Transposition of Superior Cerebellar Artery for Microvascular Decompression in Trigeminal Neuralgia Using an In Situ Superior Petrosal Vein Sling Technique

Abstract Trigeminal neuralgia (TN) due to vertebrobasilar dolichoectasia (VBD) is a rare disease that can be challenging to treat. The objectives of this study are to investigate the characteristics of patients with TN due to VBD and to analyze the efficacy of microvascular decompression (MVD) by the interposition method for treatment of the condition. From 2010 till 2020, the data of 30 patients with TN due to VBD who were treated with MVD by the interposition method were analyzed retrospectively. The characteristics of the patients were compared with those of patients with non-VBD TN (n = 815). Kaplan–Meier survival analysis was performed to determine pain-free survival. The 30 patients (21 males, 9 females; mean age, 63.03 years) accounted for 3.55% of all patients with TN during the study period. In 30 patients, the offending vessel was the basilar artery (BA) in 1 patient, the vertebral artery (VA) in 6 patients, the VA plus the superior cerebellar artery (SCA) in 6 patients, the VA plus the anterior inferior cerebellar artery (AICA) in 12 patients, and the VA+SCA+AICA in 5 patients. Compared to non-VBD TN patients, those with TN due to VBD were significantly more likely to be male, to have TN of the left side, and to have hypertension (all P < 0.001). Mean age at surgery (P = 0.057) and symptom duration (P = 0.308) were comparable between the two groups. All 30 patients had immediate relief of facial pain after MVD and could stop medication. There were no postoperative complications. Over mean follow-up of 76.67 months, 3 patients had recurrence. The mean duration of pain-free survival was 70.77 months. In conclusions, TN due to VBD appears to be more likely in males, in those with hypertension, and to involve the left side. The interposition method performed by experienced and skilled neurosurgeons is a safe and effective treatment for TN due to VBD. Further studies are needed to analyze the associated long-term results and the pain recurrence rate among this special population.

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Prevention of Superior Petrosal Vein Injury during Microvascular Decompression for Trigeminal Neuralgia: Operative Nuances

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1725036 ◽

2021 ◽

Author(s):

Minsoo Kim ◽

Sang-Ku Park ◽

Seunghoon Lee ◽

Jeong-A Lee ◽

Kwan Park

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Patient Positioning ◽

Vestibulocochlear Nerve ◽

Neurophysiologic Monitoring ◽

Petrosal Vein ◽

Cerebrospinal Fluid Leaks ◽

Superior Petrosal Vein ◽

Surgical Corridor ◽

Vein Injury

Abstract Background The superior petrosal vein (SPV) often obscures the surgical field or bleeds during microvascular decompression (MVD) for the treatment of trigeminal neuralgia. Although SPV sacrifice has been proposed, it is associated with multiple complications. We have performed more than 4,500 MVDs, including approximately 400 cases involving trigeminal neuralgia. We aimed to describe our operative technique and nuances to avoid SPV injury. Methods We have provided a detailed description of our institutional protocol, including the anesthesia technique, neurophysiologic monitoring, patient positioning, surgical approach, and SPV management. The surgical outcomes and treatment-related complications were retrospectively analyzed. Results No SPVs were sacrificed intentionally or accidentally during our MVD protocol for trigeminal neuralgia. In the 344 operations performed during 2006 to 2020, 269 (78.2%) patients did not require medication postoperatively, 58 (16.9%) tolerated the procedure with adequate medication, and 17 (4.9%) did not respond to MVD. Postoperatively, 35 (10.2%), 1 (0.3%), and 0 patients showed permanent trigeminal, facial, or vestibulocochlear nerve dysfunction, respectively. Wound infection occurred in five (1.5%) patients, while cerebrospinal fluid leaks occurred in three (0.9%) patients. Hemorrhagic complications appeared in four (1.2%) patients but these were unrelated to SPV injury. No surgery-related mortalities were reported. Conclusion MVD for the treatment of trigeminal neuralgia can be achieved safely without sacrificing the SPV. A key step is positioning the patient's vertex at a 10-degree elevation from the floor, which can ease venous return and loosen the SPV, making it less fragile to manipulation and providing a wider surgical corridor.

