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CT-Scan Guided Gasserian Ganglion Injection of Dexamethasone
and Lidocaine for the Treatment of Recalcitrant Pain Associated with HSV-1
Infection of the Ophthalmic Division of the Trigeminal Nerve
K. D. Candido, MD, A. Germanovich, DO, R. F. Ghaly MD, G. Gorelick, MD*, N. N. Knezevic, MD, PhD
Department of Anesthesiology, *Department of Radiology Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA
Case Description
Abstract
We describe the case of a 17-year old
boy with dermatologic Herpes Simplex
Virus type-1 (HSV-1) outbreaks with
incapacitating facial pain requiring
multiple hospitalizations. He failed to
respond to aggressive treatments
including
antiviral
drugs,
opioid
analgesics, stellate ganglion, supraorbital and supra-trochlear nerve blocks.
The patient elected to undergo
dexamethasone
and
lidocaine
Gasserian ganglion block under CTscan guidance. He had immediate and
complete relief of his pain for the first
time in almost two years. The patient
remained pain free during 6 month
follow-up visits. This is the first reported
use of Gasserian ganglion block for
treatment of HSV-1 infection of the
trigeminal nerve.
• 17 yo boy with dermatologic HSV-1
outbreaks with incapacitating facial pain
requiring multiple hospitalizations
• Diagnosed with HSV-1, and treated with
acyclovir and valacyclovir
• Pain was unresponsive to interventional
therapies including stellate ganglion,
supra-orbital and supra-trochlear nerve
blocks
• Pain regimens included acetaminophen,
Naproxen,
Tramadol,
Pregabalin,
hydromorphone
IV,
amitriptyline,
topiramate, topical lidocaine 5% patch
and Capsaicin cream
• Presented to our Pain Clinic for persistent, unremitting pain, desperately seeking a long-term strategy to manage the pain
• Habituated to hydromorphone (8mg tablets every 3-4 hours), with minimal benefits
• Placed into the CT scanner in the supine position with the head and neck extended.
• Skin wheal approximately 3cm lateral to the angle of the mouth with 3mL of 0.5% ropivacaine, using a 27-G 1.5inch needle
• 25-G Whitacre-type subarachnoid needle with a curve at its distal tip
• Once the needle tip was located in the foramen ovale on the left side (Figures 1a, 2a and 3a), 0.5mL of Iopamidol-200 contrast
was injected (Figures 1b, 2b and 3b).
• Contrast outlined Meckel’s cave, depicting all three branches of the trigeminal nerve (Figure 2b).
• Noting the absence of CSF and w/out paresthesias, a total of 2mg of dexamethasone and 1mL of 1% lidocaine was subsequently
slowly injected (total volume 1.5mL).
• The needle was flushed with 0.5mL normal saline, was re-styletted, and was withdrawn.
• The patient tolerated the procedure well with no immediate side effects or complications.
• It was the first time in almost two years that he had absolutely no pain.
• Opioid medications were completely discontinued on the day of the procedure and were not reinstated.
• The patient followed up in our Pain Clinic
for 6 months and he remained pain free,
on no opioids whatsoever.
• He was able to complete his high school
senior year and earn a diploma.
Conclusions
Introduction
• Gasserian ganglion block for trigeminal
neuralgia was described by Harris in
19121
• These blocks have been performed for
managing facial pain associated with
herpes zoster (HZV)
• Literature search performed on
PubMed and Medline found no
references for using Gasserian ganglion
block in the treatment of HSV-1
infection.
• This is the first reported use of
Gasserian ganglion block for treatment
of HSV-1 infection of the trigeminal
nerve.
Figure 1. CT scan images – Sagittal view
A. Needle tip seen slightly above the level of foramen ovale (circled)
B. Magnified view of “A”- contrast opacifies Meckel’s cave (in
triangle)
Figure 2. CT scan images – Coronal view
A. Needle tip seen slightly above the level of foramen ovale (circled)
B. Magnified coronal view of “A”- High density contrast opacifies the
anterior aspect of the left Meckel’s cave. Vertical linear lucency
coursing through the Meckel’s cave likely represents V3 branch of
trigeminal nerve (double arrows), superior (arrowhead) and medial
(dotted arrow) impressions likely represent ophthalmic (V1) and
maxillary (V2) branches of the left trigeminal nerve. Other structures:
foramen ovale (*), clivus (1) and vertical ramus of the mandible (2)
Figure 3. CT scan images - Axial view
A. A needle tip seen slightly above the level of foramen ovale (circled)
B. Magnified view of “A” - Contrast opacifies Meckel’s cave. Horizontal linear
lucency coursing through midaspect of contrast collection likely represents V2
branch of trigeminal nerve (arrow). Left petrous tip (*).
• This is the first case report of Gasserian
ganglion injection for recalcitrant pain due
to HSV-1 infection of the trigeminal nerve
under CT-guidance.
• We believe that Gasserian ganglion
injection of dexamethasone with lidocaine
may be useful in the treatment of HSV-1
infections of the trigeminal nerve in select
individuals suffering from recurrent severe
pain, who have failed to demonstrate a
response to non-interventional therapies.
References
1. Harris W. Proc R Soc Med 1912; 5: 115-119
2. Kikuchi A, et al. RAPM 1999; 24: 287-93
3. Kotani N, et al. NEJM 2000; 343: 1514-9