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DOI:10.2214/AJR.07.3025
AJR 2008; 191:578-581
© American Roentgen Ray Society

Clinical Observations

MRI of Glossopharyngeal Neuralgia Caused by Neurovascular Compression

Akio Hiwatashi1, Toshio Matsushima2, Takashi Yoshiura1, Atsuo Tanaka3, Tomoyuki Noguchi1, Osamu Togao1, Koji Yamashita1 and Hiroshi Honda1

1 Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
2 Department of Neurosurgery, Hamanomachi Hospital, Fukuoka, Japan.
3 Department of Radiology, Hamanomachi Hospital, Fukuoka, Japan.

Received August 14, 2007; accepted after revision February 4, 2008.

 
Address correspondence to A. Hiwatashi.


Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
OBJECTIVE. Glossopharyngeal neuralgia is rare but causes severe pain. We retrospectively evaluated preoperative MR images of patients with glossopharyngeal neuralgia caused by neurovascular compression.

CONCLUSION. MRI may be beneficial in patients with glossopharyngeal neuralgia and an offending compressing artery. If the offending vessel was the posterior inferior cerebellar artery (PICA), a loop formation at the supraolivary fossette was always seen, whereas if it was the anterior inferior cerebellar artery (AICA), glossopharyngeal neuralgia was difficult to diagnose before surgery.

Keywords: glossopharyngeal neuralgia • MRI • neurovascular compression


Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Glossopharyngeal neuralgia is characterized by severe, unilateral lancinating pain [1–21] and is a rare condition compared with trigeminal neuralgia [3]. Glossopharyngeal neuralgia can present as a severe paroxysmal pain of sudden onset in the oropharynx; the tonsillar fossa; or base of the tongue, the ear, or both locations; it is often precipitated by such activities as swallowing, chewing, or coughing [4]. It also can cause an unpleasant sensation in these areas, palatal myoclonus, syncope, and cardiac arrest [3, 5]. Glossopharyngeal neuralgia arises due to various causes such as tumor [1, 8], infection [3], Chiari I mal formation [6], infarction [9], dissection of the vertebral artery [7], or neurovascular compression [4, 10–15].

In cases of glossopharyngeal neuralgia with neurovascular compression, the most common offending vessel has been reported to be the posterior inferior cerebellar artery (PICA), followed by the vertebral artery, the anterior inferior cerebellar artery (AICA), and other vessels or combinations of vessels [11, 15]. The supraolivary fossette, which is the most medial portion of the cerebellopontomedullary angle and is close to the root entry zone of the glossopharyngeal nerve, is important for neurovascular decompression surgery [4, 22, 23]. Preoperative evaluation of glossopharyngeal neuralgia due to neurovascular compression is important; however, it is sometimes complex [16]. Schmitz et al. [17] and Huang et al. [23] previously proposed that 3D constructive interference in steady state (CISS) and 3D fast imaging with steady-state free precession (FISP) MR angiography may be useful for evaluating neurovascular contact of the root exit zone of the glossopharyngeal nerve, which is located in the supraolivary fossette. We report the MRI findings in patients with glossopharyngeal neuralgia due to neurovascular compression.


Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
Our study group consisted of 10 patients (six women and four men; age range, 43–71 years; mean age, 62 years) who underwent microvascular decompression surgery from April 1997 to October 2006. Six patients had severe pain on the left side, and the remaining four had right pharyngeal pain. All offending vessels were intraoperatively confirmed by a neurosurgeon. All patients achieved pain relief after surgery. The offending vessels were the PICA in eight patients and the AICA in two. No other vessels or combinations of offending vessels were seen.

