Teaching NeuroImages Neurology Resident and Fellow Section

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Presentation transcript:

Teaching NeuroImages Neurology Resident and Fellow Section A 55-year female with recurrent short-lasting shock-like facial pain episodes Teaching NeuroImages Neurology Resident and Fellow Section Uniyal et al. © 2013 American Academy of Neurology

Vignette A 55-year female developed recurrent short-lasting shock-like pain involving left lower face. Initiation of amlodipine for concurrent detection of hypertension relieved her of pain besides normalising her blood pressure. Interestingly, occasions of non-compliance to amlodipine used to bring her pain back. Uniyal et al. © 2013 American Academy of Neurology

Cranial MRI with MR angiogram Axial images Fast Imaging Employing Steady-state Acquisition sequence, showing left vertebral artery (white arrow) abutting antero-lateral medulla (A, B). MR angiogram, showing left vertebral artery (white arrow) taking narrower course compared to right vertebral artery (C). Anterior-inferior cerebellar artery loop (black arrow) is seen abutting left trigeminal nerve root (white arrow) (D-F). Another vascular loop is seen abutting the distal part of left trigeminal nerve root (curved white arrow) (E). Uniyal et al. © 2013 American Academy of Neurology

Amlodipine-responsive trigeminal neuralgia - An alibi for vascular compression theory Her cranial MRI revealed tortuous blood vessels compressing left rostro-antero-lateral medulla and left trigeminal nerve root. Vascular compression of medulla is known to produce neurogenic hypertension1 (Figure e-1). Possibly, a decrease in vessel tortuosity2 mediated by voltage-gated L-type calcium channels (anti-hypertensive effect) and an action on N-type channels (sympathetic modulation/anti-nociceptive effect) played a role in amlodipine’s inadvertent efficacy (Figure e-2). References: Jannetta PJ, Segal RI, Wolfson Jr SK. Neurogenic hypertension: etiology and surgical treatment. I. Observations in 53 patients. Annals of surgery. 1985 Mar;201(3):391. Love S, Coakham HB. Trigeminal neuralgia: pathology and pathogenesis. Brain 2001;124:2347–2360. Uniyal et al. © 2013 American Academy of Neurology