Trigeminal neuralgia due to vertebrobasilar dolichoectasia: Three case reports

Macrovascular decompression of a dolichoectatic vertebral artery via Kawase approach in a patient suffering from trigeminal neuralgia – A case report

Introduction

Secondary trigeminal neuralgia due to vertebrobasilar dolichoectasia is a rare entity. Surgical therapy via pterional craniotomy approach and anterior petrosectomy has already been described in literature. We present an 81-year female patient suffering from left sided trigeminal neuralgia due to vertebrobasilar dolichoectasia.

Research question

We show in this case report a macrovascular decompression of a dolichoectatic vertebral artery via Kawase approach.

Material and methods

Successful decompression under continuous intraoperative neuromonitoring via pure Kawase approach and ventro-lateral transposition of a dolichoectatic vertebral artery through a polyester-titanium sling was achieved.

Results

Postoperative the patient described an immediate improvement of the trigeminal neuralgia symptoms. At the two-month postoperative follow-up the patient remained trigeminal neuralgia painless free and suffered from a regredient facial nerve palsy.

Discussion and conclusion

We report for the first time a successful macrovascular decompression of a dolichoectatic vertebral artery via Kawase approach under continuous intraoperative neuromonitoring. In-contrast to traditional suboccipital retrosigmoidal approach our strategy obtains sufficient working space and angles. Thus, adequate transposition of the dolichoectatic vessel could be achieved.

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Secondary trigeminal neuralgia due to vertebrobasilar dolichoectasia is a rare entity.

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Successful macrovascular decompression of a dolichoectatic vertebral artery via Kawase approach.

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Transposition through a polyester-titanium sling.

Endoscopic-assisted microvascular decompression for trigeminal neuralgia secondary to vertebrobasilar dolichoectasia: A case report

INTRODUCTION AND IMPORTANCE

Trigeminal neuralgia (TN) secondary to vertebrobasilar dolichoectasia (VBD) was a rare condition. This paper reported a successful endoscopic-assisted microvascular decompression (MVD) for TN secondary to VBD.

CASE PRESENTATION

A 53-year-old male with a history of myocardial infarction and heart failure complained of left refractory facial pain three years prior to admission. His pain was intermittent, electrical-like, severe, sharp, and radiated along the maxillary and mandibular branches. He used carbamazepine 600 mg daily. Brain magnetic resonance imaging revealed a neurovascular conflict between VBD and the left trigeminal nerve. The endoscopic-assisted MVD was indicated. The shredded neurosurgical sponges were interposed between VBD and trigeminal nerve. The 0° and 30° rigid rod-lens endoscope was used to explore and confirm the complete decompression. Postoperatively, TN was disappeared entirely. At a three-month postoperative, no facial pain and paraesthesia were found. The patient discontinued carbamazepine permanently.

CLINICAL DISCUSSION

MVD was still the most effective treatment. An inspection of root entry zone (REZ) and complete MVD with a solely operating microscope were challenging due to the massive diameter of VBD and multiple offending arteries behind the VBD. However, the wide viewing field and high-quality resolution of endoscopes allowed better visualization of REZ and neurovascular conflicts behind neural structures and least cerebellar retraction. This is essential in case of less potential space created by VBD.

CONCLUSION

Endoscope-assisted MVD allowed better visualization of REZ and neurovascular conflicts behind neural structures and least cerebellar retraction in management of trigeminal neuralgia secondary to VBD.

[Microvascular decompression in trigeminal neuralgia following vertebrobasilar dolichoectasia]

OBJECTIVE

To analyze our own results with literature data and substantiate microvascular decompression in patients with trigeminal neuralgia (TN) following vertebrobasilar dolichoectasia (VBD).

MATERIAL AND METHODS

A total of 504 patients with TN underwent surgery in 1998-2018. Patients with TN following VBD were included into a retrospective study. There were 4 men and 10 women aged 66 years (range 51-80). Outcomes were evaluated using BNI (Barrow Neurological Institute) scale. PubMed database was used for literature review.

RESULTS

TN caused by VBD was diagnosed in 2.8% of patients. Left-sided trigeminal pain was observed in 10 patients, right-sided - in 4 cases. One patient had concomitant hemifacial spasm. MVD followed by shielding of trigeminal nerve root with shredded Teflon was performed in all patients. We did not perform fixation of vertebrobasilar vessels. In one case, open partial trigeminal nerve root rhizotomy was done in addition to MVD. All patients had pain-free early postoperative period. There were no deaths or major complications. There was transient cranial nerve dysfunction lasting no more than three months (facial numbness - 1, IV nerve dysfunction - 1, VI nerve dysfunction - 1, transient partial facial palsy (House-Brackmann II) - 2, hipoacusia - 2 patients). There was no facial pain recurrence in our group. Mean follow-up period was 5.5 years (range 6 months - 16 years).

