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Research ArticleHead and Neck Imaging

Role of MR Neurography for the Diagnosis of Peripheral Trigeminal Nerve Injuries in Patients with Prior Molar Tooth Extraction

R. Dessouky, Y. Xi, J. Zuniga and A. Chhabra
American Journal of Neuroradiology November 2017, DOI: https://doi.org/10.3174/ajnr.A5438
R. Dessouky
aFrom the Departments of Radiology (R.D., Y.X., A.C.)
cDepartment of Radiodiagnosis (R.D.), Faculty of Medicine, Zagazig University, Zagazig, Egypt.
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Y. Xi
aFrom the Departments of Radiology (R.D., Y.X., A.C.)
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J. Zuniga
bOral and Maxillofacial Surgery (J.Z.), University of Texas Southwestern Medical Center, Dallas, Texas
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A. Chhabra
aFrom the Departments of Radiology (R.D., Y.X., A.C.)
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  • Fig 1.
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    Fig 1.

    A, MIP coronal 3D PSIF image showing class II injury to the right IAN with mild increase in caliber (less than 50% of the left) and signal intensity of the right IAN (long arrow) in comparison with a normal left inferior alveolar nerve (short arrow). B, Sagittal reconstruction MIP 3D PSIF image showing increase in caliber and signal intensity of the right IAN (long arrow) proximal to injury site (arrowhead). C, Normal uniform caliber and signal intensity of the left IAN (short arrow).

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    Fig 2.

    A and B, MIP 3D coronal PSIF images show a hyperintense left LN (long arrow) with a 3-mm neuroma in continuity (demarcated by 3 arrowheads) compatible with class IV injury. C and D, Sagittal reconstructions show the abnormal left LN neuroma (demarcated by 3 arrowheads) compared with a normal right LN (short arrow).

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    Fig 3.

    Coronal 3D PSIF images showing A, localization of the site of the LN and IAN (short and long arrows, respectively) and B, signal intensity measurements on both sides.

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    Fig 4.

    A, MIP 3D PSIF coronal image shows class IV/V injury of the left LN with excessive granulation and possible discontinuity of its distal end (long arrow). B, On surgery, it was also called class IV/V injury (arrow) with excessive scarring and granulation tissue and was resected. The final gap was 16 mm (C) and an allograft was placed for nerve reconstruction.

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    Fig 5.

    κ correlations for A, MRN versus NST and B, MRN versus surgical classifications.

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    Fig 6.

    Differences in thickness, T2SIR, and CNR among the case and control groups.

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    Fig 7.

    ROC curves for A, IAN and B, LN.

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    Fig 8.

    Correlations between differences in nerve thickness on MRN versus NST (A) and surgery (B).

Tables

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    Table 1:

    Clinical NST for trigeminal neuropathya

    Level A: Spatiotemporal Sensory Perception Direction Sensitivity <90% Static 2-Point Discrimination <18 mmLevel B: Contact Detection with Monofilament <2.83Level C: Pain Threshold and Tolerance Heat Temperature Threshold <47 Heat Temperature Tolerance <50 Pressure Pain Threshold <1.5 lb. Pressure Pain Tolerance <2.0 lb.
    NormalPresentPresentPresent
    MildFailedPresentPresent
    ModerateFailedFailedPresent
    SevereFailedFailedElevated
    CompleteFailedFailedAbsent
    • ↵a Present: values recorded at test and control sites exhibit comparable sensitivity within published normative range. Failed: values recorded at test site sensitivity are less than that of control sites or published normative range. Elevated: values recorded at test site sensitivity are greater than that of control sites or published normative range but below maximum of test device (ie, 6 lbs.). Absent: values recorded at test site sensitivity are greater that maximum of test device (ie, 6 lbs.).

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    Table 2:

    Criteria for stratifying of nerve injuries on MRN and surgery based on Sunderland classification

    ClassMRNSurgical
    IQualitative: Homogeneous increased T2 signal of nerve with no change in caliberIntact with no internal or external fibrosis, normal mobility and neuroarchitecture (visualize fascicles and Fanconi bands)
    Quantitative: No changes
    IIQualitative: Homogeneous increased T2 signal of nerve and mild nerve thickening Perineural fibrosisIntact with no internal fibrosis with external fibrosis, restricted mobility but neuroarchitecture intact (visualized fascicles and Fanconi bands once external scar removed)
    Quantitative: <50% larger than contralateral /normal nerve
    IIIQualitative: Homogeneous increased T2 signal of nerve and moderate to marked nerve thickening Perineural fibrosisIntact with both internal and external fibrosis, restricted mobility and disturbance of neuroarchitecture (abnormal fascicle patterns and/or Fanconi bands not visible)
    Quantitative: >50% larger than contralateral/normal nerve
    IVQualitative: Heterogeneous increased T2 signal of nerve and focal enlargement in otherwise continuous nerve (neuroma in continuity) Perineural and intraneural fibrosisPartial transected nerve, but some amount of distal nerve present with or without lateral neuroma
    Quantitative: Focal swelling with heterogeneous T2 signal or fascicular disruption
    VQualitative: Discontinuous nerve with end-bulb neuromaCompletely transected nerve with or without amputation (end-bulb) neuroma
    Quantitative: Complete disruption with gap and end-bulb neuroma
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    Table 3:

    Differences in thickness, T2SIR, and CNR among the case and control groups

    NerveGroupThicknessT2SIRCNR
    Mean DifferenceSDP ValueMean DifferenceSDP ValueMean DifferenceSDP Value
    IANCases0.600.33.013.151.91.0126.534.00.01
    Controls0.220.201.341.092.201.89
    LNCases0.870.34.00014.583.40.0056.934.89.01
    Controls0.110.121.921.513.373.81
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Cite this article
R. Dessouky, Y. Xi, J. Zuniga, A. Chhabra
Role of MR Neurography for the Diagnosis of Peripheral Trigeminal Nerve Injuries in Patients with Prior Molar Tooth Extraction
American Journal of Neuroradiology Nov 2017, DOI: 10.3174/ajnr.A5438

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Role of MR Neurography for the Diagnosis of Peripheral Trigeminal Nerve Injuries in Patients with Prior Molar Tooth Extraction
R. Dessouky, Y. Xi, J. Zuniga, A. Chhabra
American Journal of Neuroradiology Nov 2017, DOI: 10.3174/ajnr.A5438
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