Microvascular Decompression In Patients Research Articles

Clinical Depression and Anxiety Are Relieved by Microvascular Decompression in Patients with Trigeminal Neuralgia-A Prospective Patient-Reported Outcome Study.

Objective: Patients with idiopathic trigeminal neuralgia (TN) live in constant fear of triggering shock-like pain episodes, which may cause symptoms of depression and a reduction in quality of life. Microvascular decompressive surgery has been demonstrated to achieve satisfactory and stable results. With this study, we wanted to investigate prevalence and risk factors for depression and perceived stress in correlation with symptom relief after surgical treatment. Methods: In this prospective study, patients undergoing microvascular decompression (MVD) for TN were included. The Barrow Neurological Institute Pain Score (BNI), Beck Depression Inventory (BDI), Chronic Pain Acceptance Questionnaire (CPAQ), Perceived Stress Questionnaire (PSQ) and McGill questionnaire were used to evaluate depression, stress and anxiety disorders before and 3 months after MVD. Results: A total of 35 patients (16 male (46%)) with a mean age of 55.4 (SD 15) years were included in this study. The BDI revealed that 24 (68.8%) patients harbored mild-to-extreme depression preoperatively (2.4 ± 1.4), which improved to 1.2 (±0.6, p < 0.0001). Pain acceptance also changed from 64 (±11.3) to 67.7 (±9.3, p = 0.006). Perceived stress decreased from 46.9 (±21.9) to 19.6 (±18.6) (p < 0.0001) postoperatively, and pain decreased from 31.0 (±11.7) to 9.4 (±12.9, p < 0.0001). Microvascular decompression reduced the mean BNI pain score significantly from 4.6 to 1.8 postoperatively (p < 0.00001). Conclusions: Depression and perceived stress are prevalent in patients with idiopathic TN. Adequate treatment not only provides a high rate of satisfaction through pain relief, but also leads to immediate and significant improvements in depression and stress. Thus, in patients with TN who do not reach an adequate and timely pain reduction through medical management and develop signs of depression, early treatment with microvascular decompression should be considered.

Long-term outcome of microvascular decompression for typical trigeminal neuralgia with autologous muscle: an analysis of 1025 patients from a developing country.

The objective was to evaluate the long-term outcome of microvascular decompression (MVD) utilizing autologous muscle for trigeminal neuralgia (TGN). A retrospective review was performed of all first-time MVD patients for typical classic TGN without prior surgical intervention who were treated between 2000 and 2019 at a tertiary supraregional neurosurgery practice. Demographic characteristics, surgical findings, operative results, complications, and recurrence rates at 1 year, 5 years, and last follow-up were collected. Pain outcome was assessed using the Barrow Neurological Institute (BNI) pain score. The chi-square test with continuity correction was used to compare categorical variables, and Kaplan-Meier curves and Cox regression were used to identify factors associated with recurrence. In total, 1025 patients were studied with a median (interquartile range [IQR]) (range) follow-up of 8 (5-13) (3-20) years. In the immediate postoperative period, 889 patients (86.7%) had complete pain relief and 106 (10.3%) had partial pain relief; neither group required medication, and 30 patients (2.9%) had no relief. One hundred forty-one recurrences (13.8%) occurred over a median (IQR) of 3 (2-6) years after surgery. The proportion of patients without recurrence was 97% at 1 year, 90% at 5 years, 85% at 10 years, 82% at 15 years, and 81% at 20 years. There was no significant difference in the probability of recurrence between patients with complete (114/907 [12.6%] recurrences) or partial (19/106 [17.9%] recurrences) postoperative pain relief (p = 0.124, log-rank test). Patients with venous compression (n = 322) had a significantly higher rate of MVD failure (n = 16 [5%]) compared to those with arterial compression (14/703 [2%]) (p = 0.015, chi-square test). In the Cox proportional hazards model, venous compression and lack of immediate postoperative pain relief had hazard ratios of 1.62 (95% CI 1.16-2.27) and 2.65 (95% CI 1.45-4.82) for recurrence, respectively. One hundred twenty-four (12.1%) complications were documented, including facial numbness (44 [4.3%]), facial nerve palsy (37 [3.6%]), CSF leak (13 [1.3%]), and diplopia (5 [0.5%]), which resolved in all patients. MVD with autologous muscle provides long-lasting pain relief in TGN patients with vascular compression with minimum morbidity and is a viable alternative to synthetic materials.

