Macrocrania

Dr. François LECHANOINE

Senior Consultant Neurosurgeon, Specialist in minimally invasive endoscopic brain, spinal, and pediatric surgery at the NeuroNEC International Center in San Marino, which coordinates surgical activity between San Marino, Milan, Naples, and France.


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 348 916 3317

Studies Program: San Marino – Milan
 

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Trigeminal neuralgia

Il pain caused by the trigeminal neuralgia It has many unpleasant characteristics: it is a chronic and sometimes unpredictable sensation, often stabbing and in some cases even burning. Furthermore, it involves the face, sometimes even both sides. This pain is due to theinflammation of the trigeminal nerve.

What is the trigeminal nerve?

Fifth cranial nerve, the trigeminal nerve It has the role of transmitting information received through the face to the brain. As its name suggests, three other nerves radiate from the trigeminal nerve, joined in the Gasserian ganglion:

  • il ophthalmic nerve (V1), which reaches the eye, forehead and nose
  • il maxillary nerve (V2), which extends from the side of the nose to the cranial meninges, the area under the eye and the upper dental arch 
  • il mandibular nerve (V3), which expands up to the jaw and “touches” the roots of the teeth

Another peculiarity of the trigeminal nerve, which explains the impact it can have on the quality of life in case of inflammation, is its "double identity": it is equipped with both a root, psychic (the largest), which allows it to affect the sensitivity of the head and face, which of a motor root, which particularly affects the muscles responsible for chewing. 

Trigeminal Neuralgia: Classification and Possible Causes

You can understand what type of trigeminal neuralgia the patient is suffering from by observing his painful symptoms e determining the causes. 

  • Type 1 (TN1) or trigeminal neuralgia typical, characterized by intermittent, sharp pain that is not easily predictable, which occurs especially during the day and increases in intensity over time. In some cases, the specific cause of its development is unknown (neuralgia idiopathic)
  • Type 2 (TN2), or trigeminal neuralgia atypical, which manifests itself with constant pain and sometimes accompanied by a burning sensation
  • Type 3 (STN): neuralgia symptomatic it is secondary to another pathology

In the case of TN1, often an artery or vein is in the wrong position and causes compression of the trigeminal nerveAlthough trigeminal neuralgia can affect people of various ages (one in 25.000 suffers from it), it usually occurs mainly in women and in people in general over 50 years old.

TN2 neuralgia and TN3 neuralgia can instead be caused by a severe stress over a long period of time, anxiety or depression which contribute to muscle tension, multiple sclerosis, Herpes Zoster (if the virus has reactivated within a branch of the trigeminal nerve), exposure to coldMore rarely, compression of the trigeminal nerve can be caused by the presence of a tumor mass, from a malformation in the connection between veins and arteries or from a aneurysm. 

Symptoms and diagnosis of trigeminal neuralgia

Since no initial symptoms of this disease can be identified, other than possibly some form of numbness or tingling in the face, it is not easy to prevent its development. As mentioned, it is pain, associated with an electric discharge, the main symptom of trigeminal neuralgia. A pain that is also rather ambiguous, as it may not appear again for a long time and then resurface again. 

Although it can occur without any apparent stimuli, it is more common to feel pain after the so-called trigger point or trigger zone: It is specific points on the face, lips or tongueSince these areas are constantly in use in various daily activities, this can happen at any time, even while chewing or consuming very cold or very hot drinks. 

These can be short, repetitive pains (up to a hundred a day), especially on the cheek near the nose or jaw. These pains can last from a few seconds to about two minutes, and their continuous recurrence can highly affect the quality of life, to the point of promoting long-term depressive states.   

This consequence is more likely to materialize if the trigeminal neuralgia presents other symptoms: 

  • eye and/or ear pain on the same side of the face
  • pain when chewing
  • tinnitus
  • light intolerance
  • paraesthesia (altered sensation in the limbs)
  • muscle spasms

Since the symptoms cannot be recognized through instrumental tests, it is necessary to meticulously analyze the pain caused by trigeminal neuralgia to exclude the presence of other pathologies. magnetic resonance It will then be essential to visualize any contact between the trigeminal nerve and a blood vessel or tumor mass.  

Treatment for trigeminal neuralgia

In most cases (about 70% of patients), the treatment for trigeminal neuralgia is pharmacological. With the advice of a specialist, you can take: anticonvulsant drugs (which have a stabilizing action on nerve membranes), muscle relaxants (which act on the muscles) and antidepressants (both for the neuralgia itself and to respond to any depression that may arise later). To stem the inflammation, you can also opt for a cortisone therapy. 

If drugs are not enough to relieve the pain or cause side effects in the patient, surgery is advisable. microvascular decompression (Janetta's procedure), particularly suitable for those who suffer from typical trigeminal neuralgia. 

