This document discusses trigeminal neuralgia, a disorder characterized by severe facial pain caused by problems with the trigeminal nerve. It defines classic and symptomatic trigeminal neuralgia and outlines their symptoms and diagnostic criteria. Treatment options discussed include medications like carbamazepine and baclofen as well as surgical interventions like radiofrequency lesioning, microvascular decompression, and gamma knife radiation. The goal of treatment is to provide relief from the debilitating pain attacks associated with this condition.
Trigeminal neuralgia is sudden, severe facial pain. It's often described as a sharp shooting pain or like having an electric shock in the jaw, teeth or gums.
Trigeminal neuralgia
Contents
Overview
Symptoms
Causes
Diagnosis
Treatment
Trigeminal neuralgia is a truly agonizing condition, in which the patient may clutch the hand over the face and experience severe, laneinating pain associated with spasmodie contractions of the facial muscles during attacks afeature that led to the use of the term (its archaie name ) “Tie Douloureux” (Painful jerking).
Are the X-Men Marvel or DC An In-Depth Exploration.pdfXtreame HDTV
The world of comic books is vast and filled with iconic characters, gripping storylines, and legendary rivalries. Among the most famous groups of superheroes are the X-Men. Created in the early 1960s, the X-Men have become a cultural phenomenon, featuring in comics, animated series, and blockbuster movies. A common question among newcomers to the comic book world is: Are the X-Men Marvel or DC? This article delves into the history, creators, and significant moments of the X-Men to provide a comprehensive answer.
Skeem Saam in June 2024 available on ForumIsaac More
Monday, June 3, 2024 - Episode 241: Sergeant Rathebe nabs a top scammer in Turfloop. Meikie is furious at her uncle's reaction to the truth about Ntswaki.
Tuesday, June 4, 2024 - Episode 242: Babeile uncovers the truth behind Rathebe’s latest actions. Leeto's announcement shocks his employees, and Ntswaki’s ordeal haunts her family.
Wednesday, June 5, 2024 - Episode 243: Rathebe blocks Babeile from investigating further. Melita warns Eunice to stay clear of Mr. Kgomo.
Thursday, June 6, 2024 - Episode 244: Tbose surrenders to the police while an intruder meddles in his affairs. Rathebe's secret mission faces a setback.
Friday, June 7, 2024 - Episode 245: Rathebe’s antics reach Kganyago. Tbose dodges a bullet, but a nightmare looms. Mr. Kgomo accuses Melita of witchcraft.
Monday, June 10, 2024 - Episode 246: Ntswaki struggles on her first day back at school. Babeile is stunned by Rathebe’s romance with Bullet Mabuza.
Tuesday, June 11, 2024 - Episode 247: An unexpected turn halts Rathebe’s investigation. The press discovers Mr. Kgomo’s affair with a young employee.
Wednesday, June 12, 2024 - Episode 248: Rathebe chases a criminal, resorting to gunfire. Turf High is rife with tension and transfer threats.
Thursday, June 13, 2024 - Episode 249: Rathebe traps Kganyago. John warns Toby to stop harassing Ntswaki.
Friday, June 14, 2024 - Episode 250: Babeile is cleared to investigate Rathebe. Melita gains Mr. Kgomo’s trust, and Jacobeth devises a financial solution.
Monday, June 17, 2024 - Episode 251: Rathebe feels the pressure as Babeile closes in. Mr. Kgomo and Eunice clash. Jacobeth risks her safety in pursuit of Kganyago.
Tuesday, June 18, 2024 - Episode 252: Bullet Mabuza retaliates against Jacobeth. Pitsi inadvertently reveals his parents’ plans. Nkosi is shocked by Khwezi’s decision on LJ’s future.
Wednesday, June 19, 2024 - Episode 253: Jacobeth is ensnared in deceit. Evelyn is stressed over Toby’s case, and Letetswe reveals shocking academic results.
Thursday, June 20, 2024 - Episode 254: Elizabeth learns Jacobeth is in Mpumalanga. Kganyago's past is exposed, and Lehasa discovers his son is in KZN.
