A Neurosurgeon Discusses Trigeminal Neuralgia, the ‘Suicide Disease’

WORDS LIM TECK CHOON

FEATURED EXPERT
DR SYED ABDULLAH AL-HADDAD
Consultant Neurosurgeon
Sunway Medical Centre

Trigeminal neuralgia, also known as the ‘suicide disease’ or tic douloureux, is a rare and agonizing condition. While it is considered a rare disease due to its low occurrence among us, it has gained notoriety due to celebrities such as George Clooney and Salma Hayek revealing that they suffer from it.

It is more prevalent among women as well as people over the age of 50.

FACTS ABOUT TRIGERMINAL NEURALGIA
Causes a sudden, intense, stabbing, or electric shock-lain pain in the jaw or face

People with this disease can experience brief bouts of intense pain while carrying out daily activities that involve facial movements, such as chewing, talking, smiling, and more.

Dr Syed Abdullah Al-Haddad reveals that such painful episode can last from a few seconds to several minutes each time.

The pain is recurrent—one could experience a few to even a few hundred such attacks in a day!

He adds: “The intense, electric shock-like one-sided facial pain characteristic of this condition often leads to misinterpretation and misdiagnosis. Patients endure years of debilitating pain with one patient describing it as worse than labour pain.”

Commonly affects one side of the face

These bouts of pain commonly affect only one side of the face (the right side is more common). It is possible for both sides of the face to be affected, but such incidences are rare in an already rare disease.

It’s due to the disruption of the function of the trigeminal nerve

The trigeminal nerve transmits touch and pain sensations from our face and head to our brain.

There are 3 branches in the trigeminal nerve:

  • The ophthalmic branch transmits nerve impulses to the top portion of our face, including our forehead.
  • The maxillary branch transmits nerve impulses to the middle region of the face, including our cheeks, nostrils and upper lip.
  • The mandibular branch transmits nerve impulses to the lower portion of our face, including the lower lip and jaw area.
Causes of trigeminal neuralgia

One of the more common causes is a blood vessel causing pressure on the trigeminal nerve.

Another common possible cause is multiple sclerosis, which causes the myelin sheath, the coating of nerve cells, to break down and put the person with multiple sclerosis at risk of developing trigeminal neuralgia.

Other possible causes include the presence of a tumour or lesion that compresses the nerves and damage to the trigeminal nerve due to surgery, stroke, or injury.

However, it is also possible for some cases of trigeminal neuralgia to have no specific identifiable cause.

It is often misdiagnosed

Due to how it is often misdiagnosed, trigeminal neuralgia can cause those affected to live with the pain for a long time. Dr Syed Abdullah Al-Haddad shares that one of his patients had one whole side of his teeth taken out due to his condition being misdiagnosed as dental pain.

Leaves a profound impact on the lives of those affected by this disease

The disease can make it difficult for those affected to perform daily activities like eating and talking as well as affect their mental health and relationships with their loved ones.

Dr Syed Abdullah Al-Haddad adds: “As they endure the intense pain, some patients decide to stop talking or even living a normal life. The symptoms can also interfere with their ability to work, impact relationships as some believe that sufferers are ‘mad’ or exaggerating their pain and lead to depression and sleep problems.”

DIAGNOSING THE DISEASE

According to Syed Abdullah Al-Haddad, the biggest challenge here is getting an accurate diagnosis.

Frequently, the condition is misdiagnosed as dental problems or issues related to the ear, nose, and throat first.

This is why it is crucial for doctors to listen to their patient’s symptoms and understand the characteristic features of the pain. The pain often described by patients is crucial and can be a sign of the disease.

Trigeminal neuralgia is diagnosed through a combination of patient-reported symptoms as well as a thorough physical examination and a magnetic resonance imaging (MRI) scan to rule out other potential causes such as multiple sclerosis or tumours.

TREATMENT

Treatment options include medications to block pain signals and surgical methods such as stereotactic radiosurgery.

The latter is a non-invasive procedure that delivers focused radiation to the trigeminal nerve root, reducing pain signals with a shorter recovery time and surgery to relieve pressure on the trigeminal nerve.

