On the Surgical Implications of Peritrigeminal Perforating Vessels in Microvascular Decompression

Abstract BACKGROUND Perforating branches arising from the superior cerebellar artery (SCA) or anterior inferior cerebellar artery (AICA) that pierces the brainstem within 5 mm of the trigeminal root may limit offending vessel transposition during microvascular decompression for trigeminal neuralgia. OBJECTIVE To investigate the microsurgical anatomy of peritrigeminal perforators and evaluate their effect on the mobility of the SCA and AICA. Additionally, we propose strategies for mitigating the potential complications caused by the presence of short peritrigeminal perforators. METHODS Retrosigmoid approaches and exposure of the upper cerebellopontine angle were performed on 11 cadaveric heads (22 sides). The number, origin, and course of perforators were recorded and each was classified as either type I, short straight (<3 mm); type II, long straight perforators (>3 mm); or type III, long circumflex (>3 mm). Transposition of each SCA and AICA away from trigeminal nerve was performed, and degree of mobilization was evaluated and graded. RESULTS A total of 123 perforators were identified, of which 44 were considered peritrigeminal. Of these, 19 arose from the AICA, 18 from the SCA, and 7 from the basilar artery. Type I peritrigeminal perforators were the most common at 77.3%. Transposition or interposition of the parent vessel was not possible in 8 (47.1%) instances. CONCLUSION Identification of inhibiting perforators is essential before performing microvascular decompression to avoid ischemic injury to the brainstem. The presence of type I perforators may necessitate extensive arachnoid dissection and use of an interpositioning technique with minimal repositioning of the offending vessel.

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Microsurgical anatomy of the choroidal arteries Fourth ventricle and cerebellopontine angles

Journal of Neurosurgery ◽

10.3171/jns.1980.52.4.0504 ◽

1980 ◽

Vol 52 (4) ◽

pp. 504-524 ◽

Cited By ~ 59

Author(s):

Kiyotaka Fujii ◽

Carla Lenkey ◽

Albert L. Rhoton

Keyword(s):

Choroid Plexus ◽

Fourth Ventricle ◽

Cerebellopontine Angle ◽

Posterior Inferior Cerebellar Artery ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Microsurgical Anatomy ◽

Lateral Recess ◽

Lateral Segment ◽

Cerebellar Artery

✓ The microsurgical anatomy of the arteries supplying the choroid plexus in the fourth ventricle and cerebellopontine angles was examined under × 3 to × 20 magnification in brains from 25 adult cadavers. In the most common pattern, the branches of the anterior inferior cerebellar artery (AICA) supplied the portion of the choroid plexus in the cerebellopontine angle and adjacent part of the lateral recess of the fourth ventricle, and the posterior inferior cerebellar artery (PICA) supplied the choroid plexus in the roof and medial part of the lateral recess of the fourth ventricle. The superior cerebellar artery (SCA) gave rise to a choroidal branch in only one brain. The choroid plexus on each side of the midline was divided into a medial and a lateral segment. Each segment was considered two parts to facilitate the description of its blood supply. The medial segment, located in the roof of the fourth ventricle, was divided into a rostral or nodular part, and a caudal or tonsillar part. The lateral segment, located in the lateral recess of the fourth ventricle and cerebellopontine angle, was separated into a medial or peduncular part, and a lateral or floccular part. The AICA most commonly supplied all the floccular part and the lateral portion of the peduncular part, and the PICA most commonly supplied all of the tonsillar and nodular parts, and the medial portion of the peduncular part.