Friday, June 21, 2024 - Episode 255: Elizabeth confirms Jacobeth’s dubious activities in Mpumalanga. Rathebe lies about her relationship with Bullet, and Jacobeth faces theft accusations.
Monday, June 24, 2024 - Episode 256: Rathebe spies on Kganyago. Lehasa plans to retrieve his son from KZN, fearing what awaits.
Tuesday, June 25, 2024 - Episode 257: MaNtuli fears for Kwaito’s safety in Mpumalanga. Mr. Kgomo and Melita reconcile.
Wednesday, June 26, 2024 - Episode 258: Kganyago makes a bold escape. Elizabeth receives a shocking message from Kwaito. Mrs. Khoza defends her husband against scam accusations.
Thursday, June 27, 2024 - Episode 259: Babeile's skillful arrest changes the game. Tbose and Kwaito face a hostage crisis.
Friday, June 28, 2024 - Episode 260: Two women face the reality of being scammed. Turf is rocked by breaking
Trigeminal neuralgia is sudden, severe facial pain. It's often described as a sharp shooting pain or like having an electric shock in the jaw, teeth or gums.
Trigeminal neuralgia
Contents
Overview
Symptoms
Causes
Diagnosis
Treatment
Trigeminal neuralgia is a truly agonizing condition, in which the patient may clutch the hand over the face and experience severe, laneinating pain associated with spasmodie contractions of the facial muscles during attacks afeature that led to the use of the term (its archaie name ) “Tie Douloureux” (Painful jerking).
Are the X-Men Marvel or DC An In-Depth Exploration.pdfXtreame HDTV
The world of comic books is vast and filled with iconic characters, gripping storylines, and legendary rivalries. Among the most famous groups of superheroes are the X-Men. Created in the early 1960s, the X-Men have become a cultural phenomenon, featuring in comics, animated series, and blockbuster movies. A common question among newcomers to the comic book world is: Are the X-Men Marvel or DC? This article delves into the history, creators, and significant moments of the X-Men to provide a comprehensive answer.
Skeem Saam in June 2024 available on ForumIsaac More
Monday, June 3, 2024 - Episode 241: Sergeant Rathebe nabs a top scammer in Turfloop. Meikie is furious at her uncle's reaction to the truth about Ntswaki.
Tuesday, June 4, 2024 - Episode 242: Babeile uncovers the truth behind Rathebe’s latest actions. Leeto's announcement shocks his employees, and Ntswaki’s ordeal haunts her family.
Wednesday, June 5, 2024 - Episode 243: Rathebe blocks Babeile from investigating further. Melita warns Eunice to stay clear of Mr. Kgomo.
Thursday, June 6, 2024 - Episode 244: Tbose surrenders to the police while an intruder meddles in his affairs. Rathebe's secret mission faces a setback.
Friday, June 7, 2024 - Episode 245: Rathebe’s antics reach Kganyago. Tbose dodges a bullet, but a nightmare looms. Mr. Kgomo accuses Melita of witchcraft.
Monday, June 10, 2024 - Episode 246: Ntswaki struggles on her first day back at school. Babeile is stunned by Rathebe’s romance with Bullet Mabuza.
Tuesday, June 11, 2024 - Episode 247: An unexpected turn halts Rathebe’s investigation. The press discovers Mr. Kgomo’s affair with a young employee.
Wednesday, June 12, 2024 - Episode 248: Rathebe chases a criminal, resorting to gunfire. Turf High is rife with tension and transfer threats.
Thursday, June 13, 2024 - Episode 249: Rathebe traps Kganyago. John warns Toby to stop harassing Ntswaki.
Friday, June 14, 2024 - Episode 250: Babeile is cleared to investigate Rathebe. Melita gains Mr. Kgomo’s trust, and Jacobeth devises a financial solution.
Monday, June 17, 2024 - Episode 251: Rathebe feels the pressure as Babeile closes in. Mr. Kgomo and Eunice clash. Jacobeth risks her safety in pursuit of Kganyago.