BE AWARE OF THIS DISEASE

Dr Syed Abdullah Al-Haddad tells us: “With trigeminal neuralgia often being misdiagnosed, it is important for rare diseases such as this one to not only be in the minds of neurologists but all healthcare professionals from general physicians, dental, ENT surgeons to the public alike so these patients can get the help they need and do not need to suffer any longer in silence.”

New Treatment for Both Acute Treatment of Migraine and Prophylactic Treatment of Episodic Migraine Now Available!

WORDS LIM TECK CHOON

FEATURED EXPERT
DR JULIA SHAHNAZ MERICAN
Consultant Neurologist
Prince Court Medical Centre

Recently, pharmaceutical company Pfizer Malaysia announced the availability of NURTEC™ (rimegepant) in Malaysia.

WHAT IS IT FOR?

Well, it’s a prescription medication designed to treat acute migraine and prevent migraine attacks.

MORE ABOUT MIGRAINE

Dr Julia Shahnaz Merican shares that migraine can present itself with or without aura.

Those suffering from migraine with aura tend to experience visual disturbances such as dots, sparks or zigzags before a migraine attack.

These visual disturbances are absent in migraine without aura, which is the more common type of migraine.

“Regardless of the type, migraines significantly disrupt one’s quality of life, often forcing patients to seek solace in a dark room until the pain and symptoms subside,” Dr Julia says.

HOW DOES THIS MEDICATION WORK?

“While the exact cause of migraine remains a mystery, over the past 30 years, clinical and preclinical studies have investigated the role of a neuropeptide called calcitonin gene-related peptide (CGRP) in migraine occurrence,” Dr Julia reveals.

NURTEC™ works as a CGRP receptor antagonist.

What this means is that it can act to block the effects of CGRP, thus helping to provide pain relief during migraine attacks.

Furthermore, this medication has received approval for use in reducing the frequency of future migraine attacks when used preventively.

NURTEC™ is for oral use and is currently available in Malaysia. It is a prescription medicine, which means you will need a doctor’s prescription to obtain it. If you believe that you may benefit from this medication, please discuss this matter further with your doctor.

Reference: Pfizer Malaysia Sdn Bhd. (2024, January 18). NURTEC™ (rimegepant) is now available in Malaysia for both acute treatment of migraine and prophylactic treatment of episodic migraine [Press release, KKLIU 0244 / EXP 15.07.2024].

A Neurologist Discusses the Link Between COVID-19, Younger Adults, and Stroke

WORDS DR JOYCE PAULINE JOSEPH

FEATURED EXPERT
DR JOYCE PAULINE JOSEPH
Consultant Neurologist
Aurelius Hospital Nilai

The COVID-19 pandemic has fundamentally altered the physiological landscape of individuals around the globe. The virus has demonstrated its ability to traverse various bodily functions, leaving a trail of physiological changes in its wake. From the intricate dynamics of the immune response to cardiovascular issues, COVID-19 has brought about unprecedented impacts on human health in various ways.

But what are the correlations, if any, between COVID-19 and an increase in stroke incidences especially amongst the young? In light of the increasing number of cases of COVID-19 in Malaysia again, we attempt to investigate the links.

THE LINK TO STROKE

Traditionally, when we speak about strokes, it tends to be an “elderly persons” disease, a health concern prevalent amongst those aged 50 and above.

However, over the past 3 years since the first outbreak of COVID-19 pandemic, a worrying connection has emerged between the virus and incidences of strokes in younger individuals.

COVID-19 is associated with a higher risk of stroke, a majority of them being ischaemic strokes caused by a blockage in an artery that supplies blood to the brain.

A study suggested a connection between the high prevalence of vascular risk factors and concurrent elevation of proinflammatory and procoagulation biomarkers in this.

In the same study, it has been proposed that the virus that causes COVID-19 infects the cells that line the inside of the blood vessels.

These infected cells release several pro-inflammatory factors that attract other immune cells to the affected area.

In turn, this leads to damage to the lining cells, activating platelets and other factors involved in clotting.

This chain of events eventually increases the risk of a blood clot that could potentially travel up to the brain and cause a stroke.

