An Intra-Arterial Therapeutic Route to the Trigeminal Nerve Ganglion

Abstract

I read with interest the article by Qureshi et al. [1] in
January issue of Journal of Neuroimaging regarding
intra-arterial delivery of medication for suppressing trigeminal nerve ganglion function in patients with refractory trigeminal neuralgia. Intra-arterial route has not
been used for diagnostic or therapeutic purposes despite
nerves and nerve ganglions being supplied by segmental
arteries and the vasa nervorum. The investigators had
used intra-arterial lidocaine in doses up to 50 mg in the
middle meningeal artery territory adjacent to the arterial
branch that supplies the trigeminal nerve ganglion and
demonstrated short-term clinical improvement as anticipated. The artery of Qureshi [2] described earlier may
also be used for delivery of neurolysis agents such as
alcohol or antineoplastic agents with neurotoxic properties to the trigeminal nerve ganglion for more sustained
benefit in patients with refractory trigeminal neuralgia.
However, the artery of Qureshi does not appear large
enough for selective catheterization and microcatheter
has to be placed in the middle meningeal artery. Therefore, one must expect that certain amounts of injected
agents are going to be distributed in the petrosal artery
which courses posteriorly and anterior and posterior
dural branches of the intracranial division of middle
meningeal artery [2]. What remains to be identified is
whether there are adverse consequences of such a distribution with previously mentioned agents. The petrosal
branch of middle meningeal artery supplies the facial
nerve and anastomoses with the stylomastoid branch of
the posterior auricular artery and inadvertent delivery of
such agents may be of concern. Furthermore, most data
regarding arterial supply are derived from patients with
trigeminal neuralgia. Due to hyperactivity of the trigeminal nerve ganglion, the arterial supply may be more
pronounced with an enlargement of the artery of Qureshi. In normal persons, the artery may actually be
smaller. Additional studies would also have to clarify
whether the artery of Qureshi (to trigeminal nerve ganglion) can originate from other arteries such as accessory middle meningeal artery as part of normal variation
between individuals.