Tuesday, June 18, 2024 - Episode 252: Bullet Mabuza retaliates against Jacobeth. Pitsi inadvertently reveals his parents’ plans. Nkosi is shocked by Khwezi’s decision on LJ’s future.
Wednesday, June 19, 2024 - Episode 253: Jacobeth is ensnared in deceit. Evelyn is stressed over Toby’s case, and Letetswe reveals shocking academic results.
Thursday, June 20, 2024 - Episode 254: Elizabeth learns Jacobeth is in Mpumalanga. Kganyago's past is exposed, and Lehasa discovers his son is in KZN.
Friday, June 21, 2024 - Episode 255: Elizabeth confirms Jacobeth’s dubious activities in Mpumalanga. Rathebe lies about her relationship with Bullet, and Jacobeth faces theft accusations.
Monday, June 24, 2024 - Episode 256: Rathebe spies on Kganyago. Lehasa plans to retrieve his son from KZN, fearing what awaits.
Tuesday, June 25, 2024 - Episode 257: MaNtuli fears for Kwaito’s safety in Mpumalanga. Mr. Kgomo and Melita reconcile.
Wednesday, June 26, 2024 - Episode 258: Kganyago makes a bold escape. Elizabeth receives a shocking message from Kwaito. Mrs. Khoza defends her husband against scam accusations.
Thursday, June 27, 2024 - Episode 259: Babeile's skillful arrest changes the game. Tbose and Kwaito face a hostage crisis.
Friday, June 28, 2024 - Episode 260: Two women face the reality of being scammed. Turf is rocked by breaking
Meet Crazyjamjam - A TikTok Sensation | Blog EternalBlog Eternal
Crazyjamjam, the TikTok star everyone's talking about! Uncover her secrets to success, viral trends, and more in this exclusive feature on Blog Eternal.
Source: https://blogeternal.com/celebrity/crazyjamjam-leaks/
Maximizing Your Streaming Experience with XCIPTV- Tips for 2024.pdfXtreame HDTV
In today’s digital age, streaming services have become an integral part of our entertainment lives. Among the myriad of options available, XCIPTV stands out as a premier choice for those seeking seamless, high-quality streaming. This comprehensive guide will delve into the features, benefits, and user experience of XCIPTV, illustrating why it is a top contender in the IPTV industry.
Hollywood Actress - The 250 hottest galleryZsolt Nemeth
Hollywood Actress amazon album eminent worldwide media, female-singer, actresses, alhletina-woman, 250 collection.
Highest and photoreal-print exclusive testament PC collage.
Focused television virtuality crime, novel.
The sheer afterlife of the work is activism-like hollywood-actresses point com.
173 Illustrate, 250 gallery, 154 blog, 120 TV serie logo, 17 TV president logo, 183 active hyperlink.
HD AI face enhancement 384 page plus Bowker ISBN, Congress LLCL or US Copyright.
Panchayat Season 3 - Official Trailer.pdfSuleman Rana
The dearest series "Panchayat" is set to make a victorious return with its third season, and the fervor is discernible. The authority trailer, delivered on May 28, guarantees one more enamoring venture through the country heartland of India.
Jitendra Kumar keeps on sparkling as Abhishek Tripathi, the city-reared engineer who ends up functioning as the secretary of the Panchayat office in the curious town of Phulera. His nuanced depiction of a young fellow exploring the difficulties of country life while endeavoring to adjust to his new environmental factors has earned far and wide recognition.
Neena Gupta and Raghubir Yadav return as Manju Devi and Brij Bhushan Dubey, separately. Their dynamic science and immaculate acting rejuvenate the hardships of town administration. Gupta's depiction of the town Pradhan with an ever-evolving outlook, matched with Yadav's carefully prepared exhibition, adds profundity and credibility to the story.