Hypercoagulability and inflammatory response cause vascular complications, increasing the risk of strokes, regardless of age.

Findings from another large-scale study suggested that COVID-19 is a risk factor for deep vein thrombosis, pulmonary embolism, and bleeding.

The risk of developing blood clots in the lungs and legs is significantly elevated for up to 6 months upon contracting COVID-19.

After the initial 30 days of infection, individuals afflicted with COVID-19 displayed heightened susceptibilities and endured a year-long burden of newly emerging cardiovascular conditions.

These conditions range from cerebrovascular issues and dysrhythmias to inflammatory heart disease, ischaemic heart disease, heart failure, thromboembolic disease, and assorted cardiac disorders.

Strikingly, these risks manifested consistently across various demographic factors, such as age, race, and gender, as well as other established cardiovascular risk factors like obesity, hypertension, diabetes, chronic kidney disease, and hyperlipidemia.

Notably, even those without any pre-existing cardiovascular conditions prior to exposure to COVID-19 exhibited these risks, suggesting a propensity for these complications to manifest in individuals traditionally considered at low risk for cardiovascular diseases.

IN SUMMARY

The data and evidence gathered do point to a heightened risk of stroke brought about by COVID-19, regardless of age.

Even though it remains an uncommon occurrence, it remains a risk especially for individuals pre-existing health conditions that are known to boost the risk of stroke.

While the correlation between incidences of stroke, COVID-19 and how it affects younger individuals remains a subject of ongoing research and study, it remains crucial in recognizing the potential risks and taking appropriate and proactive measures.

References:

  1. Mbonde, A. A., O’Carroll, C. B., Grill, M. F., Zhang, N., Butterfield, R., & Demaerschalk, B. M. (2022). Stroke features, risk factors, and pathophysiology in SARS-CoV-2-infected patients. Mayo Clinic proceedings. Innovations, quality & outcomes, 6(2), 156–165. https://doi.org/10.1016/j.mayocpiqo.2022.01.003
  2. Xie, Y., Xu, E., Bowe, B., & Al-Aly, Z. (2022). Long-term cardiovascular outcomes of COVID-19. Nature medicine, 28(3), 583–590. https://doi.org/10.1038/s41591-022-01689-3

Autoimmune Encephalitis: When Your Own Immune System Attacks Your Brain

WORDS LIM TECK CHOON

FEATURED EXPERT
DR ELLIE KOK HUEY TEAN
Consultant Neurologist and Internal Medicine Physician
Sunway Medical Centre Velocity

Autoimmune encephalitis, often abbreviated as AE, is a relatively new and hence frequently misdiagnosed group of related conditions in which the body’s own immune system attacks the brain.

According to Dr Ellie Kok Huey Tean, autoimmune encephalitis can affect people of all ages, even those with no family history of this condition.

COMMON POSSIBLE SYMPTOMS OF AUTOIMMUNE ENCEPHALITIS 
  • Frequent headaches.
  • Personality and behavioural changes.
  • Decline in cognitive function (thinking, learning, memory, decision-making, etc).
  • Seizures.
  • Abnormal, slow, and/or involuntary movement (movement disorders).
  • Hallucination and/or delusion.

If left untreated, someone with this condition may experience permanent brain injury and even death.

However, Dr Ellie shares that, because the symptoms of autoimmune encephalitis overlap with those of psychiatric disorders, this condition is often misdiagnosed.

WHAT ARE THE COMMON CAUSES AUTOIMMUNE ENCEPHALITIS?

Dr Ellie explains that there are many different possible causes, such as exposure to viruses such as herpes simplex virus and the presence of certain cancers.

ARE CERTAIN GROUPS OF PEOPLE MORE AT RISK?

“Research indicates that AE predominantly impacts individuals from their early teenage years to age 50, with women being more susceptible than men,” she added.

Furthermore, while this condition can develop in people of all ages, certain age or gender groups may exhibit higher prevalence of certain traits linked to autoimmune encephalitis.

For example, N-methyl-D-aspartate receptor (NMDAR) encephalitis tend to be more commonly observed in adolescents and young adults. It is also more prevalent among young women with tumours in their reproductive organs.

