Abstract
BACKGROUND
Microvascular decompression for trigeminal neuralgia (TN) caused by vertebrobasilar dolichoectasia is challenging due to severe arteriosclerosis of the offending vessel, and is often associated with poor improvement of the symptoms, recurrence, and increased risk of complications. The authors describe a novel method of treatment: rerouting the trigeminal nerve and not manipulating the offending vessels.
OBSERVATIONS
A 50-year-old male presented with a 7-year history of TN. MRI showed that the anterior inferior cerebellar artery (AICA) was strongly compressing the trigeminal nerve from the inferomedial direction. Given the severe dolichoectatic changes, mobilization of the offending vessels was considered extremely risky. Therefore, decompression was performed by mobilizing the trigeminal nerve instead of manipulating the offending vessels. The surgery was performed via an anterior transpetrosal approach. Meckel’s cave was opened to allow sufficient mobilization of the trigeminal nerve. A GORE-TEX sling was used to lift and decompress the trigeminal nerve by separation from the AICA. The patient’s facial pain completely disappeared immediately after surgery, and no new neurological deficits were observed.
LESSONS
The relative mobility of the trigeminal nerve allows rerouting by opening Meckel’s cave. This technique may help reduce surgical risk by avoiding direct manipulation of severely atherosclerotic arteries.
Keywords: anterior transpetrosal approach, dolichoectasia, trigeminal neuralgia
ABBREVIATIONS: AICA = anterior inferior cerebellar artery, BNI = Barrow Neurological Institute, MVD = microvascular decompression, SCA = superior cerebellar artery, TN = trigeminal neuralgia, VBS = vertebrobasilar system
Microvascular decompression (MVD) has been widely used for the treatment of typical trigeminal neuralgia (TN) since 1967.1–3 MVD relieves neural compression by repositioning the offending vessels away from the trigeminal nerve. The superior cerebellar artery (SCA) and anterior inferior cerebellar artery (AICA) are the offending vessels in 72%–85% of cases,4–6 and MVD achieves pain relief in approximately 80%–90% of patients,3 indicating favorable treatment outcomes.7 However, decompression is technically challenging in the relatively rare cases of TN associated with compression by the dolichoectatic vertebrobasilar system (VBS), in which the offending vessels are often thick and exert severe compression on the nerve. The treatment outcomes in such cases are generally suboptimal, and complication rates are higher than in typical TN cases.8–11 In particular, brainstem infarction resulting from manipulation of the dolichoectatic arteries by the sling technique has been reported,12 emphasizing the increased risk associated with arterial displacement. Several studies have described the risks of MVD for TN associated with vertebrobasilar dolichoectasia, but all these cases involved repositioning the dilated and tortuous VBS.13–15
In contrast, neurovascular decompression was successfully achieved by enhancing trigeminal nerve mobility via an anterior transpetrosal approach and rerouting the nerve in the present case. Here we describe an alternative surgical strategy that avoids direct manipulation of the dolichoectatic arteries, offering a potentially safer and more effective approach in select cases of TN associated with vertebrobasilar dolichoectasia.
Illustrative Case
A 50-year-old male with a history of hypertension, hyperuricemia, and mild decreased kidney function presented with left TN persisting for 7 years. MRI performed at a local hospital identified vertebrobasilar dolichoectasia as the cause of the trigeminal nerve compression. Medical treatment for TN was initiated, but the effect was only temporary, as multiple medications failed to provide sustained relief. Surgical treatment was deemed high-risk, so Gamma Knife radiosurgery was performed. However, the patient experienced severe, sharp, electric shock–like debilitating pain lasting approximately 30 seconds in the left mandibular (V3) region, triggered by eating and speaking, despite the Gamma Knife treatment. The Barrow Neurological Institute (BNI) pain intensity score was V. The patient was subsequently referred to our hospital for surgical management. MRI and 3D CT angiography performed at our institution revealed that the AICA, immediately after branching from the dolichoectatic VBS, had strongly compressed the trigeminal nerve from the inferomedial direction (Fig. 1). Given the worsening pain and increasing difficulty with eating, decompression surgery was performed.
FIG. 1.