Imaging Technique
MRI was performed on 1.5-T scanners (Magnetom Vision and Symphony, Siemens Medical Solutions). In addition to routine imaging studies, 3D CISS was performed in eight of our 10 patients. MR angiography was performed in all 10 patients, including six patients in whom 3D FISP was performed after the injection of 0.1 mmol/kg of contrast material ([gadopentetate dimeglumine] Magnevist, Nihon Schering [now Bayer Health-Care]). In addition, two patients underwent 3D FLASH sequences with contrast material. The remaining two patients underwent 3D time-of-flight MR angiography without contrast material. The imaging parameters were as follows: 3D CISS: Vision or Symphony system; TR range/TE range, 8.6–17/4.3–8; flip angle, 70°; field of view, 173–230 x 230 mm; matrix size, 192–512 x 512; slice thickness, 0.5–0.9 mm; acquisition time, 3 minutes 41 seconds; 3D FISP: Vision system; TR/TE, 40/6; flip angle, 40°; field of view, 150–175 x 200 mm; matrix size, 144–168 x 256; slice thickness, 0.9–1.0 mm; acquisition time, 5 minutes 2 seconds; 3D FLASH: Symphony system; 40/6; flip angle, 40°; field of view, 200 x 200 mm; matrix size, 256 x 256; slice thickness, 1.1 mm; acquisition time, 3 minutes 54 seconds; 3D TOF: Symphony system; 25/7; flip angle, 20°; field of view, 200 x 200 mm; matrix size, 230 x 256; slice thickness, 0.8 mm; acquisition time, 3 minutes 54 seconds.


Figure 1
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  		Fig. 1A —71-year-old woman with right pharyngeal pain. Coronal 3D constructive interference in steady state (CISS) image reveals right posterior inferior cerebellar artery (PICA, arrows) in contact with right glossopharyngeal nerve (large arrowhead) at supraolivary fossette (small arrowhead).

 


Figure 2
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  		Fig. 1B —71-year-old woman with right pharyngeal pain. Coronal 3D CISS image anterior to A reveals course of right PICA (arrow), right glossopharyngeal nerve (large arrowhead), and location of supraolivary fossette (small arrowhead).

 


Figure 3
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  		Fig. 1C —71-year-old woman with right pharyngeal pain. Coronal 3D CISS image on left (asymptomatic) side reveals left glossopharyngeal nerve (large arrowheads) at supraolivary fossette (small arrowhead). No vessel is in contact with this nerve at this location.

 


Figure 4
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  		Fig. 1D —71-year-old woman with right pharyngeal pain. Axial 3D CISS image reveals right glossopharyngeal nerve (large arrowhead) in contact with loop formed by right PICA (arrows) at supraolivary fossette. On left side, note PICA (arrow) that does not compress left glossopharyngeal nerve (small arrowhead).

 


Figure 5
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  		Fig. 1E —71-year-old woman with right pharyngeal pain. Axial 3D CISS image inferior to D reveals course of right glossopharyngeal nerve (small arrowhead) in contact with loop formed by right PICA (arrows). Normal left glossopharyngeal nerve (large arrowheads) is also seen.

 
Image Assessment
All MR images were viewed with the regular clinical window width and level settings. Contact of the glossopharyngeal nerve and the offending vessel was evaluated on 3D CISS images on both sides. Contact of the nerve and vessel was defined as the contiguity of the two structures. Visual assessment of the affected and the contralateral sides was performed.

The morphology of the offending vessels was analyzed on MR angiography. The diameter of the offending artery at its origin was visually assessed. The distance between the tip of the dens and the origin of the offending artery was measured, as was the corresponding distance on the contralateral side. Presence or absence of a loop of the offending artery at the supraolivary fossette was also assessed visually. All visual assessments were performed by two neuroradiologists in consensus and blinded to the symptomatic side.

Statistical Analysis
Statistical analysis was performed with commercially available software (SPSS for Windows, version 11; SPSS). The statistical significance of the distance between the tip of the dens and the origin of the artery was evaluated using Wilcoxon's signed rank test. A p value of less than 0.05 was considered statistically significant.


Figure 6
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  		Fig. 2 —67-year-old man with pain on left side of tongue. Three-dimensional CISS image reveals left anterior inferior cerebellar artery (AICA, arrow) near left glossopharyngeal nerve (large arrowhead). No abnormal vessel is seen near right glossopharyngeal nerve (small arrowhead).