New Difficulties and Experiences
The trailer indicates new difficulties anticipating the characters, as Abhishek keeps on wrestling with his part in the town and his yearnings for a superior future. The series has reliably offset humor with social editorial, and Season 3 looks ready to dig much more profound into the intricacies of rustic organization and self-awareness.
Watchers can hope to see a greater amount of the enchanting and particular residents who have become fan top picks. Their connections and the one of a kind cut of-life situations give a reviving and interesting portrayal of provincial India, featuring the two its appeal and its difficulties.
A Mix of Humor and Heart
One of the signs of "Panchayat" is its capacity to mix humor with sincere narrating. The trailer features minutes that guarantee to convey giggles, as well as scenes that pull at the heartstrings. This equilibrium has been a critical calculate the show's prosperity, resounding with crowds across different socioeconomics.
Creation Greatness
The creation quality remaining parts first rate, with the beautiful setting of Phulera town filling in as a scenery that upgrades the narrating. The meticulousness in portraying provincial life, joined with sharp composition and solid exhibitions, guarantees that "Panchayat" keeps on hanging out in the packed web series scene.
Expectation and Delivery
As the delivery date draws near, expectation for "Panchayat" Season 3 is at a record-breaking high. The authority trailer has previously created critical buzz, with fans enthusiastically anticipating the continuation of Abhishek Tripathi's excursion and the new undertakings that lie ahead in Phulera.
All in all, the authority trailer for "Panchayat" Season 3 recommends that watchers are in for another drawing in and engaging ride. Yet again with its charming characters, convincing story, and ideal mix of humor and show, the new season is set to enamor crowds. Write in your schedules and prepare to get back to the endearing universe of "Panchayat."
From Slave to Scourge: The Existential Choice of Django Unchained. The Philos...Rodney Thomas Jr
#SSAPhilosophy #DjangoUnchained #DjangoFreeman #ExistentialPhilosophy #Freedom #Identity #Justice #Courage #Rebellion #Transformation
Welcome to SSA Philosophy, your ultimate destination for diving deep into the profound philosophies of iconic characters from video games, movies, and TV shows. In this episode, we explore the powerful journey and existential philosophy of Django Freeman from Quentin Tarantino’s masterful film, "Django Unchained," in our video titled, "From Slave to Scourge: The Existential Choice of Django Unchained. The Philosophy of Django Freeman!"
From Slave to Scourge: The Existential Choice of Django Unchained – The Philosophy of Django Freeman!
Join me as we delve into the existential philosophy of Django Freeman, uncovering the profound lessons and timeless wisdom his character offers. Through his story, we find inspiration in the power of choice, the quest for justice, and the courage to defy oppression. Django Freeman’s philosophy is a testament to the human spirit’s unyielding drive for freedom and justice.
Don’t forget to like, comment, and subscribe to SSA Philosophy for more in-depth explorations of the philosophies behind your favorite characters. Hit the notification bell to stay updated on our latest videos. Let’s discover the principles that shape these icons and the profound lessons they offer.
Django Freeman’s story is one of the most compelling narratives of transformation and empowerment in cinema. A former slave turned relentless bounty hunter, Django’s journey is not just a physical liberation but an existential quest for identity, justice, and retribution. This video delves into the core philosophical elements that define Django’s character and the profound choices he makes throughout his journey.
Link to video: https://youtu.be/GszqrXk38qk
Tom Selleck Net Worth: A Comprehensive Analysisgreendigital
Over several decades, Tom Selleck, a name synonymous with charisma. From his iconic role as Thomas Magnum in the television series "Magnum, P.I." to his enduring presence in "Blue Bloods," Selleck has captivated audiences with his versatility and charm. As a result, "Tom Selleck net worth" has become a topic of great interest among fans. and financial enthusiasts alike. This article delves deep into Tom Selleck's wealth, exploring his career, assets, endorsements. and business ventures that contribute to his impressive economic standing.