Preoperative imaging. A and B: Axial MR CISS images showing that the left trigeminal nerve (arrow) is displaced laterally by the AICA (arrowheads), which originates from a dolichoectatic basilar artery (asterisk). C: Three-dimensional fusion image of CISS and 3D CTA images demonstrating the tortuous VBS (asterisk) and the trigeminal nerve (arrow) displaced superolaterally by the AICA (arrowhead).
Effective transposition of the offending AICA was considered unachievable through only manipulation, due to the presence of vertebrobasilar dolichoectasia. Mobilization of the VBS was expected to be technically challenging via the lateral suboccipital approach. Therefore, we explored the feasibility of decompression by mobilizing the trigeminal nerve itself to relieve vascular compression. To achieve this, we devised a strategy that involved opening Meckel’s cave to enhance the mobility of the trigeminal nerve, together with incision of the cerebellar tentorium to create a space above the nerve for rerouting and decompression. Based on this plan, we considered the anterior transpetrosal approach to be more suitable than the lateral suboccipital approach for mobilizing the trigeminal nerve in the rostral direction.
The surgery was performed in the supine position with the head rotated about 70° to the right. Intraoperative monitoring of the auditory brainstem response and facial nerve was used. A C-shaped skin incision was made from the front of the left auricle to about 5 cm above the auricle and 1 cm below the asterion (Fig. 2A). Craniotomy was performed and the operating microscope was introduced. Kawase’s triangle, a bony window located between the greater superficial petrosal nerve, petrous ridge, and mandibular nerve (V3), was exposed and anterior petrosectomy was performed. An incision was made in the temporal lobe dura mater, the superior petrosal sinus was cut, and an incision in the posterior fossa dura mater was made to confirm the trigeminal nerve. The cerebellar tentorium was incised to allow adequate elevation of the trigeminal nerve from the posterior cranial fossa. The VBS was located deep to the trigeminal nerve, and the AICA had compressed the nerve from the inferomedial direction (Fig. 2B). Both arteries appeared yellow in color and exhibited marked atherosclerotic changes. We attempted to relieve compression of the trigeminal nerve by mobilizing the AICA and inserting a Teflon ball, but neither the AICA nor its proximal segment, the basilar artery, could be displaced, resulting in unsuccessful decompression. Therefore, Meckel’s cave was opened to facilitate maximal rostral mobilization of the trigeminal nerve. A Teflon ball was then inserted beneath the nerve within Meckel’s cave to elevate the nerve (Fig. 2C). To reinforce the elevation of the nerve, the trigeminal nerve was wrapped with a GORE-TEX band and pulled upward to separate it from the AICA (Fig. 2D). A GORE-TEX sheet measuring 5 cm × 1 cm was trimmed into a right-angled triangular shape and fashioned into a sling, which was then gently passed under the trigeminal nerve to allow elevation. The GORE-TEX band was sutured to the temporal base dura mater with 7-0 Prolene (Fig. 2E). This rerouting of the trigeminal nerve completely released the pressure exerted by the AICA. Finally, endoscopic examination of the back of the trigeminal nerve confirmed that the vessels and nerves were completely separated (Fig. 2F). Figure 3 illustrates the details of our surgical strategy.
FIG. 2.
Intraoperative photographs. A: A C-shaped skin incision was made from the front of the left auricle to about 5 cm above the auricle and 1 cm below the asterion. B: The trigeminal nerve (arrow) is displaced superolaterally by the AICA (arrowhead) arising from the dolichoectatic VBS (asterisk). C: Meckel’s cave is opened, and a Teflon felt ball is inserted beneath the trigeminal nerve (arrow) to elevate it. D: The trigeminal nerve (arrow) is elevated by wrapping a GORE-TEX sling around it and pulling it upward. E:In the final view after decompression, the AICA (arrowhead) arising from the dolichoectatic VBS (asterisk) is separated from the trigeminal nerve (arrow), confirming successful decompression. F: Endoscopic view showing no contact between the AICA (arrowhead) arising from the dolichoectatic VBS (asterisk) and the trigeminal nerve (arrow).
FIG. 3.
