13.1.1.2.3 Trigeminal neuralgia attributed to other cause

Identification: Female patient, 41 years old, with paroxysmal facial pain for 9 months.

History of Present Illness:
Pain:

Location: Right V3 (mandibular)

Characteristic:

Paroxysms like "electric shock" (2-60 seconds)

Intensity 10/10

Frequency: 10-40 episodes/day

Triggers:

Chewing (especially hard foods)

Shaving

Associated symptoms:

Ipsilateral pulsatile tinnitus

Episodes of positional vertigo

Physical/Neurological Examination:
Trigeminal assessment:

Trigger area: right chin (1cm²)

Decreased masseter reflex

Preserved sensitivity

Craniofacial auscultation:

Bruits in the right mastoid/temporal region

Special maneuvers:

Valsalva maneuver exacerbated the pain

Complementary Exams:
3T MR Angiography:

Dural arteriovenous fistula of the occipital artery with drainage to the trigeminal venous plexus

Dilation of the inferior petrosal sinus

Cerebral angiography:

Pathological shunt with reflux into the veins of the Gasserian ganglion

Otological evaluation:

Normal otoacoustic emissions