Virtual Reality Planning of Microvascular Decompression in Trigeminal Neuralgia: Technique and Clinical Outcome.

A neurovascular conflict (NVC) is considered the cause of trigeminal neuralgia (TN) in 75% of cases, and if so, a microvascular decompression (MVD) can lead to significant pain relief. A reliable preoperative detection of NVC is essential for clinical decision-making and surgical planning, making detailed neuroradiologic imaging an important component. We present our experiences and clinical outcomes with preoperative planning of the MVD procedure in a virtual reality (VR) environment, based on magnetic resonance imaging (MRI) including magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) sequences. We analyzed the data of 30 consecutive MVDs in patients treated for TN, in a retrospective single-surgeon (R.A. Kockro) study. Out of the 30 cases, 26 were included. Preoperatively, MRA/MRV and MRI series were fused and three dimensionally reconstructed in a VR environment. All critical structures such as the trigeminal nerve as well as the arteries and veins of the cerebellopontine angle, the brainstem, the neighboring cranial nerves, and the transverse and sigmoid sinus were segmented. The NVC was visualized and a simulation of a retrosigmoid approach, with varying trajectories, to the NVC was performed. The intraoperative findings were then compared with the data of the simulation. The clinical outcome was assessed by a detailed review of medical reports, and follow-up-interviews were conducted in all available patients (20/26). The VR planning was well integrated into the clinical workflow, and imaging processing time was 30 to 40 minutes. There was a sole arterial conflict in 13 patients, a venous conflict in 4 patients, and a combined arteriovenous conflict in 9 patients. The preoperative simulations provided a precise visualization of the anatomical relationships of the offending vessels and the trigeminal nerves as well as the surrounding structures. For each case, the approach along the most suitable surgical corridor was simulated and the exact steps of the decompression were planned. The NVC and the anatomy of the cerebellopontine angle as seen intraoperatively matched with the preoperative simulations in all cases and the MVC could be performed as planned. At follow-up, 92.3% (24/26) of patients were pain free and all the patients who completed the questionnaire would undergo the surgery again (20/20). The surgical complication rate was zero. Current imaging technology allows detailed preoperative visualization of the pathoanatomical spatial relationships in cases of TN. 3D interactive VR technology allows establishing a clear dissection and decompression strategy, resulting in safe vascular microsurgery and excellent clinical results.

Online dynamic nomogram for predicting pain recurrence after microvascular decompression in trigeminal neuralgia.

Trigeminal neuralgia (TN) is one of the most common causes of facial pain. Microvascular decompression (MVD) is the first-choice surgical treatment. The present study aimed to develop a novel practical assessment system based on preoperative clinical and imaging factors for clinicians to predict the likelihood of pain recurrence following MVD in TN. A total of 56 patients with primary unilateral TN who underwent MVD were retrospectively analyzed. Patients were followed up to observe pain recurrence 1 year after MVD. An online dynamic nomogram was constructed for predicting the probability of pain recurrence after MVD in patients with TN based on multivariate logistic model. The concordance index (C-index) and receiver operating characteristic (ROC) were used to measure model discrimination. Bootstrap resampling was used for internal validation of the model and calibration curve was constructed. Decision curve analysis (DCA) was used to assess clinical applicability. Factors such as numeric rating scale (to score pain degree of patients with TN), response to neuroanalgesic drugs and neurovascular contact on magnetic resonance imaging were independent risk factors affecting the pain recurrence rate (all P<0.05). C-index was 0.973 (95%CI, 0.938-1.000) and the area under the ROC was 0.973 (95%CI, 0.938-1.000). Calibration curve with a 1,000 bootstrap resampling showed a good fit between dynamic nomogram prediction and actual observations. The DCA showed that at a threshold probability between 0 and 100%, this model can achieve a greater net benefit than if all patients had surgery or none had surgery. In conclusion, this online dynamic nomogram reliably predicted risk of pain recurrence in patients with TN following MVD.

A Case Series of Stereotactic Radiosurgery First for Trigeminal Neuralgia: A History of Stereotactic Radiosurgery Does Not Complicate Microvascular Decompression.

