Chief Resident (PGY6) Johns Hopkins University School of Medicine Baltimore, Maryland, United States
Disclosure(s):
Wuyang Yang: No financial relationships to disclose
Introduction: Patients with brain arteriovenous malformation(bAVM) presenting with Trigeminal Neuralgia(TN) has been rarely reported. The majority of TN-bAVMs reside in peri-pontine region, with nidus adjacent to the trigeminal nerve, or engorged draining vein leading to vascular compression of the nerve. Existing cases are scarce and skewed towards surgery for these deeply located bAVMs. We report the management outcomes of bAVM patients presenting with ipsilateral TN.
Methods: Our institutional bAVM database was queried for bAVMs in “pontine”, “cistern”, “brainstem”, “trigeminal nerve” or “tentorial” locations. Patients with complete data were searched for “Trigeminal Neuralgia” or “Facial pain” as presenting symptom, with TN being ipsilateral to the bAVM. Demographics, TN and bAVM characteristics, management strategies, and outcome of bAVM and TN management were reviewed.
Results: Fifty-seven peri-pontine bAVMs were identified, with 8(14.0%) having ipsilateral TN, including 4 patients(50%) in V2 distribution, while others were: V1(n=1,12.5%), V2-3(n=1,12.5%), V1-3(n=1,12.5%), and V3(n=1,12.5%). Six(75%) had Carbamazepine as initial therapy, 2(25%) had multiple rhizotomies, and 1(12.5%) underwent microvascular decompression. None of TN-bAVMs presented with hemorrhage, compared to 25(51%) for non-TN peri-pontine bAVMs(p < 0.01). TN-bAVMs tended to have non-significant yet overall smaller size compared to non-TN-bAVMs, and Spetzler-Martin grades were similar. Six patients(75%) underwent radiosurgery(mean dose 1800cGy, mean volume 0.496cc) and had complete resolution of TN symptoms(100%). Average time from radiosurgery to facial pain resolution is 193(21-360) days, and follow-up period was 5.4 years. Two patients(12.5%) were recommended for conservative management, with one undergoing subsequent rhizotomies, and another patient died of follow-up hemorrhage. Excluding the TN-bAVM with salvage embolization after hemorrhage, obliteration was 83.3% vs 34.4%(p=0.025) for treated TN vs non-TN patients.
Conclusion : TN associated with bAVM are rare conditions with limited evidence for management guidance. Radiosurgery can be effective in achieving facial pain resolution in TN-bAVMs patients. Despite deep location and unruptured presentation, obliteration can reach 83.3% with radiosurgery.
