To the Editor:--Painful tic convulsif, a term coined by Cushing in 1920, consists of ipsilateral concurrent trigeminal neuralgia and hemifacial spasm. [1]Fifty-five cases have been reported [2]since Cushing's initial report. In 7 of the 55 cases, painful tic convulsif is reported to be caused by a brain tumor. [2]We describe a patient treated for ipsilateral trigeminal neuralgia and hemifacial spasm who was found to have an undiagnosed brain tumor discovered during microvascular decompression of the 5th and 7th cranial nerves.

A 32-yr-old man was suffering from daily transient hemifacial spasm. After treatment with imipramine hydrochloride and clotiazepam for a presumed psychosomatic disorder without relief for 2 yr, he experienced severe lancinating pain in his right maxilla after dental surgery. Diagnosis of trigeminal neuralgia was made, and he was treated with pranoprofen and diclofenac sodium with temporary relief. After 1 yr, his pain increased in severity, and he was referred to the department of neurology in our hospital. The neurologic findings showed intermittent twitching of his right eyelid and right corner of the mouth. The pain affected the region innervated by the third branch of the right trigeminal nerve without distinct trigger points. Audio-metric examination, taste, and equilibrium were normal, and other cranial nerves were normal.

He was treated with 600 mg/day carbamazepine with temporary relief. To investigate the cause of his neuralgic attacks, magnetic resonance imaging (MRI) was performed but showed no brain tumor. Because of the atypical nature of the facial pain accompanied by neuralgic attacks, he was referred to our pain clinic. We performed a series of ten stellate ganglion blocks over 2 weeks under the diagnosis of atypical facial pain. His pain decreased from 10 of 10 to 3 of 10 on a visual analog scale a week after the initiation of treatment with the block. Neurosurgery was consulted regarding microvascular decompression (Jannetta's procedure) for his hemifacial spasm and neuralgic attacks. During the surgery, an epidermoid cyst, 1 cm in diameter, was found in the cerebellopontine angle, compressing the 5th and 7th cranial nerves, and was removed. His symptoms disappeared immediately after the operation, and his postoperative course was favorable.

The anesthesiologist, when asked to care for patients with tic convulsif, should be aware that the symptoms can be caused by a brain tumor, and thus, more thorough neurologic examination, involving MRI, should be considered.

Shigeo Ikeno, M.D., Assistant of Anesthesiology.

Hiromasa Mitsuhata, M.D., Instructor of Anesthesiology

Koujirou Furuya, M.D., Assistant of Anesthesiology

Reiju Shimizu, M.D., Professor and Chairman of Anesthesiology, Department of Anesthesiology, Jichi Medical School, 3311-1 Yakushiji, Minamikawachi, Kawachi-gun, Tochigi 329-04, Japan

(Accepted for publication May 31, 1995.)

Cushing H: The major trigeminal neuralgias and their surgical treatment based on experiences with 332 gasserian operations. Am J Med Sci 160:157-184, 1920.
Iwasaki K, Kondo A, Otsuka S, Hasegawa K, Ohbayashi T: Painful tic convulsif caused by a brain tumor: Case report and review of the literature. Neurosurgery 30:916-919, 1992.