Fully endoscopic far-lateral supracerebellar infratentorial approach for trigeminal neuralgia: illustrative case reports
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Abstract Background Trigeminal neuralgia (TN) is a common cause of craniofacial pain. The retrosigmoid approach is usually used to treat TN, but no cases of endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA) were used to undergo operation for TN. Case presentation Two patients were presented with severe facial pain and preliminary diagnosis was TN. Preoperative magnetic resonance imaging revealed that a superior cerebellar artery (SCA) compressed the trigeminal nerve in case 1, and a tumor located in the petrous apex extending into the Meckel’s cave compressed the trigeminal nerve in case 2. Operations were achieved through the EF-SCITA. The pain was totally relieved with no postsurgical complications in both cases. Conclusions We present the first two case reports of EF-SCITA to relieve classical and secondary TN successfully. The EF-SCITA can be a promising approach for treating TN.Keywords:
Trigeminal Nerve
Superior cerebellar artery
Presentation (obstetrics)
Facial pain
✓ Compression and distortion of the trigeminal nerve by a tortuous and elongated superior cerebellar artery (SCA) is postulated to be a frequent cause of trigeminal neuralgia. This theory and the use of operative therapy in which the offending arterial loop is separated from the trigeminal nerve has created a need for more detailed information on the relationship of the SCA and the trigeminal nerve. In order to meet this need, 50 trigeminal nerves and the adjacent SCA were examined in 25 adult cadavers. Twenty-six of the 50 nerves examined had a point of contact with the SCA, but it was uncommon for the arterial contact to produce distortion of the nerve. In six instances, the contact was at the pontine entry zone of the trigeminal nerve, the site of arterial compression postulated to be associated with trigeminal neuralgia. Four trigeminal nerves (8%) had a point of contact with the anterior inferior cerebellar artery (AICA). The fact that large arteries are commonly in contact with the trigeminal nerve is important not only because of the controversial relationship of neurovascular contact to trigeminal neuralgia, but because of the possibility that major vessels may be encountered and injured during rhizotomy and other posterior fossa operations on the trigeminal nerve.
Superior cerebellar artery
Trigeminal Nerve
Trigeminal artery
Cerebellar artery
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Abstract BACKGROUND AND IMPORTANCE Persistent trigeminal artery (PTA) is a rare but important anatomic variant that contributes to trigeminal neuralgia (TN). Microvascular decompression (MVD) of the responsible vessel(s) away from the trigeminal nerve provides the most complete and durable relief from TN. The role and technique of MVD for TN associated with a PTA has not been fully defined in the literature. Furthermore, assessment of PTA anatomy intraoperatively with a microscope is challenging. We report the first 3-dimensional (3D) microscopic video and first intraoperative endoscopic video of a successful MVD of the trigeminal nerve in a patient who suffered TN from a tortuous, compressive PTA. CLINICAL PRESENTATION A 66-yr-old right-handed female presented with right facial pain in V2 and V3 distributions with a clinical picture of TN. Imaging demonstrated trigeminal nerve compression secondary to a PTA and MVD was performed with a 3D operative microscope and an endoscope. The PTA appeared to compress the nerve directly at the trigeminal porus and also had compressive superior cerebellar artery variant branches. The nerve was decompressed at all points of compression with Teflon pledgets along its entire cisternal length. Postoperatively, she is free with trigeminal pain episodes at 4-mo follow-up. CONCLUSION In cases of TN associated with a PTA, we recommend decompression along the entire length of the nerve wherever there is compression. Furthermore, we find both the operative microscope and particularly the endoscope useful to assess vascular anatomy intraoperatively.
Microvascular Decompression
Trigeminal artery
Trigeminal Nerve
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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.