 

Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
On 3D CISS, all offending arteries were found to be in contact with the root entry zone of the glossopharyngeal nerve. However, no similar relationship was seen on the contralateral side. The diameter of the offending vessel was larger than that of the corresponding artery on the contralateral side in eight of our 10 patients on visual assessment. The remaining two patients showed a similar diameter of the offending vessels. No offending artery was smaller than the corresponding artery on the contralateral side. In the PICA group, the distance between the dens and the origin of the offending artery was larger than the corresponding distance on the contralateral side in five of eight patients; however, no statistically significant difference (mean, 16.9 ± 3.1 [SD] mm vs 12.4 ± 5.9 mm; p = 0.12) was seen. No trends were identified in the location of the offending artery in the AICA group. A vascular loop around the supraolivary fossette on the affected side was noted in all eight PICA patients (Figs. 1A, 1B, 1C, 1D, and 1E), but no such loop was seen on the contralateral side. In the AICA group, one patient showed the artery passing the glossopharyngeal nerve near the supraolivary fossette without forming a loop (Fig. 2), and the other showed no vessel at the supraolivary fossette on MRI. The MRI protocol, clinical findings, surgical results, and follow-up in the 10 patients are listed in Table 1.


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  		TABLE 1: MRI Protocol, Clinical Findings, Surgical Results, and Follow-Up in 10 Patients with Glossopharyngeal Neuralgia

 


Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
In this study, all offending arteries were found to be in contact with the root entry zone of the glossopharyngeal nerve on 3D CISS. This observation is consistent with previous case reports, which show microvascular compression of the glossopharyngeal nerve by the PICA on CISS or high-resolution T2-weighted images [18–20]. To our knowledge, this study is the first imaging study to report glossopharyngeal neuralgia caused by the AICA.

In our case series, the diameter of the offending vessel was larger than or similar to that of the corresponding vessel on the contralateral side. Laha and Jannetta [4] have reported that the glossopharyngeal nerve is compressed by a tortuous artery in patients with glossopharyngeal neuralgia. Brihaye et al. [2] have also reported glossopharyngeal neuralgia caused by an atheromatous, tortuous vertebral artery that was larger than on the contralateral side. In addition, Kondo [12] has reported that the distorted vertebral artery and the PICA can compress the rootlet of the glossopharyngeal nerve. We did not evaluate the vertebral artery in this study because it was not the offending vessel in any of our patients. However, we believe that our results are consistent with these previous studies [2, 4, 12].

The supraolivary fossette is the most medial portion of the cerebellopontomedullary angle [22, 23], and the rootlet of the glossopharyngeal nerve is located at this fossette [23]. However, in normal anatomy, there is no contact between the glossopharyngeal nerve and adjacent major vessels [24–27]. Lister et al. [24] have reported that in their series of 42 PICAs in 50 cerebellar hemispheres of cadavers, only two passed between the glossopharyngeal and vestibulo-cochlear nerves, and one passed between the glossopharyngeal and vagus nerves; the remaining 39 PICAs did not reach the level of the glossopharyngeal nerve. In our study, we found a characteristic vascular loop around the supraolivary fossette in the PICA group. These findings may represent the possibility of the vascular loop at this fossette being an offending vessel in cases of glossopharyngeal neuralgia. Childs et al. [21] have also reported a case of glossopharyngeal neuralgia caused by a looping PICA compressing the glossopharyngeal nerve.

The AICA usually divides into the caudal and rostral trunks [27], and the caudo medial trunk normally passes the supraolivary fossette [22]. In our study, we identified no abnormal configuration at this fossette in the AICA group, nor did we observe any difference in the location of the origin of the offending AICA in the two cases.

One limitation of this study was the qualitative analysis of the diameter of the artery. We initially attempted quantitative assessment; however, it failed because of the small size of the artery and a measurement error on a 1.5-T imager. Investigation using higher-resolution MRI might be needed. In addition, the design of this study may have caused a selection bias. We operated on patients with glossopharyngeal neuralgia and retrospectively evaluated their MR images; however, it is possible that neurovascular contact with the glossopharyngeal nerve may exist in asymptomatic subjects. We did not perform surgery on all the patients with glossopharyngeal neuralgia in whom conservative treatment had failed, which may have resulted in underestimation of those whose causes were neurovascular compression. A prospective MRI evaluation of patients with and without glossopharyngeal neuralgia remains to be performed.

In conclusion, MRI may be beneficial in patients with glossopharyngeal neuralgia and an offending compressing artery. Three-dimensional CISS and MR angiography may be used to visualize the offending artery. In our study, if the offending vessel was the PICA, a loop at the supraolivary fossette was always seen; however, if the AICA was the cause, glossopharyngeal neuralgia was difficult to diagnose before surgery because of its normal anatomy.


References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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