Atypical Presentation of a Meningioma Masquerading as Trigeminal Neuralgia: A Diagnostic Challenge in the Emergency Department

A woman in her mid-40s presented to the Emergency Department (ED) following a sudden new-onset threehour episode of numbness over the left maxilla and jaw, followed by electric shock-like facial pain triggered by talking and chewing.This occurred on a background of approximately four months of intermittent leftsided headache.Although the presentation initially suggested trigeminal neuralgia (TN) with concomitant pain, the prolonged sensory disturbance, left-sided proptosis, periorbital symptoms, and diplopia on left lateral gaze were clinically atypical and prompted further evaluation.Clinical examination demonstrated tenderness over the left ophthalmic (V1) and maxillary (V2) divisions of the trigeminal nerve, together with left-sided proptosis and diplopia on left lateral gaze.Neuroimaging was therefore undertaken.Computed tomography (CT) demonstrated an expansile sclerotic lesion involving the left greater wing of the sphenoid with a ground-glass appearance, initially raising suspicion of fibrous dysplasia.Subsequent magnetic resonance imaging (MRI) revealed a large en plaque meningioma involving the left sphenoid wing and middle cranial fossa, with orbital extension and compression of the left optic nerve, necessitating specialist neurosurgical evaluation.A separate right cerebellopontine angle meningioma was also identified.The patient underwent surgical resection of the symptomatic lesion, with histopathology confirming a World Health Organization (WHO) grade one meningioma.This case highlights the importance of thorough neurological assessment and early neuroimaging in patients presenting with atypical features of TN to exclude secondary causes of cranial nerve pathology more consistent with TN-like pain secondary to a structural lesion and enable timely management of any underlying lesions.