Carotid cavernous fistula after percutaneous balloon compression for trigeminal neuralgia: Endovascular treatment with coils

A technique to facilitate the cannulation of the foramen ovale for balloon compression

BACKGROUND

Percutaneous balloon compression is a safe and effective treatment for trigeminal neuralgia. Current technique consists of penetrating the foramen ovale using a sharp 14G needle with a stylet. Difficulty of cannulation of the foramen ovale, failures of cannulation and major neurovascular complications of the procedure, although rare, may be due to the relatively large caliber of this needle and its sharp tip.

OBJECTIVE

To present a novel technique to facilitate and make the cannulation of the foramen ovale with a 14G cannula safer.

METHODS

A rigid blunt-tip guide of 1.2 or 1.5 mm is used to penetrate the foramen ovale under lateral fluoroscopic control. Once the guide enters the foramen it is advanced further to the clival line, and a 14G cannula is then advanced over the guide to engage the foramen, at which point the guide is withdrawn and replaced with the balloon catheter.

RESULTS

The technique was employed to deliver a 4F balloon catheter to Meckel's cave successfully in 500 consecutive procedures performed on 416 trigeminal neuralgia patients. None of the patients had neurovascular complications like facial hematoma, arterial injury, carotid-cavernous fistula or cranial nerve palsies.

CONCLUSION

A novel technique for cannulation of the foramen ovale is described. The use of blunt tip guides of smaller diameters instead of sharp 14 G needles considerably facilitated cannulation of the foramen ovale and enabled cannulation in all cases. Absence of complications of cannulation such as facial hematoma, carotid-cavernous fistula or intracranial hemorrhage in this series of patients suggests that the technique may be safer than the use of conventional sharp tipped 14G needles in terms of avoiding neurovascular complications.

Middle meningeal artery pseudoaneurysm and pterygoid plexus fistula following percutaneous radiofrequency rhizotomy: illustrative case

BACKGROUND

Percutaneous treatment for trigeminal neuralgia is a safe and effective therapeutic methodology and can be accomplished in the form of balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation. These procedures are generally well tolerated and demonstrate minimal associated morbidity. Moreover, vascular complications of these procedures are exceedingly rare.

OBSERVATIONS

We present the case of a 64-year-old female with prior microvascular decompression and balloon rhizotomy who presented after symptom recurrence and underwent a second balloon rhizotomy at our institution. Soon thereafter, she presented with pulsatile tinnitus and a right preauricular bruit on physical examination. Subsequent imaging revealed a middle meningeal artery (MMA) to pterygoid plexus fistula and an MMA pseudoaneurysm. Coil and Onxy embolization were used to manage the pseudoaneurysm and fistula.

LESSONS

This case illustrates the potential for MMA pseudoaneurysm formation as a complication of percutaneous trigeminal balloon rhizotomy, which has not been seen in the literature. Concurrent MMA-pterygoid plexus fistula is also a rarity demonstrated in this case.

Robot-assisted percutaneous balloon compression for trigeminal neuralgia- preliminary experiences

OBJECTIVES

This study aims to discuss the availability of robot-assisted percutaneous balloon compression (PBC) for trigeminal neuralgia (TN) and share our preliminary experiences.

METHODS

Patients with TN who underwent robot-assisted PBC from June to September 2022 were enrolled. We designed a fixing plug for robot-assisted PBC, three-dimensional structured light registration was used, puncture trajectory was the line connects the medial third of inner and outer aperture of foramen ovale. Numerical Rating Scale (NRS), Barrow Neurological Institute (BNI) pain and numbness intensity score were used to evaluate the facial pain and numbness.

RESULTS

Eventually, nine patients were enrolled, the structured light registrations were successfully finished in all patients with a mean registration error of 0.68 mm. All the punctures of foramen ovales were successfully done one-time. Of note, the balloons were all got pear-shaped followed by 150 to 180 s compression. Though, postoperatively, all the patients complained of facial numbness and four patients suffered from transient masseter weakness, all patients got fully or mostly pain relief. It should be noted that is the numbness and weakness gradually relieved during follow-up.

CONCLUSION

Three-dimensional structured light registration and robot assisted PBC is an effective choice for patients with TN. Extension line between the medial third of the inner and outer aperture of foramen ovale might be a safe and effective puncture trajectory to this procedure.