Follow us on: Pinterest
Early Life and Career Beginnings
The Foundation of Tom Selleck's Wealth
Born on January 29, 1945, in Detroit, Michigan, Tom Selleck grew up in Sherman Oaks, California. His journey towards building a large net worth began with humble origins. , Selleck pursued a business administration degree at the University of Southern California (USC) on a basketball scholarship. But, his interest shifted towards acting. leading him to study at the Hills Playhouse under Milton Katselas.
Minor roles in television and films marked Selleck's early career. He appeared in commercials and took on small parts in T.V. series such as "The Dating Game" and "Lancer." These initial steps, although modest. laid the groundwork for his future success and the growth of Tom Selleck net worth. Breakthrough with "Magnum, P.I."
The Role that Defined Tom Selleck's Career
Tom Selleck's breakthrough came with the role of Thomas Magnum in the CBS television series "Magnum, P.I." (1980-1988). This role made him a household name and boosted his net worth. The series' popularity resulted in Selleck earning large salaries. leading to financial stability and increased recognition in Hollywood.
"Magnum P.I." garnered high ratings and critical acclaim during its run. Selleck's portrayal of the charming and resourceful private investigator resonated with audiences. making him one of the most beloved television actors of the 1980s. The success of "Magnum P.I." played a pivotal role in shaping Tom Selleck net worth, establishing him as a major star.
Film Career and Diversification
Expanding Tom Selleck's Financial Portfolio
While "Magnum, P.I." was a cornerstone of Selleck's career, he did not limit himself to television. He ventured into films, further enhancing Tom Selleck net worth. His filmography includes notable movies such as "Three Men and a Baby" (1987). which became the highest-grossing film of the year, and its sequel, "Three Men and a Little Lady" (1990). These box office successes contributed to his wealth.
Selleck's versatility allowed him to transition between genres. from comedies like "Mr. Baseball" (1992) to westerns such as "Quigley Down Under" (1990). This diversification showcased his acting range. and provided many income streams, reinforcing Tom Selleck net worth.
Television Resurgence with "Blue Bloods"
Sustaining Wealth through Consistent Success
In 2010, Tom Selleck began starring as Frank Reagan i
As a film director, I have always been awestruck by the magic of animation. Animation, a medium once considered solely for the amusement of children, has undergone a significant transformation over the years. Its evolution from a rudimentary form of entertainment to a sophisticated form of storytelling has stirred my creativity and expanded my vision, offering limitless possibilities in the realm of cinematic storytelling.
In the vast landscape of cinema, stories have been told, retold, and reimagined in countless ways. At the heart of this narrative evolution lies the concept of a "remake". A successful remake allows us to revisit cherished tales through a fresh lens, often reflecting a different era's perspective or harnessing the power of advanced technology. Yet, the question remains, what makes a remake successful? Today, we will delve deeper into this subject, identifying the key ingredients that contribute to the success of a remake.
From the Editor's Desk: 115th Father's day Celebration - When we see Father's day in Hindu context, Nanda Baba is the most vivid figure which comes to the mind. Nanda Baba who was the foster father of Lord Krishna is known to provide love, care and affection to Lord Krishna and Balarama along with his wife Yashoda; Letter’s to the Editor: Mother's Day - Mother is a precious life for their children. Mother is life breath for her children. Mother's lap is the world happiness whose debt can never be paid.
Scandal! Teasers June 2024 on etv Forum.co.zaIsaac More
Monday, 3 June 2024
Episode 47
A friend is compelled to expose a manipulative scheme to prevent another from making a grave mistake. In a frantic bid to save Jojo, Phakamile agrees to a meeting that unbeknownst to her, will seal her fate.
Tuesday, 4 June 2024
Episode 48
A mother, with her son's best interests at heart, finds him unready to heed her advice. Motshabi finds herself in an unmanageable situation, sinking fast like in quicksand.
Wednesday, 5 June 2024
Episode 49
A woman fabricates a diabolical lie to cover up an indiscretion. Overwhelmed by guilt, she makes a spontaneous confession that could be devastating to another heart.
Thursday, 6 June 2024
Episode 50
Linda unwittingly discloses damning information. Nhlamulo and Vuvu try to guide their friend towards the right decision.
