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Secondary Trigeminal Neuralgia – Mass Lesion — SCE Neurology MCQ

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ModerateHeadache & Facial PainSecondary Trigeminal Neuralgia – Mass LesionSCE Neurology

A 45-year-old man presents with episodic severe right-sided facial pain lasting 1–2 seconds, triggered by chewing. Neurological examination reveals right-sided facial sensory loss in the V2 and V3 distributions and right-sided masseter weakness. MRI brain with gadolinium shows an enhancing mass in the right Meckel's cave (trigeminal cistern). What is the most concerning diagnosis?

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Correct answer: D — Trigeminal neuralgia secondary to a trigeminal schwannoma or meningioma

Trigeminal neuralgia with associated neurological deficits (sensory loss, motor weakness of muscles of mastication) is classified as secondary TN and requires urgent investigation. The presence of a mass in Meckel's cave with enhancement raises concern for a trigeminal schwannoma, meningioma, or other neoplastic/inflammatory lesion. Classical TN does NOT cause neurological deficits — the presence of any deficit is a red flag. A: Classical TN has a normal neurological examination. C: Bell palsy affects CN VII, not V. D: TMJ dysfunction causes joint pain without neurological signs. E: Dental abscess does not cause trigeminal motor weakness.

Reference: NICE CG150; EAN TN Guidelines (2019); ICHD-3