Microvascular decompression for trigeminal neuralgia caused by trigeminocerebellar artery

Microvascular decompression of trigeminal nerve through endoscopic retrosigmoid keyhole approach: Anatomical considerations of the trigeminocerebellar artery, technical pearls, and pitfalls

Background

Involvement of the trigeminocerebellar artery (TCA) in trigeminal neuralgia (TN) is rare, and reports of decompression using an endoscopic retro sigmoid keyhole approach are limited. This study, the largest of its kind, examines TCA-related TN cases to highlight the anatomical and surgical importance of the TCA, discuss technical difficulties in decompression, and review strategies for managing complications, along with a summary of previous cases.

Methods

Between April and September 2024, 56 endoscopic microvascular decompression (eMVD) procedures for TN were conducted using a 0° endoscope through the retrosigmoid keyhole approach in the Department of Neurosurgery, Fujita Health University Bantane Hospital, Japan. Among these, five cases involved the TCA as the compressive artery. We analyzed patient demographics, clinical presentations, neurovascular conflict (NVC) types, decompression techniques, surgical challenges, and outcomes, including a pictorial review of the TCA's developmental background, surgical anatomy, and clinical relevance.

Results

Of the 56 patients treated with eMVD, 5 (8.9%) were confirmed to have TCA-induced TN. These patients, predominantly female (60%) with an average age of 70.3 years, presented mainly with V2 or V3 distribution pain, primarily on the left side. Intraoperative analysis revealed multiple NVC points in 80% of cases due to the TCA's complex course, with variations in conflict type. Postoperative outcomes were positive, with immediate pain relief in all cases and 80% achieving complete symptom remission. No perioperative complications were observed. Preoperative imaging with 3D reconstruction and computed tomography angiography was valuable for planning, though intraoperative indocyanine green angiography was essential to confirm NVCs and the status of perforating arteries.

Conclusion

eMVD through a retro sigmoid keyhole approach is safe and effective for TCA-induced TN. Surgeons should consider potential TCA involvement and multiple NVCs to optimize decompression strategies.

How I do it: Endoscopic microvascular decompression for a nerve penetrating trigeminocerebellar artery causing trigeminal neuralgia

BACKGROUND

The trigeminocerebellar artery is a standard variant originating from the basilar artery and can be an infrequent cause of trigeminal neuralgia.

METHOD

Total endoscopic microvascular decompression (eMVD) was performed using a 0-degree endoscope through a retro sigmoid keyhole. Multiple points of neurovascular conflict enhanced by indocyanine green angiography were identified, and the root entry zone was decompressed. The patient had an improvement in facial pain with no complications.

CONCLUSION

Complete eMVD for a nerve-penetrating artery is a practical, minimally invasive, uncomplicated technique that improves visualization and patient comfort.