Comparison of Microvascular Decompression and Two Isocenters Gamma Knife for the Treatment of Trigeminal Neuralgia Caused by Vertebrobasilar Dolichoectasia

Microvascular Decompression for Trigeminal Neuralgia Using Autologous Muscle Grafting: A Retrospective Analysis in a Resource-Limited Setting

Background Trigeminal neuralgia (TN) is a rare and painful condition that offers various treatment options. Despite the availability of multiple modalities, their comparative efficacy is still debated due to inconsistent study outcomes. Microvascular decompression (MVD) using autologous muscle grafts has recently gained attention as a treatment option. While muscle grafts were previously employed extensively, this approach is only now being introduced in Yemen, where documented outcomes related to MVD for TN are scarce. This study aims to present the outcomes of MVD for TN utilizing autologous muscle grafts in a resource-limited environment. Patients and methods This study employs a retrospective cross-sectional design involving 324 patients diagnosed with TN who underwent MVD using autologous muscle grafts between April 1, 2006, and March 25, 2020. Data regarding demographic and clinical factors, outcomes, and complications were systematically collected and analyzed. Results The mean age of the patients was 48.8±11.6 years, with the majority being female patients (n=180, 55.6%), with a significant proportion of patients exhibiting left-sided involvement (n=204; 63%). Significant nerve compression was the primary operative finding in the study population (n=251; 77.5%). In most cases, a single vessel contributed to the compression of the nerve, primarily the superior cerebellar artery (n=303; 93.5%). No major surgical complications were reported, with temporary nasal cerebrospinal fluid (CSF) leakage (n=1; 0.3%), transient facial numbness (n=16; 4.9%) that resolved within one week to one month, hyperacusis (n=5; 1.5%), and hyperesthesia (n=3; 0.9%) being the common ones. Follow-up over an average of 52.7±8.0 months indicated that the majority of patients (n=302; 93.2%) achieved favorable outcomes, as reflected in Barrow Neurological Institute (BNI) scores I and II. The BNI pain intensity score improved from V preoperatively to I and II and was statistically significant (P=0.006). The remaining patients (n=22; 6.8%) exhibited fair to poor BNI scores (III, IV, and V). Sixteen patients obtained effective pain relief through medication, while six required radiofrequency thermocoagulation. Conclusion  The findings suggest that MVD utilizing autologous muscle grafts may serve as an effective long-term surgical intervention for TN, even in resource-limited settings. Effective management of TN necessitates a comprehensive preoperative assessment, careful candidate selection, appropriate imaging techniques, and proficient surgical execution.

A Case With Twists and Turns: A Report of Vertebrobasilar Dolichoectasia

Vertebrobasilar dolichoectasia (VBD) is a rare anatomical abnormality of the vertebral artery system, defined as irregular expansion, elongation, and tortuosity of vertebral arteries. Anomalies of the vertebrobasilar artery can have a wide variety of clinical presentations, ranging from simple headaches to debilitating strokes. We present the case of an atypical presentation of VBD which mimicked trigeminal neuralgia by compressing the trigeminal nerve. There are currently no guidelines concerning the management of VBD, nor is there evidence of a definitive cure. This case invoked discussions among the medical team as to whether management should be medically or surgically focused, as well as long-term outcomes for patients with VBD. The superiority of medical versus surgical treatment of this issue is still a debated topic. This patient trialed medical management with dexamethasone and carbamazepine with no improvement in symptoms. He then underwent surgical gamma knife treatment but even this invasive measure was unsuccessful at relieving his symptoms. We hope that by presenting this case, we can display how the therapies available for VBD are limited and often unsuccessful in relieving the disease burden in patients with VBD.

Proximal trigeminal nerve atrophy is associated with favourable outcomes and persistent facial numbness following percutaneous balloon compression for primary trigeminal neuralgia

OBJECTIVE

Whether nerve atrophy can affect the prognosis of primary trigeminal neuralgia (PTN) patients undergoing percutaneous balloon compression (PBC) remains unclear. This study aimed to determine the association between nerve characteristics observed on preoperative magnetic resonance imaging (MRI) and PBC outcomes.

METHODS

Between January 2019 and December 2022, a cohort of 58 patients with unilateral PTN treated with PBC were analysed retrospectively and included in this study. The relationship between MRI findings, including the proximal and distal nerve cross-sectional areas (CSAs), and favourable pain outcomes (BNI Grades I-III) was analysed through Kaplan‒Meier analysis.

RESULTS

After a mean follow-up period of 23.8 ± 13.0 months (range, 6-50 months), 48 (82.8%) patients with PTN were pain free with or without medication. A smaller proximal CSA ratio (proximal CSA of the affected nerve/proximal CSA of the unaffected nerve) was significantly associated with favourable outcomes. The Kaplan-Meier survival analysis showed that patients with proximal nerve atrophy (proximal CSA ratio ≤ 87% after receiver operating characteristic curve analysis) had a higher estimated 4-year probability of maintaining a favourable outcome than those without nerve atrophy (94.4% vs. 30.8%, p = 0.005). In addition, patients with proximal nerve atrophy were more likely to suffer from postoperative persistent facial numbness.

CONCLUSIONS

Proximal nerve atrophy is correlated with both favourable outcomes and persistent facial numbness following PBC. Prospective studies are required to determine the optimal duration and pressure of balloon compression in relation to the proximal CSA ratio to achieve better pain outcomes and less facial numbness.

Efficacy and safety of computed tomography-guided percutaneous balloon compression for trigeminal neuralgia secondary to vertebrobasilar dolichoectasia

Percutaneous balloon compression (PBC) of Gasserian ganglion has been popularly used to treat trigeminal neuralgia (TN), one of the most painful syndromes in human experience. Vertebrobasilar dolichoectasia (VBD) is a rare cause of TN and remains challenging to treat. To our knowledge, no study has reported the therapeutic outcome of PBC for VBD-related TN (VBD-TN). In this retrospective study, we collected and analyzed the medical records of all patients undergoing PBC procedure for VBD-TN under the guidance of CT plus three-dimensional reconstruction at the Pain Management Center of Beijing Tiantan Hospital from January 2017 to December 2022. All 23 patients (15 men and 8 women) had a substantial pain relief as modified Barrow Neurological Institute (BNI) I-IIIb immediately after procedure. The follow-up duration ranged from 2 to 63 months, and at the last follow-up visit, only 3 patients (13%) relapsed (BNI IV-V). The cumulative recurrence-free survival was 95%, 87%, and 74% within 1, 3, and 5 years, respectively. Patients' reported satisfactory rate was 100% as Likert scale 4-5 throughout the whole follow-up period, with no severe complications occurring. Our data revealed promising efficacy and safety of PBC procedure for treatment of VBD-TN, thus suggesting a valuable option for pain control in these rare cases of TN. However, there has been no supporting evidence that PBC treatment is a preferred option to other treatments.