The influence of prior stereotactic radiosurgery (SRS) on outcomes of subsequent microvascular decompression (MVD) for patients with trigeminal neuralgia (TN) is not well understood. To directly compare pain outcomes in patients undergoing primary MVD vs those undergoing MVD with a history of 1 prior SRS procedure. We retrospectively reviewed all patients undergoing MVD at our institution from 2007 to 2020. Patients were included if they underwent primary MVD or had a history of SRS alone before MVD. Barrow Neurological Institute (BNI) pain scores were assigned at preoperative and immediate postoperative time points and at every follow-up appointment. Evidence of pain recurrence was recorded and compared via Kaplan-Meier analysis. Multivariate Cox proportional hazards regression was used to identify factors associated with worse pain outcomes. Of patients reviewed, 833 met our inclusion criteria. Thirty-seven patients were in the SRS alone before MVD group, and 796 patients were in the primary MVD group. Both groups demonstrated similar preoperative and immediate postoperative BNI pain scores. There were no significant differences between average BNI at final follow-up between the groups. Multiple sclerosis (hazard ratio (HR) = 1.95), age (HR = 0.99), and female sex (HR = 1.43) independently predicted increased likelihood of pain recurrence on Cox proportional hazards analysis. SRS alone before MVD did not predict increased likelihood of pain recurrence. Furthermore, Kaplan-Meier survival analysis demonstrated no relationship between a history of SRS alone and pain recurrence after MVD ( P = .58). SRS is an effective intervention for TN that may not worsen outcomes for subsequent MVD in patients with TN.

Delayed pain relief in patients with trigeminal neuralgia following microvascular decompression: A single-central retrospective study.

Compared to hemifacial spasm after microvascular decompression (MVD), delayed relief (DR) rarely occurs in patients with trigeminal neuralgia (TGN). To analyze the characteristics of post-MVD DR in TGN patients to provide useful clues for the clinical differential diagnosis of postoperative DR. The clinical data of all patients with TGN who underwent MVD in our center from January 1, 2016, to December 31, 2020, were reviewed retrospectively. In 272 TGN MVD patients, DR occurred in nine patients (3.3%) during the follow-up periods of 1-6 years. During surgery, all nine DR-TGN patients were identified as having neurovascular conflicts (NVCs), involving the offending artery (OA) in eight patients (two OAs in two patients) and both an artery and a vein in the other patient. The compression site was near the root entry zone (REZ) in most DR patients (7/9). Delayed relief was relieved in seven patients within 5 days after surgery and within 30 days in the other two patients. No recurrence or serious complications were observed within the mean 4 (1-6)-year follow-up duration. Delayed relief rarely occurs in TGN patients after MVD. Neurovascular conflicts located at the REZ and NVC of grade III may be two important factors contributing to DR in TGN patients. Delayed relief may occur when the pain gradually improves after the operation and responds effectively to a small dose of carbamazepine. The recurrence rate of TGN seems even lower in such patients.

Complications of Microvascular Decompression in patients with Trigeminal Neuralgia

Objective: To determine the frequency of complications of microvascular decompression for patients with trigeminal neuralgia undergoing surgical decompression. Materials and Methods: A descriptive case study was carried out in the Neurosurgery Unit 1, Lahore General Hospital. The study included 80 patients who fulfilled the inclusion criteria. Informed consent was obtained and possible outcomes and complications of surgery were explained beforehand to the patients. Demographic details were noted. Surgical site infection, CSF leak, Facial numbness, Facial palsy, Hearing impairment, and Postoperative hematoma as complications were assessed. The presence of complications was recorded. Data was stratified for age and gender from. Chi-square was used as a statistical test, taking a p-value ?0.05 as the level of significance. Results: The study included 80 patients. The mean age of the patients was 40.8 ± 11.7 years. Overall complications were reported in 21 (26.3%) patients. Distribution of complications was as follows; surgical site infection 2 (9.5%), CSF leak (19.0%), facial palsy 5 (23.8%), facial numbness 9 (42.9%), hearing impairment 2 (9.5%) and post-operative hematoma 5 (23.8%). Conclusion: Microvascular decompression (MVD) is recommended neurosurgical procedure for medically refractory patients with trigeminal pain if there is no contraindication for surgery. Surgical complications can be minimized by meticulous surgery resulting in adequate tissue respect. Another means to get better and long-lasting results with fewer complications is by using an autologous muscle graft.

