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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 184-186

A report of cerebellopontine angle epidermoid presenting with trigeminal neuralgia


1 Department of Radiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
2 Department of Medicine, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India

Date of Submission01-Nov-2018
Date of Decision16-Dec-2018
Date of Acceptance06-Jan-2019
Date of Web Publication13-Aug-2019

Correspondence Address:
Paramdeep Singh
Department of Radiodiagnosis, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_150_18

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  Abstract 


Trigeminal neuralgia is typified by recurrent attacks of unilateral facial pain that is often severe and starts with cutaneous stimulation. These paroxysms usually last for few seconds, and the etiology comprises compression of the trigeminal nerve by vessels and space-occupying lesions of the brain and involvement by inflammatory plaques. It is rare for intracranial epidermoids to present as trigeminal neuralgia which is usually seen at the cerebellopontine angle, third ventricle, and suprasellar area and comprise about 1% of all intracranial tumors. We present the case of a 35-year-old male who had episodes of left-sided facial pain for the last few months. Magnetic resonance imaging revealed left cerebellopontine epidermoid which showed restriction on diffusion-weighted imaging and was operated upon. The symptoms completely resolved after the surgery.

Keywords: Cerebellopontine angle, epidermoid, magnetic resonance imaging, neuralgia, trigeminal


How to cite this article:
Singh P, Kaur R, Kaur R. A report of cerebellopontine angle epidermoid presenting with trigeminal neuralgia. CHRISMED J Health Res 2019;6:184-6

How to cite this URL:
Singh P, Kaur R, Kaur R. A report of cerebellopontine angle epidermoid presenting with trigeminal neuralgia. CHRISMED J Health Res [serial online] 2019 [cited 2019 Aug 20];6:184-6. Available from: http://www.cjhr.org/text.asp?2019/6/3/184/264376




  Introduction Top


Trigeminal neuralgia or tic douloureux is a well-known entity which is commonly seen in patients aged above 50 years with a female preponderance. This disorder usually presents with paroxysms of severe and lancinating hemifacial pain, most frequently in the second and third trigeminal divisions. These episodes of pain are often triggered by eating, speaking, washing, or touching, all of which lead to low-intensity mechanical stimulation and hence provoke episodes of pain. The management of this disorder usually comprises anticonvulsant medications, whereas in intractable cases, surgical management is also an option.[1]

Majority of patients with trigeminal neuralgia have unremarkable clinical, imaging, and biochemical investigations, whereas a minority of patients have a known secondary etiology which usually causes compression or inflammatory involvement of the trigeminal nerve.[2] We present a rare case of a patient who presented with episodes of severe left hemifacial pain.


  Case Report Top


A 35-year-old female presented with episodes of left facial pain of 11-month duration. The pain was in the region of the mandibular division of trigeminal nerve and was precipitated by speaking and swallowing. Recently, the pain had increased in intensity as well as in the frequency of the attacks. Neurological examination was unremarkable. Magnetic resonance imaging (MRI) was done which revealed a large lobulated space-occupying lesion (SOL) causing mild indentation of the brainstem. The mass was encasing the cisternal part of the left trigeminal nerve and showed hyperintensity on T2-weighted (T2W) images with patchy areas of diffusion restriction on diffusion-weighted images (DWIs) [Figure 1] and [Figure 2]. Left retromastoid craniectomy was done with excision of the SOL, with histopathology confirming the diagnosis of epidermoid. There were no postoperative complications, and the patient was completely free of facial pain after 1 month of follow-up.
Figure 1: Axial brain magnetic resonance imaging (three-dimensional T2-SPACE sequence) shows a large lobulated extra-axial mass at the left cerebellopontine angle, with mass effect on the brainstem and encasing the trigeminal nerve

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Figure 2: Diffusion-weighted axial magnetic resonance imaging image showing that the space-occupying lesion has bright signal intensity with low apparent diffusion coefficient values on the corresponding apparent diffusion coefficient maps, which is suggestive of diffusion restriction