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Analysis of Failed Microvascular Decompression in Patients with Trigeminal Neuralgia

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1692683 ◽

2019 ◽

Vol 81 (05) ◽

pp. 567-571

Author(s):

Zhenyu Huang ◽

Benfang Pu ◽

Fusheng Li ◽

KaiZhang Liu ◽

Chunhui Hua ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Symptom Relief ◽

Superior Cerebellar Artery ◽

Complete Relief ◽

Cerebellar Artery ◽

Definitive Therapy ◽

Primary Trigeminal Neuralgia ◽

Early Reoperation

Background Microvascular decompression (MVD) has been widely accepted as a definitive therapy for primary trigeminal neuralgia (TN). However, some patients may not experience relief of TN symptoms following surgery. In this study, the findings of redo MVD are discussed.Methods Between 2015 and 2017, 205 patients with primary TN underwent MVD surgery in Shanghai Tongren Hospital. Among these patients, 187 had immediate complete relief of symptoms, 8 improved apparently, and 10 reported no symptom relief. Of the 10 patients without relief, 6 underwent reoperation within 5 days, 2 underwent reoperation 3 months after the first procedure, and 2 refused to undergo reoperation.Results The symptoms of those patients who received reoperation disappeared immediately after the surgery. In the second operations, new conflict sites at the motor roots were found in five cases. The real offending vessels were the superior cerebellar artery (SCA) or branch of the SCA in seven cases and the petrosal vein in one case. The nerve was not decompressed completely in either of the two cases. At the 12-month follow-up, no recurrence was found. For the other two patients who did not have reoperation, their symptom persisted. Postoperative complications showed no significant differences between the first and second operations.Conclusion Compression of the motor roots might be one of the causes of TN. Thorough exploration of both sensory and motor roots of the trigeminal nerve is essential to performing a successful MVD operation. Early reoperation for resistant TN after MVD does not increase the incidence of complications.

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Use of Superior Petrosal Venous Complex to Transpose the Superior Cerebellar Artery in Microvascular Decompression for Trigeminal Neuralgia: 2-Dimensional Operative Video

World Neurosurgery ◽

10.1016/j.wneu.2020.08.056 ◽

2021 ◽

Vol 145 ◽

pp. 107

Author(s):

Yonghui Jiao ◽

Li Cai ◽

Guilherme H.W. Ceccato ◽

Guoqiang Chen ◽

Xiaosong Wang

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Superior Cerebellar Artery ◽

Cerebellar Artery

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Use of the Arachnoid Membrane of the Cerebellopontine Angle to Transpose the Superior Cerebellar Artery in Microvascular Decompression for Trigeminal Neuralgia: Technical Note

Operative Neurosurgery ◽

10.1227/01.neu.0000367556.35258.fa ◽

2010 ◽

Vol 66 (suppl_1) ◽

pp. ons-88-ons-91 ◽

Cited By ~ 2

Author(s):

Miran Skrap ◽

Francesco Tuniz

Keyword(s):

Pain Relief ◽

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Microvascular Decompression ◽

Cerebellopontine Angle ◽

Technical Note ◽

Superior Cerebellar Artery ◽

Arachnoid Membrane ◽

Recurrent Pain ◽

Cerebellar Artery

Abstract Background: Microvascular decompression is an accepted, safe, and useful surgical technique for the treatment of trigeminal neuralgia. Autologous muscle or implant materials such as shredded Teflon are used to separate the vessel from the nerve but may occasionally be inadequate, become displaced or create adhesions and recurrent pain. Objective: The authors evaluated the use of arachnoid membrane of the cerebellopontine angle to maintain the transposition of vessels from the trigeminal nerve. Methods: The authors conducted a retrospective review of microvascular decompression operations in which the offending vessel was transposed and then retained by the arachnoid membrane of the cerebellopontine cistern, specifically by the lateral pontomesenchepalic membrane. Results: This technique was used in 30 patients of the most recently operated series. Postoperatively, complete pain relief was achieved in 90% of the patients without any observed surgical complications. Conclusion: To the authors’ knowledge this is the first report in which the arachnoid membrane is used in the microvascular decompression of the trigeminal nerve. While this technique can be used only for selected cases, the majority of the vascular compressions on the trigeminal nerve are due to the SCA, so this sling transposition technique can be useful and effective.