Friday, 7 June 2024
Episode 51
Jojo's life continues to spiral out of control. Dintle weaves a web of lies to conceal that she is not as successful as everyone believes.
Monday, 10 June 2024
Episode 52
A heated confrontation between lovers leads to a devastating admission of guilt. Dintle's desperation takes a new turn, leaving her with dwindling options.
Tuesday, 11 June 2024
Episode 53
Unable to resort to violence, Taps issues a verbal threat, leaving Mdala unsettled. A sister must explain her life choices to regain her brother's trust.
Wednesday, 12 June 2024
Episode 54
Winnie makes a very troubling discovery. Taps follows through on his threat, leaving a woman reeling. Layla, oblivious to the truth, offers an incentive.
Thursday, 13 June 2024
Episode 55
A nosy relative arrives just in time to thwart a man's fatal decision. Dintle manipulates Khanyi to tug at Mo's heartstrings and get what she wants.
Friday, 14 June 2024
Episode 56
Tlhogi is shocked by Mdala's reaction following the revelation of their indiscretion. Jojo is in disbelief when the punishment for his crime is revealed.
Monday, 17 June 2024
Episode 57
A woman reprimands another to stay in her lane, leading to a damning revelation. A man decides to leave his broken life behind.
Tuesday, 18 June 2024
Episode 58
Nhlamulo learns that due to his actions, his worst fears have come true. Caiphus' extravagant promises to suppliers get him into trouble with Ndu.
Wednesday, 19 June 2024
Episode 59
A woman manages to kill two birds with one stone. Business doom looms over Chillax. A sobering incident makes a woman realize how far she's fallen.
Thursday, 20 June 2024
Episode 60
Taps' offer to help Nhlamulo comes with hidden motives. Caiphus' new ideas for Chillax have MaHilda excited. A blast from the past recognizes Dintle, not for her newfound fame.
Friday, 21 June 2024
Episode 61
Taps is hungry for revenge and finds a rope to hang Mdala with. Chillax's new job opportunity elicits mixed reactions from the public. Roommates' initial meeting starts off on the wrong foot.
Monday, 24 June 2024
Episode 62
Taps seizes new information and recruits someone on the inside. Mary's new job
2. Dr.Haris PS/OMR
Introduction
Disorder characterized by lancinating
attacks of severe facial pain
Diagnosis based primarily on a history of
characteristic pain attacks that are
consistent with specific research & clinical
criteria
3. Dr.Haris PS/OMR
In majority of patients, clinical exam-
ination, imaging and lab tests are
unremarkable – Classic TN
In a smaller group, signs & symptoms
secondary to another disease affecting the
trigeminal system – Symptomatic TN
4. Dr.Haris PS/OMR
Nicolas Andre, 1756
“Tic douloureux”
commented that it was exclusive &
distinctive from all other diseases
John Fothergill, 1773
outlined major clinical features, clearly
establishing the disorder as a discrete
syndrome
5. Dr.Haris PS/OMR
Epidemiology and Demographics
- Incidence of approx 4 in 100,000
Familial cases also reported
- Majority of cases occur spontaneously
- Slight female predominance
- Over age 50
6. Dr.Haris PS/OMR
- Pain typically consists of lancinating
paroxysms
- Mostly in Second & Third trigeminal
divisions
- Right side most often involved
- Pain attacks stereotyped
- Symptom free between attacks
- Chronic disorder, most patients will
experience pain attacks for years unless
appropriately treated
7. Dr.Haris PS/OMR
Etiology and Pathogenesis
Cause – not known
Injury to the nerve root – an initiating factor?
(Benign tumors and vascular anomalies
that compress the trigeminal nerve root
can produce symptoms clinically
indistinguishable from classic TN)
8. Dr.Haris PS/OMR
Based on the morphologic and physio-
logic changes following partial nerve injury,
Devor et al proposed “ignition hypothesis”.