Illustrations of TN caused by compression from the AICA, which originates from vertebrobasilar dolichoectasia treated via the anterior transpetrosal approach. A: Preoperative illustration showing that the left trigeminal nerve (V) is displaced superolaterally by the AICA. B: Postoperative illustration showing that Meckel’s cave is opened, a Teflon felt ball is inserted beneath the trigeminal nerve (V), and the nerve is elevated using a GORE-TEX sling. These procedures achieve rerouting of the trigeminal nerve and complete decompression from the AICA. VBD = vertebrobasilar dolichoectasia.
Postoperatively, the patient experienced immediate pain relief without new neurological deficits, but a mild residual numbness persisted in the V2 territory of the trigeminal nerve. Postoperative MRI revealed no cerebral infarction (Fig. 4A) and resolution of the contact between the trigeminal nerve and the offending vessel (Fig. 4B and C). The patient had no postoperative complications, including CSF leakage, and was discharged with a modified Rankin Scale score of 0. At the 6-month follow-up, the patient had no facial numbness and remained completely pain free (BNI pain intensity score I) without requiring any pharmacological treatment.
FIG. 4.
Postoperative imaging. A: Diffusion-weighted MR image showing no ischemic lesions. B: MR CISS image showing that the left trigeminal nerve (arrow) is decompressed from the AICA (arrowhead), which originates from a dolichoectatic basilar artery (asterisk). C: Three-dimensional fusion image of CISS and 3D CTA images demonstrating rerouting of the trigeminal nerve (arrow) by a GORE-TEX sling (dotted arrow).
Informed Consent
The necessary informed consent was obtained in this study.
Discussion
Observations
MVD is the first-line surgical procedure for TN caused by vascular compression of the trigeminal nerve, which achieves decompression by mobilizing the offending vessel.3 However, if the offending vessel is severely atherosclerotic, dilated, and tortuous, as in vertebrobasilar dolichoectasia, this vessel-centric approach may not be feasible or safe.16–18 Attempting to mobilize such arteries can carry a high risk of ischemic complication due to involvement of perforating branches.6,12,19 In the present case, we could avoid such difficulties by successfully rerouting the trigeminal nerve itself to achieve decompression, rather than manipulating the dolichoectatic vessel. This nerve-centric approach, facilitated by opening Meckel’s cave, may offer a valuable alternative in anatomically and surgically constrained scenarios.
The SCA is the most commonly responsible vessel for TN, followed by the AICA, which together account for 72%–85% of vascular compression of the trigeminal nerve.4–6 Conversely, TN associated with vertebrobasilar dolichoectasia, which includes dilation, tortuosity, and atherosclerotic changes of the VBS, is relatively rare, with a reported frequency of 1.4%–7.6%.8–11 The need for a deep surgical field and the presence of advanced atherosclerosis may contribute to a high risk of brainstem infarction due to manipulation of the dolichoectatic VBS.11,12,20 Consequently, treatment outcomes are generally poor, with frequent reports of inadequate symptom relief and recurrence.16–18 Two of 13 patients with TN associated with vertebrobasilar dolichoectasia treated with the interposition method via the lateral suboccipital approach subsequently developed severe atherosclerosis, and the presence of brainstem perforators made it difficult to mobilize the offending artery, resulting in residual postoperative pain due to insufficient decompression.16 Similarly, minimal residual contact between the vessel and nerve can contribute to persistent postoperative pain after MVD via the lateral suboccipital approach.17 The presence of vertebrobasilar dolichoectasia and other cranial nerves occupying the cistern may also prevent adequate transposition of the offending vessel, thereby complicating the surgery.17 The recurrence rate has been reported to be 10%.18 Furthermore, the risk of complications is higher in cases involving vertebrobasilar dolichoectasia.8–11 Since the perforating branches of the VBS directly supply the brainstem, there is a risk of brainstem infarction due to excessive extension or impairment of the perforating branches during the translocation of the dolichoectatic VBS.6,12,19 Additionally, 41% of patients experienced new or worsened facial numbness, 23% developed transient diplopia due to abducens nerve palsy, and 13% experienced hearing loss due to cochlear nerve injury.21 The senior author (S.O.) has previously performed the interposition method via the lateral suboccipital approach in 7 patients with vertebrobasilar dolichoectasia–related TN, with 1 case of recurrence and 1 case of permanent abducens nerve palsy during a median follow-up of 8.6 years (unpublished data). Therefore, a novel strategy was used in the present case to reroute the trigeminal nerve instead of the offending vessel to avoid the limitations of attempting to mobilize thick and rigid arteries with advanced atherosclerotic changes.