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Bridging veins and veins of the brainstem in microvascular decompression surgery for trigeminal neuralgia and hemifacial spasm

Neurosurgical FOCUS ◽

10.3171/2018.4.focus18122 ◽

2018 ◽

Vol 45 (1) ◽

pp. E2 ◽

Cited By ~ 10

Author(s):

Hiroki Toda ◽

Koichi Iwasaki ◽

Naoya Yoshimoto ◽

Yoshihito Miki ◽

Hirokuni Hashikata ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Decompression Surgery ◽

Vascular Compression ◽

Petrosal Vein ◽

Venous Compression ◽

Bridging Veins ◽

Superior Petrosal Vein ◽

Microvascular Decompression Surgery

OBJECTIVEIn microvascular decompression surgery for trigeminal neuralgia and hemifacial spasm, the bridging veins are dissected to provide the surgical corridors, and the veins of the brainstem may be mobilized in cases of venous compression. Strategy and technique in dissecting these veins may affect the surgical outcome. The authors investigated solutions for minimizing venous complications and reviewed the outcome for venous decompression.METHODSThe authors retrospectively reviewed their surgical series of microvascular decompression for trigeminal neuralgia and hemifacial spasm in patients treated between 2005 and 2017. Surgical strategies included preservation of the superior petrosal vein and its tributaries, thorough dissection of the arachnoid sleeve that enveloped these veins, cutting of the inferior petrosal vein over the lower cranial nerves, and mobilization or cutting of the veins of the brainstem that compressed the nerve roots. The authors summarized the patient characteristics, operative findings, and postoperative outcomes according to the vascular compression types as follows: artery alone, artery and vein, and vein alone. They analyzed the data using chi-square and 1-way ANOVA tests.RESULTSThe cohort was composed of 121 patients with trigeminal neuralgia and 205 patients with hemifacial spasm. The superior petrosal vein and its tributaries were preserved with no serious complications in all patients with trigeminal neuralgia. Venous compression alone and arterial and venous compressions were observed in 4% and 22%, respectively, of the patients with trigeminal neuralgia, and in 1% and 2%, respectively, of those with hemifacial spasm (p < 0.0001). In patients with trigeminal neuralgia, 35% of those with artery and venous compressions and 80% of those with venous compression alone had atypical neuralgia (p = 0.015). The surgical cure and recurrence rates of trigeminal neuralgias with venous compression were 60% and 20%, respectively, and with arterial and venous compressions the rates were 92% and 12%, respectively (p < 0.0001, p = 0.04). In patients with hemifacial spasm who had arterial and venous compressions, their recurrence rate was 60%, and that was significantly higher compared to other compression types (p = 0.0008).CONCLUSIONSDissection of the arachnoid sleeve that envelops the superior petrosal vein may help to reduce venous complications in surgery for trigeminal neuralgia. Venous compression may correlate with worse prognosis even with thorough decompression, in both trigeminal neuralgia and hemifacial spasm.

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Microsurgical Decompression of Trigeminal Neuralgia Caused by Simultaneous Double Arterial (SCA and AICA) and Petrosal Vein Complex Compression

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669968 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S428-S430

Author(s):

Domagoj Gajski ◽

Alicia Dennis ◽

Kenan Arnautović

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Video Clip ◽

Senior Author ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Petrosal Vein ◽

Microsurgical Decompression ◽

Cerebellar Artery ◽

The Right

Trigeminal neuralgia is a chronic pain disorder affecting the face. In approximately 80% of cases, it is most commonly caused, when the root entry zone (REZ) of the trigeminal nerve is compressed by the superior cerebellar artery (SCA). The etiology of the remaining 20% of cases is distributed among venous, arteriovenous malformations, posterior fossa tumors, multiple sclerosis plaque compressions, and other pathologies. Combinations of those compressive factors are very rare.1 2 3 4 Herein, we present a video clip of microvascular decompression (MVD) in a 73-year-old female, who has failed conservative treatment with 6 medications over 10 years. She was affected by a unique triple compression of the right REZ by the SCA, anterior inferior cerebellar artery (AICA), and petrosal vein complex (Fig. 1A). Right-sided microsurgical decompression of the REZ of the trigeminal nerve through standard retrosigmoid craniotomy was performed by the senior author (K.I.A.). The SCA and AICA were separated from the nerve using Teflon pledgets. The petrosal vein complex was coagulated and divided, freeing up the right trigeminal nerve (Fig. 1B). The patient was discharged home on the third postoperative day with complete resolution of trigeminal neuralgia.The link to the Video can be found at: https://youtu.be/PYVvImGW0yE.

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