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Retrosigmoid Craniotomy for the Removal of Left Sided Tentorial and Posterior Fossa Meningioma Combined with Microvascular Decompression for Hemifacial Spasm

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1675167 ◽

2018 ◽

Vol 80 (S 03) ◽

pp. S294-S295

Author(s):

Yu-Wen Cheng ◽

Chun-Yu Cheng ◽

Zeeshan Qazi ◽

Laligam N. Sekhar

Keyword(s):

Facial Nerve ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Preoperative Imaging ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Root Exit Zone ◽

Tentorial Meningioma ◽

Cerebellar Artery ◽

The Right

This 68-year-old woman presented with repeated episodes of bilateral hemifacial spasm with headache for 5 years and with recent progression of left sided symptoms. Preoperative imaging showed a left sided tentorial meningioma with brain stem and cerebellar compression. Left facial nerve was compressed by the vertebral artery (VA) and the right facial nerve by the anterior inferior cerebellar artery (AICA). This patient underwent left side retrosigmoid craniotomy and mastoidectomy. The cisterna magna was drained to relax the brain. The tumor was very firm, attached to the tentorium and had medial and lateral lobules. The superior cerebellar artery was adherent to the lateral lobule of the tumor and dissected away. The tumor was detached from its tentorial base; we first removed the lateral lobule. Following this, the medial lobule was also completely dissected and removed. The root exit zone of cranial nerve (CN) VII was dissected and exposed. The compression was caused both by a prominent VA and AICA. Initially, the several pieces of Teflon felt were placed for the decompression. Then vertebropexy was performed by using 8–0 nylon suture placed through the VA media to the clival dura. A further piece of Teflon felt was placed between cerebellopontine angle region and AICA. Her hemifacial spasm resolved postoperatively, and she discharged home 1 week later. Postoperative imaging showed complete tumor removal and decompression of left CN VII. This video shows the complex surgery of microsurgical resection of a large tentorial meningioma and microvascular decompression with a vertebropexy procedure.The link to the video can be found at: https://youtu.be/N5aHN9CRJeM.

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Microvascular Decompression by Interposition Method for Treatment of Trigeminal Neuralgia Due to Vertebrobasilar Dolichoectasia: A Retrospective Single-Center Study

10.21203/rs.3.rs-1180077/v1 ◽

2021 ◽

Author(s):

Feng Yu ◽

Jia Yin ◽

Pei-gang Lu ◽

Zhen-yu Zhao ◽

Yong-qiang Zhang ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Microvascular Decompression ◽

Long Term Results ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Symptom Duration ◽

Free Survival ◽

Kaplan Meier ◽

Vertebrobasilar Dolichoectasia ◽

Cerebellar Artery

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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Segmental anatomy of cerebellar arteries: a proposed nomenclature

Journal of Neurosurgery ◽

10.3171/2011.3.jns101413 ◽

2011 ◽

Vol 115 (2) ◽

pp. 387-397 ◽

Cited By ~ 30

Author(s):

Ana Rodríguez-Hernández ◽

Albert L. Rhoton ◽

Michael T. Lawton

Keyword(s):

Cerebral Arteries ◽

Posterior Inferior Cerebellar Artery ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Microsurgical Anatomy ◽

Numbering System ◽

Segmental Anatomy ◽

Cerebellar Artery ◽

Intracranial Arteries

Object The conceptual division of intracranial arteries into segments provides a better understanding of their courses and a useful working vocabulary. Segmental anatomy of cerebral arteries is commonly cited by a numerical nomenclature, but an analogous nomenclature for cerebellar arteries has not been described. In this report, the microsurgical anatomy of the cerebellar arteries is reviewed, and a numbering system for cerebellar arteries is proposed. Methods Cerebellar arteries were designated by the first letter of the artery's name in lowercase letters, distinguishing them from cerebral arteries with the same first letter of the artery's name. Segmental anatomy was numbered in ascending order from proximal to distal segments. Results The superior cerebellar artery was divided into 4 segments: s1, anterior pontomesencephalic segment; s2, lateral pontomesencephalic segment; s3, cerebellomesencephalic segment; and s4, cortical segment. The anterior inferior cerebellar artery was divided into 4 segments: a1, anterior pontine segment; a2, lateral pontine segment; a3, flocculopeduncular segment; and a4, cortical segment. The posterior inferior cerebellar artery was divided into 5 segments: p1, anterior medullary segment; p2, lateral medullary segment; p3, tonsillomedullary segment; p4, telovelotonsillar segment; and p5, cortical segment. Conclusions The proposed nomenclature for segmental anatomy of cerebellar artery complements established nomenclature for segmental anatomy of cerebral arteries. This nomenclature is simple, easy to learn, and practical. The nomenclature localizes distal cerebellar artery aneurysms and also localizes an anastomosis or describes a graft's connections to donor and recipient arteries. These applications of the proposed nomenclature with cerebellar arteries mimic the applications of the established nomenclature with cerebral arteries.