Superior cerebellar artery
Trigeminal Nerve
Microvascular Decompression
Cerebellar artery
Neurovascular bundle
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Trigeminal neuralgia (TN), also known as tic douloureux is a chronic neuropathic pain disorder characterized by sporadic episodes of extreme, sudden burning or shock-like face pain that last from a few seconds to 2 minutes. Trigeminal neuralgia has a reported incidence of 5.9/100,000 women and 3.4/100,000 men in USA. The exact pathophysiology is still unclear, but demyelization leading to abnormal discharge in fibers of the trigeminal nerve is a probable cause. In the majority of cases, no structural lesion is detected but in almost 15% of patients medical imaging methods like MRI, CT or angiography can identify a vein or artery that compresses the nerve which results in focal demyelization. The authors present a case of trigeminal neuralgia investigated by MRI, which identified a vascular compression of the nerve 9 mm after emerging the pons by the superior cerebellar artery (SCA) and one of its branches. The authors also realize a review of the MRI anatomy of the trigeminal nerve.
Trigeminal Nerve
Superior cerebellar artery
Cerebellar artery
Pons
Microvascular Decompression
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Objective To explore the efficacy ofmicrovascular decompression (MVD) for trigeminal neuralgia and the anatomical characteristics of the responsible blood vessels.Methods In a study of using MVD for the treatment of 136 cases with trigeminal neuralgia,the origins of the responsible blood vessels and sites of compression at the trigeminal root were observed and determined, and the anatomical characteristics of the responsible blood vessels and their efficacy correlation were analyzed.Results The number of the responsible blood vessels of superior cerebellar artery (SCA) lateral branches compressing the upper surface of the trigeminal nerve was 80 sides (58.8%),which was mostly frequently observed;the number of anterior inferior cerebellar artery (AICA) branches compressing the lower surface of the trigeminal nerve was 20 sides (14.7%),which was not so frequently observed;the number of two arteries respectively compressing the upper and lower surfaces of the trigeminal nerve was 18 sides (13.2%);the number of sole veins compressing the trigeminal root was 12 sides (8.8%);and,the number with no vascular compression but evident increase in the thickness of the trigeminal-coated arachnoid mater was 6 sides (4.4%).In the 136 cases,neuralgia of 134 cases disappeared after decompression,namely,the curative rate was 98.5% and MVD failed in two cases.The follow-up study for the 112 cases,with the average of 4.3 year,found that neuralgia of 102 cases disappeared completely,of 4 cases,was partially alleviated and of the other 6 cases,recurred or made no progress at all.□Conclusion Compression of the adjacent blood vessels is one of the primary etiological factors for trigeminal neuralgia and microvascular compression is by far the most effective therapy for the treatment of this disease,the efficacy of which depending on the mastery of professional microsurgical anatomy knowledge and microsurgical techniques.The key to enhancing the efficacy and reducing postoperative complications is carefully searching and assuredly isolating all the responsible blood vessels,and protecting the nerves and blood vessels in adjacent areas.
Microvascular Decompression
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Trigeminal Nerve
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Trigeminal neuralgia occurs in 1-7% patients with multiple sclerosis (MS). We assessed the efficacy of microvascular decompression of the trigeminal nerve in MS patients.We studied MS patients with trigeminal neuralgia who underwent microvascular decompression of the trigeminal nerve. Results and сonclusion. The superior cerebellar artery was compressed in 5 patients, the vein in 1. At the follow up of 3-5 years, no relapses of trigeminal pain syndrome were observed after the successful surgery. There were no complications of surgical treatment. Indications to this treatment should be made on the basis of MRI.Цель исследования. Боли в лице, характерные для невралгии тройничного нерва, встречаются у 1-7% пациентов, страдающих рассеянным склерозом (РС). Цель исследования - оценка эффективности васкулярной декомпрессии корешка тройничного нерва у больных РС. Материал и методы. Наблюдали 5 пациентов с РС и невралгией тройничного нерва, которым была проведена васкулярная декомпрессия тройничного нерва. Результаты и обсуждение. У 5 оперированных больных компримирующим сосудом была верхняя мозжечковая артерия, у 1 - вена. При наблюдении на протяжении 3-5 лет после успешной операции рецидивов тригеминального болевого синдрома не отмечалось. Осложнений хирургического лечения не было. Показания к такому лечению должны определяться с учетом МРТ.