CONCLUSION

MVD is an effective option in the treatment of TN following VBD. In these cases, operation is technically more difficult compared to MVD with intact vessels. However, surgery is much more effective than all the available alternatives. The possibilities of vessel transposition in VBD with or without fixation are limited and ineffective. Teflon wool interposition at the points of conflict is an effective and sufficient technique.

Microvascular decompression for trigeminal neuralgia secondary to vertebrobasilar dolichoectasia. Case report, literature review, and pooled case analysis

INTRODUCTION

Vertebrobasilar dolichoectasia is a condition in which there is elongation and dilatation of the vertebral and basilar arteries. Few studies have been reported that focus on cases of trigeminal neuralgia (TN) secondary to vertebrobasilar dolichoectasia (VD) and treated by microvascular decompression (MD).

PATIENTS AND METHODS

A case is presented of trigeminal neuralgia caused by vertebral artery compression. An analysis of the microsurgical technique, as well as a systematic review of the literature about this uncommon nerve compression is performed, in order to investigate, by pooled case analysis, if MD is a good option for this type of patient.

RESULTS

A total of 7 studies were included for analysis, to which the present case was added, making a total of 56 patents. There were excellent results in 53 cases, and partial recovery in 3, with a mean follow up of 54 months. No major complications were found.

DISCUSSION

The good clinical results and absence of postoperative mortality or severe morbidity in our pooled case series lead us to recommend MD as the preferred treatment for TN caused by VD in patients in whom major surgery is not contraindicated.

Multimodality Imaging of Vertebrobasilar Dolichoectasia: Clinical Presentations and Imaging Spectrum

Vertebrobasilar dolichoectasia (VBD) is characterized by ectasia, elongation, and tortuosity of the vertebrobasilar arteries, with a high degree of variability in clinical presentation. The disease origin is believed to involve degeneration of the internal elastic lamina, thinning of the media secondary to reticular fiber deficiency, and smooth muscle atrophy. The prevalence of VBD is variable, ranging from 0.05% to 18%. Most patients with VBD are asymptomatic and their VBD is detected incidentally; however, it is important to recognize that the presence of symptoms, which can lead to clinically significant morbidity and sometimes mortality, may influence clinical management. The most important clinical presentations of VBD are vascular events, such as ischemic stroke and catastrophic intracranial hemorrhage, or progressive compressive symptoms related to compression of adjacent structures, including the cranial nerves, brainstem, or third ventricle, causing hydrocephalus. The imaging diagnostic criteria for computed tomography and magnetic resonance (MR) imaging include three quantitative measures of basilar artery morphology: laterality score, height of bifurcation, and basilar artery diameter. The authors review the relevant anatomy and disease origin of VBD; pertinent imaging findings, including intraluminal thrombus and relation to the cranial nerves; and imaging pitfalls, such as the hyperintense vessel sign on MR images and artifacts related to slow flow in the dolichoectatic vessel. In addition, clinical manifestations, the role of radiology in diagnosis and management of this condition, and available management options are reviewed. (©)RSNA, 2016.

Application of Antidromic Conduction Monitoring in Ganglion Radiofrequency Thermocoagulation for Locating Trigeminal Branches in Trigeminal Neuralgia

OBJECTIVE

The aim of this study was to investigate whether antidromic conduction monitoring (ACM) can be utilized to map the trigeminal system under sedation as a potential substitute for subjective paresthesia description (SPD) during percutaneous ganglion radiofrequency thermocoagulation (PGRT).

METHODS

Eighty-two patients with 152 pain divisions of trigeminal neuralgia (TN) were treated by computed tomography (CT)-guided PGRT. After the puncture needle entered the foramen ovale (FO), sensory and motor stimulation were applied to locate the pain division. And the corresponding voltage values were recorded by patients' SPD. In the following, the proper location was certified by ACM. The corresponding earliest waves and voltage values in the identified trigeminal branch were also recorded to outline a comparison between two methods.

RESULTS

The correlation of ACM and patients' SPD with voltage at ≤ 0.5 V was statistically significant (P < 0.05, r = 0.159; Spearman's rank correlation analysis). Although ACM and SPD showed weak correlation, as their interclass correlation coefficient was significant (F = 1.868, P < 0.01) with coefficient of internal consistency. Moreover, the two methods had consistency. Kruskal-Wallis test showed that ophthalmic (V1), maxillary (V2), and mandibular (V3) divisions had significant differences for test sensitivity (H = 15.945, P < 0.01). For comparison of sensitivities with ACM, V3 was most sensitive followed by V2 and then V1.

CONCLUSION

ACM could potentially substitute for SPD of the paresthesias intra-operatively, enabling greater specificity and eliminating the need to interrupt the administration of anesthetic. These improvements would increase patient satisfaction and practitioner efficiency and accuracy.