Another example is araneoplastic encephalitis, which affects elderly persons with occult cancer. Occult cancer is a term for cancer cases in which cancer cells are detected in the person’s body, but the doctors can’t locate the tumour from which these cancer cells originate from.

WHAT CAN WE DO ABOUT AUTOIMMUNE ENCEPHALITIS?

Dr Ellie advises that family members or caretakers of the elderly should be vigilant for symptoms, especially given that the elderly are more vulnerable to infections, one of the primary causes of autoimmune encephalitis.

“It is also crucial to monitor for symptoms such as memory decline, behavioural changes, seizures, and gait problems, such as loss of balance while walking,” she elaborates.

IS THERE A CURE FOR AUTOIMMUNE ENCEPHALITIS?

Dr Ellie reveals that most people with this condition can be cured after receiving proper diagnosis and the appropriate immunotherapy treatment.

Immunotherapy typically involves the use of immunoglobulin injected into the patient’s bloodstream as well as plasma exchange and the use of immunosuppression agents. The purpose of this treatment is to eliminate the antibodies that direct the immune cells to attack the patient’s brain.

“However, a small number of patients may experience a relapse within 5 years after treatment,” says Dr Ellie, adding that this is the reason why it is important for people that have completed treatment to go for medical follow-ups. These follow-ups will allow the doctor to detect and take steps to prevent the chances of recurrence.

What Do You Know about Alzheimer’s Disease? Find Out from a Geriatrician!

WORDS LIM TECK CHOON

FEATURED EXPERT
DR TEH HOON LANG
Consultant Geriatrician
Sunway Medical Centre

21 September is World Alzheimer’s Day. We’re pleased and really appreciative of the fact that, in conjunction with this day, Dr Teh Hoon Lang has graciously shared her insight on Alzheimer’s disease with us.

IS DEMENTIA THE SAME THING AS ALZHEIMER’S DISEASE?

Dr Teh explains that:

  • Dementia is a complex brain function impairment set that interferes with daily life.
  • Alzheimer’s disease is a common type of dementia.
  • It is a progressive brain disorder characterized by the buildup of abnormal proteins in the brain.
  • This buildup will lead to a gradual decline of memory, thinking, and reasoning skills.
  • This condition will get worse over time.
An overview of Alzheimer’s disease. Click on the image to view a larger, clearer version.
  • According to some studies, over 8.5% of Malaysians aged 60 and above have dementia, with a higher prevalence among women.
  • However, note that Alzheimer’s disease and other forms of dementia can also occur to people at a younger age. They should not be considered as merely ‘old people’s disease’.
WE SHOULD BE VIGILANT & KEEP AN EYE OUT FOR EARLY SIGNS

According to Dr Teh, symptoms of dementia can be mild and hence overlooked.

“Many people may assume these symptoms as part of the normal ageing process,” she adds.

COMMON EARLY SIGNS OF DEMENTIA (OF WHICH ALZHEIMER’S DISEASE IS ONE TYPE)
  • Recent memory loss, such as being unable to recall recent events or appointments.
  • Difficulties in planning and carrying out tasks or solving problems such as following a recipe, managing their finances, or managing their own medicines.
  • Difficulty in completing familiar tasks such as cooking, driving or using appliances.
  • Confusion about time and/or place—they may lose track of the date, time, or where they are. They may also get lost in familiar places.
  • Trouble understanding visual images and spatial relationships. This can manifest as difficulties in understanding maps, following directions, judging distances, determining the size of objects, etc.
  • Problems with languages, such as difficulty finding the right words or using the wrong words during a conversation.
  • Frequently misplacing things and losing the ability to retrace steps.
  • Decreased or poor judgement. They may make poor decisions, such as giving away large sums of money or insisting on driving when they are no longer fit to drive.
  • Withdrawal from work or social activities that they used to enjoy. They may also become isolated and avoid interacting with others.
  • Changes in mood or personality such as becoming depressed, anxious, or irritable. They may also experience personality changes, such as becoming more passive or withdrawn.
CERTAIN FACTORS CAN INCREASE ONE’S RISK OF DEVELOPING ALZHEIMER’S DISEASE & OTHER FORMS OF DEMENTIA

