Trigeminal neuralgia

Hemifacial spasm

Glossopharyngeal neuralgia

Arterial hypertension


Trigeminal neuralgia

Trigeminal neuralgia is a facial pain with a very characteristic manifestation in the region of supply of  the fifth cranial nerve (trigeminal nerve). Pain related to trigeminal neuralgia is located in one or several branches of the nerve. The pain is classically described as sharp, lancinating and electrifying. Usually the pain is located only on one side, but in 5-6% the pain occurs on both sides. The pain attacks last from seconds to minutes. Some attacks persist for several days. Pain can be triggered by eating, laughing, brushing teeth, talking, shaving, or touching the face. Occasional slight numbness around the mouth can be present.

In rare cases trigeminal neuralgia is caused by to
tumors along the nerve or multiple sclerosis. For the majority of the cases, a vascular loop with a compressive effect on the nerve (so-called neurovascular compression) near the root entry zone can be assumed.
Medical treatment consists of tegretal (carbamazepine), phenytoin, gabapentine, pregabalin and lioresal. If a
tumor has been diagnosed, depending of the histology surgical removal, stereotactic radiation or chemotherapy can be taken into consideration. If the pain is resistant to medical therapy, progression of the pain or strong side effects due to medication occur, surgical procedures like microvascular decompression, radiofrequency, retroganglion glycerol injection, or stereotactic radiation are alternatives to be discussed. Radiofrequency and glycerol injection are destructive techniques which aim to block the pain pathways.


Microvascular decompression introduced by Jannetta is the causal therapy with the goal to remove surgically the neurovascular compression of the nerve. In contrast to the other destructive methods, excellent long-term results concerning freedom from pain, preservation of function and quality of life can be expected.


Hemifacial spasm

Hemifacial spasm is a rare condition of the facial nerve (cranial nerve VII). It presents as uncontrollable half sided contractions of the mimic facial muscles around the mouth and eye which are called synkenisia. The contractions can be twitches or lasting tonic cramps which entirely distort one side of the face. Usually hemifacial spasm is not painful. The affected person suffers mainly from a loss of social status and integration (i.e. setback in career, isolation).

Tumors along the facial nerve, inflammatory changes or injuries to the nerve as well as pathologic changes of the brain stem can be causes of hemifacial spasm in rare cases. In most cases we find a neurovascular compression of the nerve at its root entry zone in the posterior cranial fossa. MRI is the diagnostic procedure of choice. A high-resolution MRI together wit 3D-image processing can detect a neurovascular compression. 

Medical treatment of hemifacial spasm includes carbamazepine, phenytoin, and Baclofen, but is not very effective. Injections of botulinum toxin in the affected facial muscle causing a temporary paralysis of the corresponding muscles serve as symptomatic trearment. The effect usually subsides after a certain period of time and the symptoms return. Repetition of this procedure can result in permanent weakness of the affected muscles or antibodies against botox develop, which reduce the effectiveness dramatically.

Microvascular decompression is the causal therapy for the neurovascular compression in hemifacial spasm. In 80-90% of the cases this procedure results in permanent success without a loss of functionality. Destructive methods such as severing the nerve causing functional disorder should be avoided.


Glossopharyngeal neuralgia

Glossopharyngeal neuralgia (GN) is a pain that occurs in the pharynx, tongue and lingual base and can also reach the external auditory canal in extreme cases. The pain is described as sharp, shooting, lancinating and electrifying. It can sometimes have "destructive" characteristics. The pain can occur spontaneously or at the onset of swallowing, talking, coughing or touching the tongue or throat. Arrhythmia can occur during some pain attacks. Left-sided glossopharyngeal neuralgia can also be conjunct with arterial hypertension.

In rare cases GN is associated with tumors along the nerves or the neck, inflammatory alterations of the nervous system or damage to the nerve itself. In most cases no clear cause can be detected and these are then classified as idiopathic glossopharyngeal neuralgia. In most instances, this form displays a vascular loop at the root entry/exit zone of the cranial nerve IX & X leading to a neurovascular compression. Neurovascular compression can be identified regularly by high resolution MRI.

Carbamazepine, phenytoin and gabapenthine are used for medical treatment. Apart from that, various methods concerning the infiltration of anaesthetics or alcohol at different extra cranial locations along the nerve are performed and mainly result in a partial relief of pain.

Microvascular decompression has resulted into high rates of success with permanent pain relief without loss of function. This method is increasingly being recognized as the best way to treat this entity. Destructive techniques such as severing the nerve are not recommendable.


Arterial hypertension

High blood pressure is prevalent in about 10% of the population. Over 80% of these patients suffer from the so-called essential hypertension, having no clear etiology of their disease.  Longstanding hypertension causes arteriosclerosis, stroke and heart attack. Therefore many patients depend on live long medication.

It is known that the central nervous system plays a major role in regulating the blood pressure. Newest findings frequently show in patients with arterial hypertension contacts between vessels and cranial nerves IX & X like neurovascular compression at the ventrolateral medulla.

These contacts were removed in a certain number of patients - microvascular decompression - and led not only to a lowering of the blood pressure but also in some cases to complete normalization. We can therefore assume a association between neurovascular compression and the essential hypertension.

This association is being investigated in a cooperative scientific study of the department of neurosurgery and the medical clinic IV - nephrology of the University Erlangen-Nuremberg. A neurovascular compression at the brain stem in arterial hypertension can be easily proven by high resolution MRI. In selected cases resistant to medical therapy microvascular compression can be taken into consideration.