A0020 An Unusual Case of Acute Trigeminal Neuralgia Attack Precipitating Acute Heart Failure and Subsequent Anesthetic Management

Background: Trigeminal neuralgia is a neuropathic pain disorder characterized by episodes of paroxysmal electric shock-like pain in the distribution of one or more divisions of trigeminal nerve. Cardiac symptoms like syncope associated with trigeminal neuralgia have been reported before. We report a case of patient whose acute trigeminal neuralgia attack precipitated an acute heart failure.

Case Description: An 82-year-old woman was posted for microvascular decompression (MVD) of trigeminal nerve for trigeminal neuralgia. Her past medical history included hypertension and mild mitral regurgitation. The preoperative investigations, including 2D echo, were essentially normal. Two days before the surgery, patient developed acute exacerbation of trigeminal neuralgia and within 2 hours developed breathlessness which was due to an acute left ventricular failure. Echo revealed LVEF of 34% with severe systolic dysfunction and severe MR. She was appropriately treated in CCU. Later she was reviewed by a neurosurgeon and anesthetist. The decision was taken to change her treatment from MVD to percutaneous balloon compression (PBC) of TGN.

PBC involves cannulation of the foramen ovale, followed by inflation of a Fogarty balloon in Meckel's cave under fluoroscopic guidance to damage retrogasserian trigeminal fibers. It is a short-duration, minimally invasive procedure done as a day care case under GA. Trigeminal neuralgia attacks are amongst the most painful conditions known. Acute pain can cause activation of sympathetic nervous system and increased catecholamine levels resulting in increased cardiac work. It also causes activation of the renin-angiotensin-aldosterone system leading to fluid retention and overload.

Conclusions: Cardiac symptoms are very rare manifestations of trigeminal neuralgia. Balloon compression of trigeminal nerve is an important and useful treatment option for patients with trigeminal neuralgia in elderly and frail people when other forms of more invasive treatments are not suitable.