Chronological Patterns of Long-Term Outcomes After Microvascular Decompression for Hemifacial Spasm Over 5 Years

The postoperative course of hemifacial spasm (HFS) varies. We analyzed the clinical outcomes from 1 to ≥5years after microvascular decompression (MVD) in patients with HFS. Between July 2004 and January 2015, 528 patients who were followed up for ≥5years after MVD for HFS were included. We evaluated chronological patterns of clinical outcomes from 1 to ≥5years. The outcomes at 2, 3, 4, and ≥5years postoperatively were individually compared with those at 1year postoperatively, and the relationships between clinical features, surgical findings, and outcomes over time were analyzed. Eight groups were created according to the similarity in the pattern of clinical outcomes from 1 to ≥5years postoperatively. Individual postoperative outcomes at 2-4years were consistent with those at 1year postoperatively, whereas postoperative outcomes at ≥5years were not (P=0.020). There was substantial to moderate agreement between the outcomes at 1year and at 2-4years postoperatively, but the agreement decreased over time. Patients without diabetes (P=0.015), an intraoperative offending vessel without a vein (P=0.005), and intraoperative discoloration of the facial nerve (P=0.036) showed better outcomes at ≥5years postoperatively. Long-term outcomes from 1 to ≥5years after MVD in patients with HFS were diverse. Nondiabetes, intraoperative offending vessel without a vein, and intraoperative discoloration of the facial nerve were better prognostic factors for outcomes at ≥5years postoperatively. It is advisable to consider these results when evaluating the long-term outcomes of this surgery.

Multidata Analysis Based on an Artificial Neural Network Model for Long-Term Pain Outcome and Key Predictors of Microvascular Decompression in Trigeminal Neuralgia

To investigate use of multidata analysis based on an artificial neural network (ANN) to predict long-term pain outcomes after microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and to explore key predictors. Perioperative and long-term follow-up multidata of 1041 patients with TN who received MVD surgery at Hangzhou First People's Hospital from March 2013 to May 2018 were collected to construct an ANN model for prediction. The prediction results were compared with the actual follow-up outcomes, and the variables in each input layer were changed to test the effectiveness of ANN and explore the factors that had the greatest impact on prediction accuracy. The ANN model could predict the long-term pain outcomes after MVD in patients with TN with an accuracy rate of 95.2% and area under the curve of 0.862. Four factors contributed the most to the predictive performance of the ANN: whether the neurovascular offending site of the trigeminal nerve corresponded the region of facial pain, immediate postoperative pain remission after MVD, degree of nerve compression by culprit vessels, and the type of culprit vessels. After these factors were sequentially removed, the accuracy of the ANN model decreased to 74.5%, 78.6%, 87.2%, and 90.1%, while the area under the curve was 0.705, 0.761, 0.793, and 0.810. The ANN model, constructed using multiple data, predicted long-term pain prognosis after MVD in patients with TN objectively and accurately. The model was able to assess the importance of each factor in the prediction of pain outcome.

Efficacy and complications of microvascular decompression in patients over 70years with trigeminal neuralgia.

Treatment of choice for trigeminal neuralgia (TN) by neurovascular conflict in case of failure of medical treatment is microvascular decompression (MVD). It is a safe and effective technique in the short and long term. But what about older patients who are considered more fragile anesthetically and surgically? Our Objective is to demonstrate the efficacy and complication rate of microvascular decompression (MVD) for older and younger patients with trigeminal neuralgia (TN) due to neurovascular conflict. 102 patients with TN due to neurovascular conflict were included (June 2005-December 2016) in a single Regional hospital. 25 were included in the group composed of ≥ 70-year-old patients (G1), while 77 were included in the < 70-year-old group (G2). The patients were operated on by the same surgical team using a retro-sigmoid approach to access the neurovascular conflict. The epidemiologic, clinical, anesthetic, and surgical data were extracted. The immediate efficacy of surgical treatment (BNI pain intensity = I) was 96% in G1 and 96.10% in the G2 group (p = 0.71). At 3-year follow-up, the efficacy rate was 89% and 86%, respectively (p = 0.93). At 5years, it was 92% and 92% (p = 0.98). Complication rates were comparable between the two groups (20% versus 27%; p = 0.47) and no deaths occurred despite the fact that G1 group had worst preoperative anesthetic score (ASA-NYHA). MVD is a durable procedure in patients over 70years of age diagnosed with essential TN. The complication rate and immediate-, medium-, and long-term efficacy were similar to those of younger patients.

