Computed Tomography Cisternography for Evaluation of Trigeminal Neuralgia When Magnetic Resonance Imaging Is Contraindicated: Case Report and Review of the Literature

Background: Trigeminal neuralgia (TGN) causes severe unilateral facial pain. The etiology is hypothesized to be segmental demyelination of the trigeminal nerve root via compression by the superior cerebellar artery (SCA). Microvascular decompression (MVD) allows immediate and long-term pain relief. Preoperative evaluation includes magnetic resonance imaging (MRI) and/or magnetic resonance angiography of the brain. Having a pacemaker is a contraindication for MRI. There have been isolated reports of using computed tomography (CT) cisternography scans for radiation planning for TGN. Case Description: A 75-year-old male with a permanent pacemaker who had refractory TGN in the V2 (maxillary) distribution of the trigeminal nerve underwent CT cisternography to prepare for MVD. CT angiography with Isovue 370 intravenous contrast injection and 0.625-mm axial images were obtained from the skull base across the posterior fossa. An intrathecal injection of Isovue 180 was performed at the L2/3 level. Imaging revealed the right SCA abutting the medial margin of the proximal right trigeminal nerve. In surgery (K.D.), a standard retrosigmoid suboccipital craniotomy was performed to access the cerebellopontine angle and separate the abutting SCA and trigeminal nerve. The patient had immediate pain relief. Conclusions: MRI is the preferred method of evaluating for TGN because it offers excellent visualization of vasculature in relation to the trigeminal nerve without accompanying radiation exposure. However, for patients who have contraindications to MRI, CT cisternography is shown to also be an effective method for visualizing the trigeminal root entry zone and nearby vasculature in preparation for MVD of the trigeminal nerve.