 

When this type of operation is impossible, for example if the patient is elderly or suffers from other pathologies that make general anesthesia risky, it is possible to proceed with percutaneous interventions of a destructive nature, which have as their objective the injury or interruption of a part of the nerve. 

 

If, however, the trigeminal neuralgia originates in other pathologies, it is naturally necessary to establish a specific therapeutic pathIf a tumor mass is compressing the nerve, it will be necessary to remove the tumor itself. If the pain is caused by trigeminal herpes zoster, antiviral and painkiller medications should be started promptly. 

Pituitary adenoma

Pituitary adenoma and endonasal endoscopy

The pituitary adenoma is a benign tumor, which strikes the pituitary gland and in particular its anterior part (adenohypophysis). No specific risk factors have been identified, with the exception of familiarityTo understand the possible consequences, it is worth knowing the role of the pituitary gland in our body.

Pituitary adenoma is usually treated surgically using endoscopic surgery.

What is the pituitary gland for?

The pituitary gland is a endocrine gland Small in size, measuring less than 1 centimeter in diameter. It is located inside the skull and contained within a bony saddle (the "sella turcica"), located behind the nose and between the eyes. It consists of two sections, an anterior (adenohypophysis) and a posterior (neurohypophysis).

Although its structure makes one think of a gland of little importance, the pituitary gland is actually the equivalent of an orchestra conductor: the hormones it secretes in turn stimulate the activity of other glands, thus influencing the regulation of our body's metabolism, growth and reproduction.

For this reason, if one of the pituitary hormone lines is affected by a particular disorder, potentially very serious pathologies can arise. The pituitary gland can be affected by various types of lesions, mostly benign, of which Pituitary adenoma is the most common.

Types of pituitary adenoma

When a pituitary adenoma forms, we see the abnormal development of a part of the pituitary gland and its cells. It can secrete hormones (secreting) or not (non-secreting). Below a diameter of 1 centimeter, we speak of pituitary microadenoma; once the centimeter is exceeded, it is a question of pituitary macroadenoma. Size, location and secretory or non-secretory state determine the possible consequences:

  • hypersecretion syndrome: occurs when the adenoma produces too many hormones (TSH, prolactin, ACTH, growth hormone). This causes a significant imbalance in the body, which causes pathologies such as Cushing's disease (which manifests itself with excessive amounts of fat along the entire trunk and on the face), acromegaly (excessive growth of some bone structures), prolactinoma (cancer that negatively affects fertility in both men and women)
  • insufficiency syndrome, which sees the adenoma invade the space occupied by the pituitary gland and hinders its normal functioning. This leads to a decrease in the production of hormones (hypopituitarism)
  • mass syndrome: the size of the adenoma ends up causing compression of the optic nerves, resulting in loss of visual acuity or reduction of the lateral visual field

Pituitary adenoma and symptoms

It is not a given that a pituitary adenoma will manifest itself with recognizable symptoms: on the contrary, it is possible that it is identified by chance, during diagnostic tests performed for other reasons. 

Among the most common symptoms, especially in the case of macroadenoma, are included: headache, blurred vision, visual field alterationIn case of particularly invasive macroadenoma, there may also be disorientation, vomiting, drowsiness, bulimia, and diabetes insipidus (which is not related to sugar metabolism, but to the lack of the hormone vasopressin). 

Other symptoms, due to the loss of pituitary gland function, may include menstrual problems and breast discharge in women, changes in the face, hands, and feet, hypertension, decreased libido, infertility in both women and men, sweating, increased hairiness, gigantism in children or adolescents, fragile skin, stretch marks, and osteoporosis. 

Key figures for the treatment of a pituitary adenoma

As mentioned, diagnosing pituitary adenoma is not easy. The patient must describe their symptoms as precisely as possible and any family history of similar cases. Based on this information, the doctor may prescribe: blood and urine tests to analyze hormone levels and subsequently a CT scan and an MRI to detect any lesions. If the symptoms also involve the visual field, a vision assessment exam.

Dealing with this pathology is therefore a team play, in which each subject involved is essential:

- the patient, who is always at the center of the whole process with his personal and clinical history

- the doctor which has an important coordinating role

- L 'endocrinologist, contact person for diagnosis, monitoring and treatment of the pathology

- the neuroradiologist, expert in the diagnostic study of the nervous system

- L 'oculist, a reference point for screening, diagnosis and monitoring of eye disorders

- the neurosurgeon, which treats the pathology through surgical removal

Treatment of pituitary adenoma: the surgery

The therapy involves surgery in most cases, with the exception of small adenomas that secrete prolactin or growth hormone, which can be treated with specific drugs. The evolution of technology and skills in this field has made a type of intervention possible minimally invasive very effective: the transnasal transsphenoidal endoscopic surgery.

See the GVM News of April 04, 2021: Pituitary Adenoma 

Pituitary adenoma and endonasal endoscopy