Advances in Intraoperative Neurophysiology During Microvascular Decompression Surgery for Hemifacial Spasm.

Microvascular decompression (MVD) is a widely used surgical intervention to relieve the abnormal compression of a facial nerve caused by an artery or vein that results in hemifacial spasm (HFS). Various intraoperative neurophysiologic monitoring (ION) and mapping methodologies have been used since the 1980s, including brainstem auditory evoked potentials, lateral-spread responses, Z-L responses, facial corticobulbar motor evoked potentials, and blink reflexes. These methods have been applied to detect neuronal damage, to optimize the successful decompression of a facial nerve, to predict clinical outcomes, and to identify changes in the excitability of a facial nerve and its nucleus during MVD. This has resulted in multiple studies continuously investigating the clinical application of ION during MVD in patients with HFS. In this study we aimed to review the specific advances in methodologies and clinical research related to ION techniques used in MVD surgery for HFS over the last decade. These advances have enabled clinicians to improve the efficacy and surgical outcomes of MVD, and they provide deeper insight into the pathophysiology of the disease.

External Neurolysis in Microvascular Decompression for Magnetic Resonance Imaging–Negative Idiopathic Trigeminal Neuralgia

Internal neurolysis has been proposed as an alternative to microvascular decompression in patients with idiopathic trigeminal neuralgia (TN) in whom neurovascular compression is not confirmed by magnetic resonance imaging (MRI). External neurolysis, which straightens and realigns the trigeminal nerve root axis by dissecting the arachnoid membranes around the nerve, was reported 20 years ago in the context of so-called negative exploration when MRI did not confirm the absence of the offending vessel, but is not currently used. External neurolysis was performed in 4 patients with idiopathic TN with typical evoked neuralgic pain despite the absence of suspected offending vessels on MRI. The surgical findings that caused TN were summarized and the outcomes were evaluated using the Barrow Neurological Institute Pain Intensity Scale (BNI-PS). Tethering and distortion of the nerve root by surrounding arachnoid membranes were commonly found. All 4 patients showed complete pain relief immediately after surgery. During the follow-up period of 26.5 ± 16.92 months (±standard deviation), 3 of 4 patients had no pain (score I, BNI-PS). One patient received a score of IIIa on the BNI-PS assessment. There was no instance of recurrence or side effects associated with the surgery. Idiopathic TN can be induced by individual variation of the surrounding inner arachnoid membranes supporting the trigeminal nerve root, and the condition cannot be identified by MRI. Intradural external neurolysis may be considered an effective treatment for MRI-negative idiopathic TN.

Outcomes of Microvascular Decompression in Patients with Trigeminal Neuralagia

Objective: To determine the treatment outcomes of microvascular decompression in patients with trigeminal neuralagia. Study Design: Prospective/Observational Place and Duration: The study was conducted at Neurosurgery department Bacha Khan Medical College/ Mardan Medical Complex, Mardan and Al Nafees Medical College, Islamabad for duration of six months i.e from July 2020 December 2020. Methods: Thirty four patients of both genders presented with trigeminal neuralagia were enrolled in this study. Patient’s detailed demographics were recorded after taking written consent. All patients underwent microvascular decompression. Outcomes were assessed by using Borrow Neurological Institute Pain score (BNIP). Follow-up was taken at 5th post-operative day. Data was analyzed by SPSS 24.0. Results: Mean age of patients was 54.26±9.78 years. There were 20 (58.82%) were females while 14 (41.17%) were males. Postoperatively 17 (50%) patients had BNIP score 1-2 with no medication required, 12 (35.29%) patients had partial recovery with BNIP score 3 and 5 (14.71%) patients showed no recovery with BNIP score 4. Conclusion: Microvascular decompression is safe and effective treatment procedure for trigeminal neuralagia with fewer rate of complications. Keywords: Trigeminal Neuralagia, Microvascular Decompression (MVD), Effectiveness

Recurrence Rates After Microvascular Decompression in Patients With Primary Trigeminal Neuralgia and Its Influencing Factors: A Systematic Review and Meta-Analysis Based on 8,172 Surgery Patients