The lateral suboccipital approach has been widely used in the past, but the transpetrosal approach has been used more recently to achieve safe and effective vascular transposition.13–15 The transpetrosal approach offers the advantage of improved visualization in the direction of vessel mobilization and may reduce the risks of hearing loss and perforator injury, and thus is a valuable option for centers with expertise in skull base surgery. The trigeminal nerve is considered to possess both resilience and plasticity to mechanical stress and compression,22 and thus is frequently mobilized during the resection of skull base meningiomas. This nerve rerouting technique depends on these characteristics. Rerouting the nerve allows for complete decompression without manipulating the offending vessel, thus reducing the risk of perforator injury and brainstem infarction. A similar concept involving vascular transposition combined with Meckel’s cave opening has been reported in 1 previous case.15 However, no technique has been described that transposes the trigeminal nerve, rather than the compressing vessel, to achieve decompression in the setting of vertebrobasilar dolichoectasia. Furthermore, the use of a GORE-TEX sling for nerve transposition appears to be a novel technique. We summarize the literature from the past 10 years in Table 1.611,13,15,16,18,20,23–35 Table 1 indicates that decompression involving mobilization of the VBS is associated with an estimated 25% risk of complications, even with recent advances in surgical techniques and devices.
TABLE 1.
Summary of cases of TN caused by vertebrobasilar dolichoectasia during the past decade
| Authors & Year | No. of Cases | Offending Vessel (cases) | MVD Method (material) | Approach | Pain-Free Ratio (%) | Complications (cases) | Mean FU, mos |
|---|---|---|---|---|---|---|---|
| Present case | 1 | Lt VA | Nerve rerouting (GORE-TEX sling) | ATP | 1 (100) | Temporary facial numbness | 7 |
| Jiang et al., 202523 | 1 | Lt VA | Interposition (Teflon) | RS | 1 (100) | No | 17 |
| Yindeedej et al., 202515 | 1 | Rt VA | Transposition (Teflon) | CTP | 1 (100) | No | 84 |
| Visocchi et al., 20246 | 1 | BA | Interposition (Teflon) | RS | 1 (100) | No | 12 |
| Chelmis et al., 202424 | 1 | BA | Interposition (Teflon) | RS | 1 (100) | No | 8 |
| Takei et al., 202325 | 1 | Lt VA | Transposition (Teflon) | RS | 1 (100) | No | NA |
| Zheng et al., 202326 | 14 | NA | Transposition (Teflon) | RS | 12 (85.7) | Herpes simplex (1), facial numbness (2), facial palsy (1) | 23.7 |
| Früh & Vajkoczy, 202227 | 1 | Lt VA | Transposition (polyester-titanium sling) | ATP | 1 (100) | Facial nerve palsy | 2 |
| Yu et al., 202218 | 30 | VA (29), BA (1) | Interposition (Teflon) | RS | 30 (100) | No | 76.67 |
| Zhao et al., 202128 | 46 | VA (37), BA (9) | Interposition (Teflon), transposition (Teflon) | RS | 43 (93.5) | Facial numbness (3), dry eyes (1), facial nerve palsy (1), taste hypoesthesia (2), hearing loss (3), diplopia (1), CSF leak (1), wound infection (2) | NA |
| Duong et al., 202129 | 1 | VBD (vessel unclear) | Interposition (neurosurgical sponge) | RS | 1 (100) | No | 3 |
| Shulev et al., 202030 | 14 | BA (10), VA (4) | Transposition (Teflon) | RS | 14 (100) | Facial numbness (1), 6th dysfunction (1), 4th dysfunction (1), 7th dysfunction (2), hypoacusia (2) | 65 |
| Chai et al., 202031 | 39 | VA (31), BA (8) | Interposition (16), transposition (23) | RS | 37 (94.9) | Facial palsy (1), facial hypoesthesia (3), taste hypoesthesia (1), hearing loss (3), diplopia (1) | NA |
| Barrow & Ellis, 201932 | 2 | VA (2) | Transposition (Durepair) | RS | 2 (100) | NA | NA |
| Yoon et al., 201913 | 1 | BA | Transposition (GORE-TEX sling) | ATP | 1 (100) | Facial numbness, 6th palsy | 8 |
| Arai et al., 201833 | 3 | VBD (vessel unclear) | Tentorium cut & split | RS | 3 (100) | Trigeminal anesthesia (1) | 23 |
| Honey & Kaufmann, 201816 | 13 | BA (7), VA (6) | Transposition (Teflon) | RS | 13 (100) | Hypoesthesia (3), nystagmus (1), gaze palsy (1) | NA |
