Trigeminusneuralgie versus cluster hoofdpijn – pdf anoxic brain injury stories


16 -carbamazepine(stronger evidence) or oxcarbazepine(better tolerability) should be offered as first-line treatment for pain control -for patients with TN refractory to medical therapy early surgical therapy may be considered. Gasserian ganglion percutaneous techniques, gamma knife and microvascular decompression may be considered. -microvasculardecompression may be considered over other surgical techniques to provide the longest duration of pain freedom -the role of surgery versus pharmacotherapy in the management of TN in patients with multiple sclerosis remains uncertain

17 complications of surgery PGL: percutaneousgasserianlesions (includes radiofrequency thermocoagulation, glycerol rhizotomy, balloon compression) MVD: microvascular decompression GKS: gamma knife surgery.Anoxic brain injury stories

18 percutane interventies voor TN (1) microvascular decompression is considered the gold standard percutaneous techniques remain an effective option for some patients most common procedures: balloon compression (BC), glycerol rhizotomy (GR), and radiofrequency thermocoagulation (RF) no randomized clinical trial exists comparing the efficacy and long-term outcomes of these procedures atypical symptoms are negative predictor of long-term efficacy across all treatments patients with MS have higher recurrence rates and require more treatments

19 percutane interventies voor TN (2) BC selectively injures larger pain fibers while sparing small fibers (useful in va pain: sparing of the corneal reflex) does not require an awake, cooperative patient more often trigeminal depressor response (hypotension, bradycardia) pain relief inup to 91% at 6 months and 66% at 3 years patients unable to tolerate general anesthesia or those with significant cardiac histories are generally poor candidates dysesthesia in10% to 20%, severe numbness in 20% masseter weakness typically resolves within 12 months

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20 percutane interventies voor TN (3) RF T monitoring, short-acting anesthetic agents and electric stimulation with awake-patient feedback is needed to minimize side effects somatotopic nerve mapping and selective division lesioning pain relief in up to 97% initially and 58% at 5 years multiple treatments improve outcomes but carry significant morbidity risk masticatory weakness up to 29%, dysesthesia average3.7%, corneal numbness average 9.6%

21 percutane interventies voor TN (4) GR does not require an awake patient trigeminal depressor response in up to 20% contrast cisternogram and injection of glycerol in sitting position after injection patient remains sitting for 2 h to prevent leakage into the posterior fossa pain relief in up to 90% at 6 months and 54% at 3 years pain relief correlates with degree of numbness dysesthesias in 8.3%, corneal numbness in 8.1%, masseter weakness in 3.1%

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26 12 L/minuut gedurende 15 min non rebreathing mask JAMA 2009;302(22):



29 interventies voor (C)CH (1) infiltratie GON alfridi et al (pain 2006): 19 pt, lidocaine + steroid, ECH vs CCH 53% (10/19) complete pain free for mean 17 days 15% (3/19) 30% pain reduction ambrosini et al (pain 2005): 23 ECH / 7 CCH, lidocaine + steroid vs lidocaine 84% (11/13) at least 4 weeks complete pain relief 38% (5/13) 4 months leroux et al (lancet neurology 2011): 28 ECH / 15 CCH, 3 inject, steroid vs placebo steroid: mean 10,6 attacks first 15 days vs placebo: mean 30,3 attacks SPG block devoghel et al (acta anesthesiol. Belgica 1981) 85% (102/120) temporary pain relief

30 interventies voor (C)CH (2) SPG RFA sanders M et al. (J neurosurg. 1997), 56 ECH / 10 CCH, mth follow-up ECH: 60,7% complete relief, 25% partial(= from3.3 to 2.3 a/d) CCH: 30% complete relief, 30% partial relief (4 pt: 1 RF, 3 pt: 2 RF, 3 pt: 3 RF) a paroxysmal, slight, deep-seated, troublesome sensation in the orbitotemporalregion, com-binedwith parasympathetic symptoms, remained in some cases maxillary deafferentationpain (partial peripheral lesion of the maxillary nerve) was the major complication in 6.1% of patient because of the small number of patients in our study who suffered from chronic CH we will not make conclusive remarks concerning the efficacy of treatment in this subpopulation.Anoxic brain injury stories

31 interventies voor (C)CH (3) SPG RFA narouze set al. (headache. 2009), 15 CCH who responded to SPG blocks mean attack intensity and frequency was significantly reduced over 18 months 20% (3/15) headache-free for duration of follow-up (18-24 months) 46.7% (7/15) reported return to ECH at 18 months

32 interventies voor (C)CH (4) DBS 63 pt, 70% response, delay mean 42 days because of risk of transient ischemic attack (TIA), hemorrhage, stroke, and death, peripheral stimulators (ONS, SPG) should always be tried first ONS burns et al (neurology 2009): 14 CCH 21% (3/14) 90% improvement 21% (3/14) 40% improvement magis et al (headache 2011): 15 CCH 80% (11/15) 90% improvement 60% pain free periods 36% side shift SPG stimulation schydz et al (cephalgia 2013) 25%(7/28): pain relief in 50% of treated attacks 36%(10/28): 50 % reduction in attack frequency 7%(2/28): both