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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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Microvascular Relations of the Trigeminal Nerve: An Anatomical Study

Neurosurgery ◽

10.1227/00006123-198610000-00007 ◽

1986 ◽

Vol 19 (4) ◽

pp. 535-539 ◽

Cited By ~ 42

Author(s):

Boris Klun ◽

Borut Prestor

Keyword(s):

Trigeminal Neuralgia ◽

Anatomical Study ◽

Superior Cerebellar Artery ◽

Anterior Inferior Cerebellar Artery ◽

Marked Contrast ◽

Entry Zone ◽

Root Entry Zone ◽

Cerebellar Artery ◽

History Of ◽

Trigeminal Root

Abstract The neurovascular relationships in the trigeminal root entry zone were studied in 130 trigeminal root entry zones of 65 cadavers. No history of facial or trigeminal pain had been obtained during life in these subjects. The technique of intravascular injection, which allowed good visualization and evaluation of the neurovascular relationships, is described. A total of 42 examples of contact with the root entry zone and 10 examples of compression were identified. In 30 of the examples of contact, the finding could be related to an artery; in the other examples, it appeared to be due to veins. Of the arterial compressions, the superior cerebellar artery was responsible in 53.8%, the anterior inferior cerebellar artery was responsible in 25.6%, and pontine branches of the basilar artery were responsible for the remaining 20.6%. Only one instance of unequivocal compression by a vein was found. Other anatomical observations of interest are reported. The absence of a history of trigeminal neuralgia in the 7% of examined nerves in which root entry zone showed arterial compression is in marked contrast to the finding of 80% or more in the operative series for trigeminal neuralgia. It seems that vascular compressions may be the predominant but not the sole cause of trigeminal neuralgia.

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Hemifacial Spasm: Endoscopic Vascular Decompression

Otolaryngology ◽

10.1016/s0194-5998(97)70118-9 ◽

1997 ◽

Vol 117 (4) ◽

pp. 308-314 ◽

Cited By ~ 32

Author(s):

J. Magnan ◽

F. Caces ◽

P. Locatelli ◽

A. Chays

Keyword(s):

Hemifacial Spasm ◽

Marked Improvement ◽

Cerebellopontine Angle ◽

Posterior Inferior Cerebellar Artery ◽

Endoscopic Examination ◽

Anterior Inferior Cerebellar Artery ◽

Cerebellar Artery ◽

The Mean ◽

Vascular Decompression

Sixty patients with primitive hemifacial spasm were treated by means of a minimally invasive retrosigmoid approach in which endoscopic and microsurgical procedures were combined. Intraoperative endoscopic examination of the cerebellopontine angle showed that for 56 of the patients vessel-nerve conflict was the cause of hemifacial spasm. The most common offending vessel was the posterior inferior cerebellar artery (39 patients), next was the vertebral artery (23 patients), and last was the anterior inferior cerebellar artery (16 patients). Nineteen of the patients had multiple offending vascular loops. In one patient, another cause of hemifacial spasm was an epidermoid tumor of the cerebellopontine angle. For three patients, it was not possible to determine the exact cause of the facial disorder. Follow-up information was reviewed for 54 of 60 patients; the mean follow-up period was 14 months. Fifty of the patients were in the vessel-nerve conflict group. Forty of the 50 were free of symptoms, and four had marked improvement. The overall success rate was 88%, and there was minimal morbidity (no facial palsy, two cases of severe hearing loss).