| Sun et al., 201720 | 15 | BA (7), VA (8) | Interposition (Teflon) | RS | 15 (100) | Angulus oris numbness (2) | 29.8 |
| Apra et al., 201711 | 3 | BA (3) | Interposition (Teflon) | RS | 3 (100) | Facial palsy (1), 6th palsy (2) | 20 |
| Vanaclocha et al., 201634 | 8 | BA (8) | Transposition (Teflon) | RS | 7 (87.5) | Facial hypoesthesia (4) | 56.5 |
| Grigoryan et al., 201635 | 12 | BA (8), VA (4) | Transposition (muscle/fat/fascia/silicone) | RS | 12 (100) | NA | NA |
ATP = anterior transpetrosal; BA = basilar artery; CTP = combined transpetrosal; FU = follow-up; NA = not available; RS = retrosigmoid; VA = vertebral artery; VBD = vertebrobasilar dolichoectasia.
We attempted to mobilize the AICA and basilar artery, but these vessels were minimally mobile due to severe atherosclerotic changes, so effective decompression could not be achieved. Instead, the trigeminal nerve was pulled away from the offending vessel by opening Meckel’s cave. This procedure may help minimize the risk of cerebral infarction associated with manipulation of the basilar artery. Moreover, unlike the lateral suboccipital approach, this method avoids inadvertent manipulation of both the abducens and auditory nerves, thereby reducing the risk of cranial nerve injury. Additionally, the interposition method has involved exacerbation of nerve compression and complications due to granulomatous reactions from inserted materials.36,37 In contrast, the present technique allows for minimal use of such materials.
The anterior transpetrosal approach is somewhat more complicated than the conventional lateral suboccipital approach and requires specific surgical expertise to avoid complications such as nerve injury, venous congestion, temporal lobe contusion, and postoperative CSF leakage. In particular, patients with a well-developed superior petrosal sinus, as well as those exhibiting a sphenopetrosal venous drainage pattern, may be considered to have contraindications to this approach due to limited surgical access and increased risk of venous injury. Therefore, this approach should only be considered at institutions with substantial experience in skull base surgery. In addition, unpleasant paresthesia due to significant mobilization of the trigeminal nerve may occur. However, we believe that careful manipulation of the trigeminal nerve can limit neurological impairment to an acceptable level, as observed in this case. To our knowledge, the use of a GORE-TEX sling for transposing the trigeminal nerve has not been previously reported. Therefore, the actual risks remain unclear, but potential complications include foreign body reaction and granuloma formation. However, no such adverse events were observed in our case. Experience with more cases is necessary to evaluate the long-term analgesic efficacy and potential for delayed complications.
Lessons
Nerve decompression achieved by mobilizing the offending arteries in patients with TN associated with vertebrobasilar dolichoectasia carries a high risk of brainstem infarction and cranial nerve injury. The present technique of nerve decompression based on the relative mobility of the trigeminal nerve performed via the anterior transpetrosal approach is a highly effective alternative treatment method with minimal complication risks.
Disclosures
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Author Contributions
Conception and design: Aihara, Nakazato. Acquisition of data: Aihara, Nakazato, Itabashi. Analysis and interpretation of data: Aihara, Nakazato, Mukada. Drafting the article: Aihara, Nakazato. Critically revising the article: Aihara, Oya. Reviewed submitted version of manuscript: Aihara, Kunitomi, Oya. Approved the final version of the manuscript on behalf of all authors: Aihara. Administrative/technical/material support: Aihara. Study supervision: Oya.
Correspondence
Masanori Aihara: Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan. masa.a6221@gunma-u.ac.jp.
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