Facial Pain Case

[NOSfan]

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76 y/o M presented with 'double vision' and Left facial pain (V1, V2 and retro-orbital). CTA revealed b/l supraclinoid ICA fusiform aneurysms. Patient underwent coiling by IR with MRI below.

Exam shows OS ophthalmoplegia with minimal abduction, unable to open left eyelid (complete ptosis), dysthesia in Left V1 and V2, pupils are equal and some anhidrosis on the left forehead.

Consulted for procedural consideration secondary to intractable left facial pain unresponsive to neuromodulators and opioids...….If any, what is your intervention?

 

[Ligament]

76 y/o M presented with 'double vision' and Left facial pain (V1, V2 and retro-orbital). CTA revealed b/l supraclinoid ICA fusiform aneurysms. Patient underwent coiling by IR with MRI below.

Exam shows OS ophthalmoplegia with minimal abduction, unable to open left eyelid (complete ptosis), dysthesia in Left V1 and V2, pupils are equal and some anhidrosis on the left forehead.

Consulted for procedural consideration secondary to intractable left facial pain unresponsive to neuromodulators and opioids...….If any, what is your intervention?


View attachment 320052

Very interesting case thank you. If you want to start "conservatively", SGB, then SPG, then gasserian. Also make sure no significant upper cervical pain; TON can cause fairly severe pain in this region (not the other symptoms, but just pain. Could have concommitant refrerred facial pain from upper cervical pathology).

 

[chudat]

Gasserian in a patient with fusiform aneurysms? What does the post coiling cta look like?

 

[lobelsteve]

I did RF of V2 2 weeks ago for AVM. But surgeon asked if I would do rf ahead of possible surgery. All better now from pain standpoint.

 

[NOSfan]

Thank everyone for their reply.

Just a quick neuroanatomy review in the cartoon below.

The cavernous sinus houses CN III, CN IV, CN V 1st and 2nd division and CN VI as well as the sympathetics catching a ride on the internal carotid.

The patient has a flare of sympathetically mediated pain and exam somewhat consistent with such. Dysesthetic Left V1/V2 with intact gross sensory. There are features of Horner's dryness of left forehead and ptosis, but the latter could just be the insult to CN III. Against, sympathetically mediated pain are some features of Horner's; however, the patient has EQUAL pupils.

My plan is to have ophthalmology perform a topical Cocaine test on his OS and help verify if sympathetics are indeed intact. If so, then will move with SGB. If not, then will look at Trigeminal RFA at foramen ovale.