A trigeminal injury induces physiologic
changes that result in a population of hyper-
excitable and functionally linked primary
sensory neurons. The discharge of any
individual neuron of this group can quickly
spread to activate the entire population.
Such a discharge could underlie the
sudden jolt of pain in TN attack.
9. Dr.Haris PS/OMR
Clinical Presentation and
Physical Findings
Diagnosis of TN based on distinctive signs &
symptoms.
White & Sweet articulated diagnostic criteria
for TN.
Consists of 5 major clinical features that
define the diagnosis of TN
10. Dr.Haris PS/OMR
Sweet diagnostic criteria
1. Pain is paroxysmal
2. The pain may be provoked by light touch
to the face (trigger zones)
3. The pain is confined to the trigeminal
distribution
4. The pain is unilateral
5. The clinical sensory examination is
normal
11. Dr.Haris PS/OMR
Patients who did not meet all the criteria
rarely benefited.
The Sweet criteria were incorporated into
the criteria published by IASP & IHS.
ICHD II (IHS) subdivides Trigeminal
Neuralgia (code 13.1) into,
- Classic TN (code 13.1.1)
- Symptomatic TN (code 13.1.2)
12. Dr.Haris PS/OMR
Classic TN (13.1.1)
Most common form- idiopathic, and also
associated with vascular compression.
“a unilateral disorder characterized by brief electric
shock-like pains, abrupt in onset and termination, limited
to the distribution of one or more divisions of trigeminal
nerve. Pain is commonly evoked by trivial stimuli
including washing, shaving, smoking, talking and/or
brushing the teeth (trigger factors) and frequently occurs
spontaneously. Small areas in the nasolabial fold and/or
chin may be particularly susceptible to the precipitation
of pain (trigger areas). The pains usually remit for
variable periods.”
13. Dr.Haris PS/OMR
ICHD Criteria for Classical TN (13.1.1)
A. Paroxysmal attacks of pain lasting from a fraction of a
second to 2 minutes, affecting one or more divisions of
the trigeminal nerve and fulfilling criteria B and C
B. Pain has at least one of the following characteristics:
1. intense, sharp, superficial or stabbing
2. precipitated from trigger areas or by trigger factors
C. Attacks are stereotyped in individual patient.
D. There is no clinically evident neurological deficit.
E. Not attribute to another disorder.
14. Dr.Haris PS/OMR
Symptomatic TN (13.1.2)
- Results from another disease process
(MS or a cerebellopontine angle tumor)
“Pain indistinguishable from 13.1.1
classic TN but caused by a demonstrable
structural lesion other than vascular
compression.”
15. Dr.Haris PS/OMR
ICHD Criteria for Symptomatic TN (13.1.2)
A. Paroxysmal attacks of pain lasting from a fraction of a
second to 2 minutes, with or without persistence of
aching between paroxysms, affecting one or more
divisions of trigeminal nerve and fulfilling criteria B and C.
B. Pain has at least one of the following characteristics:
1. Intense, sharp, superficial or stabbing
2. Precipitated from trigger areas or by trigger factors.
C. Attacks are stereotyped in individual patient.
D. A causative lesion, other than vascular compression, has
been demonstrated by special investigations and/or
posterior fossa exploration.
16. Dr.Haris PS/OMR
The pain of TN……
- Paroxysmal attacks
- Electric shock like quality
- Sudden onset & severe in intensity facial
grimace
- Duration btw 1 sec and 2 min
- Instantaneous electric shock sensation that’s
over in much less than a sec – ‘lightning bolt’
- Symptom free btw attacks.
17. Dr.Haris PS/OMR
Trigger zones……
A TN “trigger zone” is an area of facial skin or oral
mucosa where a low intensity mechanical
stimulation can elicit a typical pain attack.
- Only a few mm in size
- In perioral region
- First division trigger zones are very rare.
- Presence of trigger zone pathognomonic.
- May result from ephatic coupling btw partially
damaged trigeminal axons.