Dr Teh shares that common risk factors include:

  • Sedentary living—not getting regular physical activity.
  • Smoking and/or excessive alcohol consumption.
  • History of head injuries.
  • Infrequent social contact and isolation. This can lead to depression, a risk factor. Thus, we, especially the elderly, are encouraged to stay socially active no matter our age.
  • Less or low levels of education in early life, as this can affect cognitive reserve—the ability of the brain to maintain our cognitive function and withstand deterioration and damage.
  • Obesity, especially during one’s mid-life.
  • High blood pressure or hypertension.
  • Diabetes, primarily type 2 diabetes.
  • Hearing impairment or individuals with hearing loss. Hearing aids may help reduce this risk.
WHY EARLY DETECTION IS CRUCIAL

Any damage to the brain is irreversible; there is no way to treat or undo the damage.

“It is important to see a doctor for an assessment as soon as possible, as early diagnosis and treatment can help to prevent or delay irreversible brain damage,” Dr Teh states.

HOW ABOUT SCREENING FOR ALZHEIMER’S DISEASE?

“According to guidelines, routine cognitive screening isn’t recommended for everyone, it’s only recommended to screen people at risk,” Dr Teh shares.

She adds, “However cognitive screening is not 100% accurate, hence, it’s crucial to educate the public about the early warning signs of dementia.”

Furthermore, some conditions may resemble dementia, such as vitamin B12 deficiency and hypothyroidism, and these can be reversed by early treatment.

INNOVATIONS OF THE PHARMACEUTICAL INDUSTRY IN DEVELOPING A TREATMENT FOR ALZHEIMER’S DISEASE

In other news, the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) has released a video highlighting the challenges and advances made by the pharmaceutical industry in finding means to slow the progression of Alzheimer’s disease. Have a look!

For more information, visit the IFMPA (link opens in a new tab).

How Robotics Can Help a Stroke Survivor’s Brain to Relearn How to Walk at a Faster Rate

WORDS LIM TECK CHOON

FEATURED EXPERT
DR KOK CHIN YONG
Consultant Neurologist and Internal Medicine Physician
Sunway Medical Centre Velocity
FIRST, LET’S TAKE A LOOK AT STROKE

Stroke is a medical emergency caused by the disruption of blood flow to your brain.

Without enough oxygen, your brain will stop working properly. This is why stroke is often considered the brain’s version of a heart attack.

 

Ischaemic stroke

This occurs when there is blood flow disruption to the brain. This can occur when the blood vessels in your brain are blocked by blood clots or other substances.

This is the most common type of stroke and is often linked to poorly controlled type 2 diabetes, high blood pressure, and/or high blood cholesterol levels.

Haemorrhagic stroke

This type of stroke occurs when there is internal bleeding in the brain. Accumulated blood in certain areas of the brain can exert pressure to brain tissues in these areas and damage these tissues.

While not as common as ischaemic stroke, this type of stroke is especially dangerous because the affected person’s symptoms can get worse very quickly and urgent medical attention is needed to prevent permanent brain damage and even death.

MOST STROKE SURVIVORS EXPERIENCE GAIT DISABILITY

Stroke is one of the main causes of disability.

2005 statistics from the American Heart Association revealed that more than 80% of stroke survivors suffer from gait disability—the loss of mobility due to impaired ability to walk normally.

Gait disability can affect the survivor’s quality of life.

However, there are also other repercussions of this disability on the person: the person’s confidence and sense of independence can be compromised.

Furthermore, gait disability is linked to increased risks of cardiovascular diseases and death in people approaching 80.

Because of this, gait therapy is an important aspect of rehabilitation for a stroke survivor.

ALL IS NOT LOST, AS THE BRAIN HAS A CHANCE TO ADAPT & RECOVER

The brain is an amazing organ. The network of nerves and other tissues involved in brain function can adapt to changes by reorganizing themselves, or ‘rewire’ in response to these changes.

“This can happen after a stroke,” Dr Kok explains, “as the brain begins to compensate for the damage caused by the stroke.”