The pros and cons of multiple puncture in percutaneous balloon compression for treatment of trigeminal neuralgia

Background

Percutaneous balloon compression (PBC) is an effective and well-established surgery for treating trigeminal neuralgia (TN). However, if the initial attempt fails to produce a distinct pear shape, there is no conventional strategy to follow: repeat a few days later or re-puncture?

Aims

This study aimed to analyze the risk and gain of re-puncturation in PBC surgery for TN treatment.

Methods

We reviewed radiographs and medical records from 79 consecutive PBC cases. The complications and surgical outcomes were compared between one-time success pears and multiple re-puncturing pears. Re-puncturing methods included selecting a more appropriate entry point, a more possible entry angle, finding a stretchy spot around the margin of foramen ovale (FO) with a trocar, and exploring the direction with more resistance using a thinner guiding needle.

Results

In 50% of cases, satisfactory pears were obtained after the first puncture, and in 35% of cases, satisfactory pears were obtained following re-puncturation. Except for hemihypogeusia, which was significantly more in multiple punctures cases (p < 0.05), no additional adverse effects were statistically different between the two groups. There are very few rare complications associated with re-puncturation. Log-Rank test of pain-free rate revealed no statistically significant differences between the two groups (p = 0.129).

Conclusion

This study establishes the safety of re-puncturation in PBC surgery for TN treatment. The operation increases pears and does not cause any serious complications. The surgical outcomes of re-puncturation pears are almost identical to those one-time success pears.

Microvascular decompression for trigeminal neuralgia caused by persistent trigeminal artery associated with craniosynostosis: a case report

BACKGROUND

Persistent trigeminal artery (PTA) is a rare arterial anastomosis between the basilar artery (BA) and internal carotid artery (ICA). It plays an indispensable role in a number of neurological disorders, including trigeminal neuralgia (TN).

CASE PRESENTATION

We report a unique case of a 58-year-old Han female patient with TN caused by PTA associated with craniosynostosis. Preoperative three-dimensional time-of-flight (3D-TOF) magnetic resonance (MR) and 3D constructive inference in steady state (3D-CISS) imaging showed that the PTA run though Meckel's cave. Complete pain relief was immediately achieved after microvascular decompression (MVD), without facial numbness and other complications. No recurrence was recorded at the 1-year follow up.

CONCLUSIONS

Microvascular decompression is a feasible option for the treatment of complex TN combined with other abnormalities. For patients deemed suitable for percutaneous balloon compression, PTA should be ruled out. Preoperative 3D-TOF and 3D-CISS MR imaging were essential to identify PTA neurovascular conflicts.

Cone Beam CT With Flat Panel Detector and Biplane Fluoroscopy-Guided Percutaneous Trigeminal Nerve Rhizotomy Using Three-Dimensional Needle Trajectory Planning

Trigeminal-mediated pain disorders can be devastating for patients refractory to medical therapy. Gasserian ganglion blocks and percutaneous trigeminal rhizotomy have been used with success to treat these patients, however, serious complication risks include facial hematoma, cranial nerve palsy, and stroke. Cone beam CT, combined with fluoroscopy and needle navigation has been shown to decrease needle pass rates, procedure time, radiation exposure, and complications in multiple interventional radiology procedures, but hitherto has not been utilized for Gasserian ganglion interventions. Here, we present two cases of trigeminal-mediated pain successfully treated via cone beam CT combined fluoroscopy and needle navigation.

Anatomical relationship between the foramen ovale and the lateral plate of the pterygoid process: application to percutaneous treatments of trigeminal neuralgia

Our aim was to clarify the variations in the positional relationship between the base of the lateral plate of the pterygoid process and the foramen ovale (FO), which block inserted needles during percutaneous procedures to the FO usually used for the treatment of trigeminal neuralgia. Ninety skulls were examined. The horizontal relationship between the FO and the posterior border of the base of the lateral plate of the pterygoid process was observed in an inferior view of the skull base. Skulls that showed injury to either the FO or the lateral plate of the pterygoid process on either side were excluded. One hundred and sixty sides of eighty skulls were eligible. The relationship between the FO and the posterior border of the base of the lateral plate was classified into four types. Among the 160 sides, type III (direct type) was the most common (35%), followed by type I (lateral type, 29%) and type IV (removed type, 21%); type II (medial type) was the least common (15%). Of the 80 specimens, 53 showed the same type bilaterally. In type IV, the posterior border of the base of the lateral plate is disconnected from the FO, so percutaneous procedures for treating trigeminal neuralgia could fail in patients with this type.