18. Dr.Haris PS/OMR
- Pain confined to trigeminal zone
- Most frequently in 3rd division
- Less frequently in 2nd or in both divisions
- Pain attacks are stereotyped
- Unilateral
- Bilateral in MS
- Clinical sensory examination is normal
19. Dr.Haris PS/OMR
Clinical evaluation
Diagnosis based on clinical history,
supplemented by physical examination
findings and cranial imaging studies.
Detailed intraoral examination to rule out
odontogenic and non odontogenic source
for the pain
Examination of CN V, VII & VIII
Symptomatic TN from a CPA mass often
shows facial weakness and hearing loss on
that side
20. Dr.Haris PS/OMR
Diagnostic testing
Diagnostic brain imaging to visualize
anatomic landmarks around trigeminal
ganglion and CPA
CT, MRI – to rule out CPA lesions and to
visualize subtle vascular anomalies
causing compression
21. Dr.Haris PS/OMR
Medical Management and
Treatment
TN unique – majority of patients respond to
treatment and may have total elimination
of pain attacks
22. Dr.Haris PS/OMR
Pharmacologic therapy
Primary drug therapy
Bergouignan, 1942 found that the
anticonvulsant phenytoin effectively
controlled attacks of TN
Similarity in mechanisms between epilepsy &
TN pain attacks.
23. Dr.Haris PS/OMR
Routine therapy begins with single agent, in
gradually increasing doses until pain
attacks are suppressed or satisfactorily
reduced.
Carbamazepine (CBZ)
Baclofen (BCF)
Lamotrigine (LTG)
24. Dr.Haris PS/OMR
CBZ superior to Phenytoin
CBZ monotherapy provides symptom control
in up to 80% patients
BCF equally effective, better tolerated
Others
- Clonazepam, Gabapentin, Topiramate,
Oxcarbazepine, Tiagabine, Levetiracetam
and Zonisamide.
25. Dr.Haris PS/OMR
Multiple drug therapy
- When a patient respond only partially to
single drug therapy at dosages that evoke
side effects……
- When patients do not satisfactorily respond
to 2 AED’s, they should be considered for
surgical interventions.
26. Dr.Haris PS/OMR
Surgical options
Highly effective and well tolerated
Cumulative risk of multiple pharmacological
agents may exceed the risk of surgical
complications, especially in the elderly
27. Dr.Haris PS/OMR
3 SURGICAL APPROACHES
1. Percutaneous stereotactic radiofrequency
thermal lesioning of the trigeminal ganglion
and/or root (RFL)
2. Posterior fossa exploration and microvascular
decompression (MVD) of the trigeminal root
3. Gamma knife radiation to the trigeminal root
entry zone (GKR)
Produce satisfactory relief of TN symptoms in 80 –
90% of patients. Incidence of complications is
low and specific for the technique employed.
28. Dr.Haris PS/OMR
1. RFL
- Produce mild injury to the sensory fibers
in the trigeminal root.
- Minimally invasive
- Controls symptoms in > 85% of patients
- Principal side effect – sensory loss and
occasional dysesthesia
29. Dr.Haris PS/OMR
2. Posterior fossa exploration and MVD
- More complex and invasive
- Directly treats the hypothetical cause
while minimizing any sensory damage
30. Dr.Haris PS/OMR
3. GKR
- Relatively recent
- Employs computerized stereotactic
methods to concentrate gamma radiation
on the trigeminal root entry zone
- Could be highly effective
- Long term benefits to be established
31. Dr.Haris PS/OMR
RFL for patients who are elderly or medically
frail.
Posterior fossa exploration and MVD for
younger healthier patients who can tolerate the
longer more invasive surgical procedure.
GKR as an alternative to RFL in frail or elderly
patients. MVD or RFL remains the standard for
surgical treatment of younger patients who have
considerable life expectancy
32. Dr.Haris PS/OMR
Conclusion
- Many fundamental questions about patho-
physiology of the disorder remain unanswered
- Development of drugs specific for TN
- Lack of objective testing remains as a problem
- fMRI – potential future diagnostic tool