CLINICAL REPORT
Intracranial Hemorrhage After Percutaneous Radiofrequency Trigeminal Rhizotomy Girija P. Rath, MD, DM*; Hari H. Dash, MD*; Parmod K. Bithal, MD*; Vinay Goyal, MD, DM† *Department of Neuroanaesthesiology, and †Neurology, All India Institute of Medical Sciences, New Delhi, India
䊏 Abstract: Radiofrequency thermocoagulation (RFT) of trigeminal ganglion is a commonly performed percutaneous procedure for the management of trigeminal neuralgia. However, it is not free from potentially life-threatening complications. A case of intracranial hemorrhage following RFT, which was managed conservatively, is reported. The authors suggest that coagulation parameters be normalized and intra-procedural blood pressure controlled while performing this technique. As RFT is carried out as an ambulatory procedure, absence of any intracranial complication must be ascertained clinically before the patient is discharged. 䊏 Key Words: intracranial hemorrhage, radiofrequency thermocoagulation, trigeminal neuralgia
INTRODUCTION Percutaneous radiofrequency thermocoagulation (RFT) of trigeminal ganglion is one of the most common surgical treatments performed for trigeminal neuralgia.1 It typically is considered a low-risk procedure with high rate of efficacy in providing early pain relief.2 CompliAddress correspondence and reprint requests to: Dr. Girija Prasad Rath, MD, DM, Assistant Professor, Department of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi110029, India. E-mail:
[email protected]. Submitted: April 10, 2008; Accepted: August 6, 2008 DOI. 10.1111/j.1533-2500.2008.00246.x
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cations like corneal anesthesia (20%), keratitis (1–3%), facial numbness (10%), dysesthesia (5–25%), and anesthesia dolorosa (1–4%) may occur following this procedure.2,3 Other complications like masseter muscle weakness (4%), transient paralysis of cranial nerves III and IV (0.8%), meningitis (0.3%), and rarely even death have been reported.2,4,5 We report a case of intracranial hemorrhage (ICH) following RFT.
CASE REPORT A 40-year-old female patient with idiopathic trigeminal neuralgia (right side) was referred to our clinic for the management of pain. She received carbamazepine 900 mg/day and gabapentin 900 mg/day orally with minimal relief. Her medical history was otherwise unremarkable. RFT under fluoroscopic guidance was planned. Hertel’s technique6 was followed to place a standard 10 mm 20-gauge needle with stylet, into the trigeminal cistern. Proper placement of the tip was further confirmed by egress of cerebrospinal fluid (CSF) from the hub of the needle after the stylet was removed. An electrode carrying a thermocouple was inserted through the needle for stimulation and lesion generation in the affected divisions of the nerve (V2, V3). A total of five cycles of RFT were performed at both divisions of the nerve at a temperature ranging from 70°C to 90°C, for 60 seconds each. The procedure was performed under monitored anesthesia care (electrocardiogram,
Intracranial Hemorrhage after Trigeminal Rhizotomy • 83
heart rate, pulse oximetry, and noninvasive blood pressure) with the patient requiring intermittent boluses of fentanyl and propofol. The patient remained hemodynamically stable throughout the procedure, with the blood pressure fluctuating from a baseline value of 134/ 70 mm Hg to a maximum value of 158/88 mm Hg. Following the procedure, the patient reported complete pain relief with numbness in the affected region of the face. Ten minutes after the procedure, the patient complained of a “reeling” sensation and a severe headache on the affected side associated with repeated episodes of vomiting. The patient was examined by a neurologist, reassured, and managed symptomatically. She was afebrile, with no signs of meningitis. However, there was no relief of the disturbing new symptoms after 24 hours. Hence, a computed tomographic scan of the head was performed that revealed ICH in the temporal lobe, ipsilateral to the side of RFT lesioning (Figure 1). As there was no neurological deficit, the patient was kept under observation in hospital. She was managed conservatively with bed rest, intravenous mannitol and maintenance fluids. Her symptoms resolved after 24 hours. She was discharged on postoperative day 5 following an
Figure 1. Focal hemorrhage in the right temporal lobe.
otherwise uneventful hospital stay, with advice for follow-up.
DISCUSSION This case serves as a reminder that invasive procedures are not innocuous. Sweet and Poletti7 reviewed over 7,000 cases of trigeminal rhizotomy, most underwent RFT. Focal ICH was reported in 19 patients: 15 at sites unrelated with the needle placement. Only four patients had hemorrhage in the ipsilateral infratemporal area, which implies that ICH during RFT is not a common complication. In spite of technical ease of execution of this procedure, RFT may pose significant problems. Extratrigeminal complications may occur depending on the trajectory of needle insertion as it passes through the foramen ovale. When the angle is too steep, the needle tip may enter into the subarachnoid space, and even into the temporal lobe. Egress of CSF from needle hub at that point in the procedure does not necessarily mean that it is in Meckel’s cave as CSF may obviously flow from the subarachnoid space as well. When the needle position is too far posterior, it may enter into the brainstem. A needle position that is too medial may puncture the cavernous sinus and internal carotid artery.8 Moreover, arterial bleeding may occur as a result of damage to a tortuous carotid artery or an accessory meningeal artery traversing the foramen ovale.9 The possible mechanisms for intracranial bleeding resulting from percutaneous procedures of the trigeminal ganglion include direct vascular injury by a misplaced needle. The infratemporal veins are divided into a lateral group, which cannot be injured by a misplaced needle, and a medial group (formed by uncal, anterior hippocampal and medial temporal veins), which course along the medial edge of the temporal lobe. It is possible that one of these veins may be torn during RFT. Parenchymal disruption caused by the needle is another possible explanation. In the case presented, at no point in the procedure did the needle tip appear to stray from the desired location. We attribute the cause of ICH in this case to vascular injury. It has been emphasized that ICH occurring in patients undergoing percutaneous procedures are not always related to a vascular puncture.10 It can also be attributed to the use of anticoagulants or a bleeding tendency or to an abrupt arterial blood pressure rise during the procedure. Hence, assessment of the preoperative coagulation profile is recommended as most patients with trigeminal neuralgia are elderly and many
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are on drugs like aspirin or carbamazepine, contributing to an increased risk of bleeding. In our case, the patient received carbamazepine, however, preprocedural prothrombin time was normal. Hence, we ruled out deranged coagulation profile as a cause for ICH. It is equally important to control the abrupt rise in blood pressure, although the mechanism of its occurrence during heating of gasserian ganglion is not known. If not controlled, the sudden rise of blood pressure may result to ICH or even, ischemic cardiac complications. In conclusion, although a minimally invasive procedure, RFT may be complicated by ICH. Preoperative coagulation parameters should be normalized and intra-procedural blood pressure should be controlled while performing this technique. As RFT is carried out as an ambulatory day unit procedure, absence of any intracranial complication must be ascertained, albeit clinically, before the patient is discharged.
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