 1Department of Oral and Maxillofacial Surgery, Sri Saraswati Dhanwantari Dental College and Hospital, Parbhani, Maharashtra, India E-mail: ghantarajesh@ yahoo.co.in
References Figure 3: Intraoperative endoscopic image showing large right anterior inferior cerebellar artery in contact with glossopharyngeal and vagal cranial nerves
Neurology India | Jul-Aug 2012 | Vol 60 | Issue 4
1. Gaul C, Hastreiter P, Duncker A, Naraghi R. Diagnosis and neurosurgical treatment of glossopharyngeal neuralgia: Clinical findings and 3-D visualization of neurovascular compression in 19 consecutive patients. J Headache Pain 2011;12:527-34. 443
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Bruyn GW. Glossopharyngeal neuralgia. Cephalalgia 1983;3:143-57. Kim SH, Han KR, Kim do W, Lee JW, Park KB, Lee JY, et al. Severe pain attack associated with neurocardiogenic syncope induced by glossopharyngeal neuralgia: Successful treatment with carbamazepine and a permanent pacemaker -a case report-. Korean J Pain 2010;23:215- 8. Hiwatashi A, Matsushima T, Yoshiura T, Tanaka A, Noguchi T, Togao O, et al. MRI of glossopharyngeal neuralgia caused by neurovascular compression. AJR Am J Roentgenol 2008;191:578-81. Naidich TP, Kricheff II, George AE, Lin JP. The normal anterior inferior cerebellar artery: Anatomic–radiographic correlation with emphasis on the lateral projection. Radiology 1976;119:355-73. Xiong NX, Zhao HY, Zhang FC, Liu RE. Vagoglossopharyngeal neuralgia treated by microvascular decompression and glossopharyngeal rhizotomy: Clinical results of 21 cases. Stereotact Funct Neurosurg 2012;90:45-50. Ferroli P, Fioravanti A, Schiariti M, Tringali G, Franzini A, Calbucci F, et al. Microvascular decompression for glossopharyngeal neuralgia: A long-term retrospectic review of the Milan-Bologna experience in 31 consecutive cases. Acta Neurochir (Wien) 2009;151:1245-50. Kawashima M, Matsushima T, Inoue T, Mineta T, Masuoka J, Hirakawa N. Microvascular decompression for glossopharyngeal neuralgia through the transcondylar fossa (supracondylar transjugular tubercle) approach. Neurosurgery 2010;66:275-80. Rak R, Sekhar LN, Stimac D, Hechl P. Endoscope-assisted microsurgery for microvascular compression syndromes. Neurosurgery 2004;54:876- 81. Chakravarthi PS, Ghanta R, Kattimani V. Microvascular decompression treatment for trigeminal neuralgia. J Craniofac Surg 2011;22:894-8. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.100731
Received: 13-06-2012 Review completed: 15-06-2012 Accepted: 04-07-2012
Intracranial lipoma with subgaleal extension: An interesting case report with review of literature Sir, Intracranial lipoma with subgaleal extension causing fenestration of superior sagittal sinus (SSS) and associated with a persistent falcine sinus has been reported only once in literature.[1] Hence, this case report. A 13-year-old boy was brought with history of progressively increasing swelling over the scalp in the occipital region of 5 years duration and no other 444
associated symptoms. Child had undergone surgery for a similar swelling at the same site at one month of age. Upon evaluation, a 5 × 6 cm, soft swelling was noted in the midline parieto-occipital region with a positive cough impulse and an overlying scar. Computed tomography (CT) scan and magnetic resonance imaging (MRI) brain showed extra cranial extension of a lesion in the posterior inter hemispheric region through a defect in the calvarium [Figures 1a-d]. The imageological findings were consistent with a lipoma and a band of tissue was noted communicating it with the tectum displacing the latter posteriorly and superiorly. An atretic parietal encephalocele was noted in relation to the tectum. On MR venogram, SSS was found to be fenestrated by the lipoma, a persistent falcine sinus was noted and straight sinus was absent. He underwent repeat surgical excision of the subgaleal part of lipoma for cosmetic reasons. During surgery, the extra cranial part of lipoma was excised and the calvarial defect was closed by opposing the edges of the pericranium around the defect [Figure 1e]. Histopathological findings were consistent with lipoma and no atypical changes. Intracranial lipomas are most commonly located in the inter hemispheric fissure in the region of the pericallosal (50%), ambient or quadrigeminal cisterns (20-25%). Other sites include cerebellopontine, suprasellar, sylvian, prepontine cisterns and rarely over the cerebral hemispheres.[2] Majority of intracranial lipomas are detected incidentally. Symptoms, if present include those of raised intracranial pressure (due to obstructive hydrocephalus), seizures, and psychomotor retardation and cranial nerve deficits. Those with subcutaneous extension of the intracranial portion present for cosmetic reasons. Half of intracranial lipomas are associated with midline brain malformations of varying severity which include hypoplasia/aplasia of corpus callosum and vascular abnormalities. The latter include distension, kinking or narrowing of arteries and veins, engulfment of cerebral arteries, arteriovenous malformation and aneurysm. Intracranial lipoma with subgaleal extension is rare with isolated case reports in literature. Intracranial lipomas result from abnormal persistence and mal-differentiation of meninx primitiva.[3] Secondary dehiscence of the cranium with evagination of a small tuft of meninx primitiva has been proposed as the embryological basis for the extra cranial portion of lipoma. Any insult to the mesenchyme at the level of cranial sutures in the sagittal plane may lead to anomalies of SSS, straight sinus, tentorium and parietal bones which explain the associated anomalies. The anatomic location of the extra cranial part and/or time of appearance of the lipoma determine its relationship to the SSS. A lipoma Neurology India | Jul-Aug 2012 | Vol 60 | Issue 4