This process, called brain neuroplasticity, can involve the formation of new connections between remaining healthy nerves and ‘recruiting’ other parts of the brain to take over the functions that were handled by the now-damaged part of the brain.

Much research is being done on the neuroplasticity of the brain to explore possible ways to improve the rehabilitation process of people that had a stroke or other brain injuries that affect their normal day-to-day function.

Currently, research data increasingly suggests that techniques that can stimulate the part of the brain affected by stroke can help improve the rehabilitation of the lost function linked to that part of the brain.

HENCE, GAIT THERAPY IS AN ESSENTIAL COMPONENT OF A STROKE SURVIVOR’S REHABILITATION

Dr Kok Chin Yong mentions that the restoration of a stroke survivor’s ability to walk can be a complex process.

The stroke survivor’s inability to walk normally is usually due to the stroke disrupting the function of the nerve pathways in the region of the brain that plans and controls movement called the motor cortex.

Furthermore, the stroke survivor also often suffers from other debilitations that make it harder for them to walk, such as changes in their muscle tone and strength as well as impaired heart function.

Additionally, the more gait therapy is delayed, the harder it is to achieve a good outcome because the organs involved in walking will further weaken and waste away due to lack of use.

Hence, gait therapy should be prioritized as soon as it is feasible to do so.

ROBOTICS-ASSISTED GAIT THERAPY CAN BENEFIT STROKE SURVIVORS CONSIDERABLY
If you have not read Dr Foong Chee Chong’s explanation of what robotic-assisted gait therapy is, you can do so by clicking here. Have a read, and then hit the back button to come back here and continue reading—it will help you better understand the rest of this article!

Dr Kok explains that the first line of rehabilitation is conventional physiotherapy.

“During this stage, we will assess the patient’s suitability for robotics-assisted gait therapy,” he explains, adding that the criteria for suitability are similar to those explained by his colleague Dr Foong is the above-linked article.

“The main benefit of the use of robotics is that many patients can regain their normal physiological walking at a faster rate than conventional physiotherapy,” he shares.

He elaborates that this is due to the robotic exoskeleton stimulating the neuroplasticity of the patient’s brain, helping it to relearn how to order and control the movement of the patient’s lower limbs at a much faster rate.

He reiterates that such outcome is more likely achieved when the robotics-assisted gait therapy is initiated as early as it is feasible to do so.

Hence, he encourages stroke survivors to consult their doctors further on whether such a therapy is suitable for them.

THIS IS THE SECOND PART OF THE SERIES LEARNING TO WALK AGAIN

Below are the articles in this series:

  1. A Rehab Specialist Explains How a Robot Can Help You to Learn Safely & Successfully to Walk Again
  2. How Robotics Can Help a Stroke Survivor’s Brain to Relearn How to Walk at a Faster Rate (you’re reading this article now)

References:

  1. Duncan, P. W., Zorowitz, R., Bates, B., Choi, J. Y., Glasberg, J. J., Graham, G. D., Katz, R. C., Lamberty, K., & Reker, D. (2005). Management of adult stroke rehabilitation care: A clinical practice guideline. Stroke, 36(9), e100–e143. https://doi.org/10.1161/01.STR.0000180861.54180.FF
  2. Newman, A. B., Simonsick, E. M., Naydeck, B. L., Boudreau, R. M., Kritchevsky, S. B., Nevitt, M. C., Pahor, M., Satterfield, S., Brach, J. S., Studenski, S. A., & Harris, T. B. (2006). Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA, 295(17), 2018–2026. https://doi.org/10.1001/jama.295.17.2018
  3. Su, F., & Xu, W. (2020). Enhancing brain plasticity to promote stroke recovery. Frontiers in neurology, 11, 554089. https://doi.org/10.3389/fneur.2020.554089
  4. Selves, C., Stoquart, G., & Lejeune, T. (2020). Gait rehabilitation after stroke: review of the evidence of predictors, clinical outcomes and timing for interventions. Acta neurologica Belgica, 120(4), 783–790. https://doi.org/10.1007/s13760-020-01320-7