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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. (Neurosurgery 19:535-539, 1986)
Superior cerebellar artery
Trigeminal Nerve
Microvascular Decompression
Neurovascular bundle
Cerebellar artery
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Trigeminal neuralgia (TN) is often caused by vascular compression of the trigeminal nerve cisternal segment. TN due to the primitive trigeminal artery formed by developmental variants of cerebral vessels is rare. We report here a 59-year-old male with TN whose preoperative MRI showed a primitive trigeminal artery that compressed the trigeminal nerve, and microvascular decompression (MVD) was performed to separate the vessel from the trigeminal nerve cisternal segment. The pain was relieved after MVD, but it recurred two months later. MRI reexamination showed that although MVD relieved the vascular compression of the trigeminal nerve cisternal segment, the nerve in the Meckel’s cave was still compressed by PTA, which was thought to be the cause of TN recurrence. Due to the limitations of the surgical microscope view, completing the vascular decompression at the Meckel’s cave is challenging. So percutaneous balloon compression was performed. After the procedure, the TN subsided. The patient remained pain free at one year follow-up. To our knowledge, this is the first case of primitive trigeminal artery-associated TN treated by percutaneous balloon compression. This case suggests that percutaneous balloon compression may be considered for TN caused by compression of the primitive trigeminal artery when MVD is difficult to perform.
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Trigeminal Nerve
Microvascular Decompression
Superior cerebellar artery
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Trigeminal neuralgia is caused by compression of the trigeminal nerve by arteries or veins in the posterior fossa. A persistent primitive trigeminal artery variant (PPTAv) is an anomalous artery that may cause trigeminal neuralgia. A 65-year-old man presented with left facial pain. Brain magnetic resonance imaging revealed a PPTAv. Constructive interference in steady state showed that both the PPTAv and the superior cerebellar artery (SCA) compressed the trigeminal nerve. Thus, we performed microvascular decompression and the patient's symptoms improved. PPTAv is a rare anomaly in the posterior fossa that can cause trigeminal neuralgia. Dual compression of the trigeminal nerve by the SCA and PPTAv demonstrates that trigeminal neuralgia may originate from multiple sources. It is therefore important to check preoperative images to adequately treat trigeminal neuralgia.
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Trigeminal Nerve
Microvascular Decompression
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Posterior fossa
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Objective To discuss the evaluation effect of magnetic resonance angiography before vascular decompression in patient with trigeminal neuralgia. Methods Magnetic resonance angiography was performed in 21 patients who had diagnosed trigeminal neuralgia with vascular compression before vascular decompression. The trigeminal nerve and vascular imaging was obtained by using high- resolution magnetic resonance 3D- FIESTA( 3D- fast imaging employing steady state acquisitio,3D- FIESTA) and 3D- TOF( 3D- time- of- flight,3D- TOF) sequence. Original images were processed on workstation,and they were compared with intraoperative findings. Results The images showed the location and form of trigeminal nerve on two sides in 21 patients by trigeminal vascular imaging before the surgery. It was found 20 offending vessels in 19 patients,and intraoperative finding was confirmed consistent with the images. We could hardly find the offending vessels by using MR in two patients,but we discovered that the trigeminal nerve was compressed by tiny anterior inferior cerebellar artery. Conclusion The location and form of trigeminal nerve and offending vessels are displayed clearly by trigeminal MRA with 3D- FIESTA and 3D- TOF sequence before surgery,and it is very helpful to make preoperative planning and decrease operation process.
Microvascular Decompression
Superior cerebellar artery
Trigeminal Nerve
Magnetic resonance angiography
Trigeminal artery
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