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Clinicoradiological Review: Symptomatic Superior Cerebellar Artery Aneurysm Imitating Cerebellopontine Angle Tumor

Neurosurgery ◽

10.1227/01.neu.0000156467.05456.9d ◽

2005 ◽

Vol 56 (4) ◽

pp. 836-840 ◽

Cited By ~ 2

Author(s):

Ricardo J. Komotar ◽

E Sander Connolly ◽

Alexander Khandji ◽

George P. Teitelbaum ◽

Sean D. Lavine

Keyword(s):

Cerebellopontine Angle ◽

Artery Aneurysm ◽

Superior Cerebellar Artery ◽

Cerebellopontine Angle Tumor ◽

Cerebellar Artery

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Microsurgical Anatomy of the Superior Cerebellar Artery

Neurosurgery ◽

10.1227/00006123-198001000-00002 ◽

1980 ◽

Vol 6 (1) ◽

pp. 10-28 ◽

Cited By ~ 96

Author(s):

David G. Hardy ◽

David A. Peace ◽

Albert L. Rhoton

Keyword(s):

Superior Cerebellar Artery ◽

Microsurgical Anatomy ◽

Cerebellar Artery

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Multiple aneurysms on the subarcuate artery arising from the anterior inferior cerebellar artery in a patient with a Borden type I transverse-sigmoid dural arteriovenous fistula manifesting as subarachnoid hemorrhage: A case report

Interventional Neuroradiology ◽

10.1177/1591019918799299 ◽

2018 ◽

Vol 25 (1) ◽

pp. 90-96 ◽

Cited By ~ 2

Author(s):

Tomoaki Suzuki ◽

Kouichirou Okamoto ◽

Nobuyuki Genkai ◽

Yasushi Ito ◽

Hiroshi Abe

Keyword(s):

Subarachnoid Hemorrhage ◽

Arteriovenous Fistula ◽

Dural Arteriovenous Fistula ◽

Anterior Inferior Cerebellar Artery ◽

Type I ◽

Feeding Artery ◽

Multiple Aneurysms ◽

Arteriovenous Shunts ◽

Cerebellar Artery ◽

Subarcuate Artery

Background Peripheral anterior inferior cerebellar artery (AICA) aneurysms are rare and commonly associated with vascular malformations, such as cerebellar arteriovenous malformations (AVMs). We present a case wherein multiple AICA feeding aneurysms on the subarcuate artery as a feeding artery of a Borden type I transverse-sigmoid dural arteriovenous fistula (dAVF) manifested as subarachnoid hemorrhage. Case description A 67-year-old woman presented with acute severe headache. Brain computed tomography (CT) demonstrated subarachnoid hemorrhage mainly in the posterior fossa. A transverse-sigmoid dAVF was detected on magnetic resonance angiography (MRA) and three-dimensional-CT angiography (3D-CTA), with no cortical venous reflex. The patient underwent conventional angiography, which showed multiple aneurysms on a small branch of the AICA, feeding a transverse-sigmoid dAVF (Borden type I). The AICA aneurysms seemed flow dependent and ruptured owing to high-flow arteriovenous shunts through the dAVF. Based on the source images of the MRA, the small artery arising from the AICA was considered the subarcuate artery, and it was confirmed on 3D-CTA after the artery was successfully embolized with Onyx without any complications. Multiple aneurysms on the subarcuate artery are extremely rare, and the artery has not been identified as a feeding artery of the transverse-sigmoid dAVF. Conclusion A rare case of multiple ruptured aneurysms on the subarcuate artery was reported in a patient with a Borden type I dAVF at the transverse-sigmoid sinuses manifesting as subarachnoid hemorrhage. Onyx embolization of the parent artery occlusion was feasible and useful in treating this type of feeding artery aneurysm of the AICA with a dAVF.

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