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  Discussion Top


Intracranial epidermoids are benign lesions showing slow growth; contain keratin, cellular debris, and cholesterol; and are covered by stratified squamous epithelium. These tumors encompass 1% of all intracranial tumors, and majority of them are detected in the cerebellopontine angle (CPA), suprasellar region, and third ventricle. Multiple sclerosis and infarct are the most frequent abnormalities of the brainstem that cause trigeminal neuralgia. Rarely, it is ascribed to an intracranial tumor (incidence <0.8%), with the majority of them seen in posterior fossa such as acoustic and trigeminal schwannomas, meningiomas, epidermoid cysts, lipomas, and metastases. Epidermoids are believed to cause trigeminal nerve neuropathy by either compressing the nerve directly or producing an inflammatory response indirectly by the discharge of its contents. Surgical excision of these lesions usually produces excellent results, although a conservative approach is frequently recommended because aggressive surgery may cause cranial nerve dysfunction during the postoperative period. Because of the scarcity of this presentation, most of the cases reported are limited to single case reports or short series.[3],[4],[5],[6],[7],[8],[9],[10] Meng et al. studied 24 cases and found that an epidermoid may be the cause of trigeminal neuralgia in younger patients.[11] Mohanty et al. in a series of 25 patients with CPA epidermoids found TN due to epidermoid in 13 cases. Complete excision was attained in 12 patients, near-total removal in eight cases, and partial removal in five cases. Due to the juxtaposition of CPA epidermoids to the brainstem and cranial nerves, complete excision is not achievable in all cases.[8]

Epidermoid cysts show hyperintense signal on T2W MRI sequences and do not show contrast enhancement. Epidermoids frequently show similar signal intensities as that of arachnoid cysts, inflammatory cysts (neurocysticercosis), and prominent cerebrospinal fluid spaces. Therefore, epidermoids may sometimes be difficult to distinguish from other brain cysts; however, MR DWI acts as a problem-solving tool, as the former appear bright due to diffusion restriction, unlike other brain cysts. DWI characteristics of epidermoid cysts may be somewhat explained by restricted diffusion due to keratinaceous fragments within the lesions.[12]


  Conclusion Top


Epidermoids should be always included in the differential diagnosis of patients with trigeminal neuralgia and should be ruled out with MRI especially DWI that helps to differentiate it from other brain cysts besides having an excellent soft-tissue resolution. Surgery helps in decompression of the V nerve with relief of symptoms.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gronseth G, Cruccu G, Alksne J, Argoff C, Brainin M, Burchiel K, et al. Practice parameter: The diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): Report of the quality standards subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008;71:1183-90.  Back to cited text no. 1
    
2.
Love S, Coakham HB. Trigeminal neuralgia: Pathology and pathogenesis. Brain 2001;124:2347-60.  Back to cited text no. 2
    
3.
Schiefer TK, Link MJ. Epidermoids of the cerebellopontine angle: A 20-year experience. Surg Neurol 2008;70:584-90.  Back to cited text no. 3
    
4.
Kobata H, Kondo A, Iwasaki K. Cerebellopontine angle epidermoids presenting with cranial nerve hyperactive dysfunction: Pathogenesis and long-term surgical results in 30 patients. Neurosurgery 2002;50:276-85.  Back to cited text no. 4
    
5.
Phuong HL, Matsushima T, Hisada K, Matsumoto K. Glossopharyngeal neuralgia due to an epidermoid tumour in the cerebellopontine angle. J Clin Neurosci 2004;11:758-60.  Back to cited text no. 5
    
6.
Jiménez Caballero PE, Portilla Cuenca JC, Casado Naranjo I. Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) secondary to epidermoid cyst in the right cerebellopontine angle successfully treated with surgery. J Headache Pain 2011;12:385-7.  Back to cited text no. 6
    
7.
Cirak B, Kiymaz N, Arslanoglu A. Trigeminal neuralgia caused by intracranial epidermoid tumor: Report of a case and review of the different therapeutic modalities. Pain Physician 2004;7:129-32.  Back to cited text no. 7
    
8.
Mohanty A, Venkatrama SK, Rao BR, Chandramouli BA, Jayakumar PN, Das BS, et al. Experience with cerebellopontine angle epidermoids. Neurosurgery 1997;40:24-9.  Back to cited text no. 8
    
9.
Majoie CB, Verbeeten B Jr., Dol JA, Peeters FL. Trigeminal neuropathy: Evaluation with MR imaging. Radiographics 1995;15:795-811.  Back to cited text no. 9
    
10.
Fitt AW, Pigott TJ, Marks PV. Undiagnosed epidermoid cyst presenting as trigeminal neuralgia: A need for MRI. Br J Neurosurg 1994;8:101-3.  Back to cited text no. 10
    
11.
Meng L, Yuguang L, Feng L, Wandong S, Shugan Z, Chengyuan W, et al. Cerebellopontine angle epidermoids presenting with trigeminal neuralgia. J Clin Neurosci 2005;12:784-6.  Back to cited text no. 11
    
12.
Chen S, Ikawa F, Kurisu K, Arita K, Takaba J, Kanou Y, et al. Quantitative MR evaluation of intracranial epidermoid tumors by fast fluid-attenuated inversion recovery imaging and echo-planar diffusion-weighted imaging. AJNR Am J Neuroradiol 2001;22:1089-96.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]



 

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