Background: Primary trigeminal neuralgia (PTN) is known to reoccur following microvascular decompression (MVD) surgery. However, the rates and contributing factors related to PTN recurrence remain controversial. The purpose of this study was to explore the postoperative recurrence rates and related influencing factors of patients with PTN after MVD. Additionally, recurrence rates after different treatments were compared to provide guidelines for clinicians.Methods: We conducted systematic reviews and meta-analyses in accordance with the preferred reporting items of the PRISMA guidelines. We searched nine databases, namely, the PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, CBM, CNKI, VIP, and Wanfang databases, from establishment to July 13, 2020, selecting for studies about the long-term postoperative efficacy of MVD in the treatment of PTN. Factors associated with higher recurrence rates after MVD and long-term postoperative results of other treatments underwent formal meta-analysis, where odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) were calculated. The dose-response model was used to inspect the associations between several factors and higher recurrence rates.Results: Seventy-four studies (8,172 patients, 32 case series studies, and 42 non-randomized controlled trials) were analyzed in our research. Overall, 956 out of 8,172 patients relapsed, and the pooled recurrence rate was 0.096 (0.080–0.113). Influencing factors of relatively higher recurrence rates included atypical trigeminal neuralgia symptoms, lack of nerve groove, non-arterial compression, patients who were 50–60 years old, and longer disease duration. Dose–response analysis showed that the recurrence rate had a significant trend with the published year and the follow-up time. Simultaneously, the recurrence rate of MVD treatment was much lower than that of conventional drug treatment, gamma knife surgery, percutaneous balloon compression, and radiofrequency thermocoagulation. When the surgical technique was improved or combined with partial sensory rhizotomy (PSR), the postoperative recurrence rates were significantly reduced.Conclusions: Even for PTN patients who have a successful operation, ~10% of them will still relapse. This research identifies several factors that can affect the recurrence rate. Compared with other operations, MVD has a relatively lower recurrence rate. Our analysis suggests that improved surgical techniques and combining PSR and MVD will yield better results.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42020159276.

Commentary: Outcome of Endoscope-Assisted Microvascular Decompression in Patients With Hemifacial Spasm Caused by Severe Indentation of the Brain Stem at the Pontomedullary Sulcus by the Posterior Inferior Cerebellar Artery.

Commentary: Outcome of Endoscope-Assisted Microvascular Decompression in Patients With Hemifacial Spasm Caused by Severe Indentation of the Brain Stem at the Pontomedullary Sulcus by the Posterior Inferior Cerebellar Artery.

Outcome of Endoscope-Assisted Microvascular Decompression in Patients With Hemifacial Spasm Caused by Severe Indentation of the Brain Stem at the Pontomedullary Sulcus by the Posterior Inferior Cerebellar Artery.

Microvascular decompression (MVD) is the most effective treatment option for hemifacial spasm (HFS). However, deeply located forms of compression would require proper identification to allow for adequate decompression. To describe the usefulness of endoscopic visualization in one of the most challenging compression patterns in HFS, where the posterior inferior cerebellar artery (PICA) loop is severely indenting the brain stem at the proximal root exit zone of facial nerve along the pontomedullary sulcus. Radiological and operative data were checked for all patients in whom severe indentation of the brainstem by PICA at pontomedullary sulcus was recorded and endoscope-assisted MVD was performed. Clinical correlation and outcome were analyzed. A total of 58 patients with HFS were identified with radiological and surgical evidence proving brainstem indentation at the VII transitional zone. In 31 patients, PICA was the offending vessel to the facial nerve. In 3 patients, the PICA loop was mobilized under visualization of a 45° endoscope. A total of 31 patients had a mean follow-up duration of 52.1 mo. The mean duration between start of complaints and surgery was 7.2 yr. In the last follow-up, all patients had remarkable spasm improvement. A total of 5 patients had more than 90% disappearance of spasms and 26 patients experienced spasm-free outcome. Although severe indentation of brain stem implies morphological damage, outcome after MVD is excellent. A 45° endoscope is extremely helpful to identify compression down at the pontomedullary sulcus. Deeply located compression site can easily be missed with microscopic inspection alone.

Challenging Microvascular Decompression Surgery for Hemifacial Spasm

Microvascular decompression (MVD) is the most effective treatment for hemifacial spasm (HFS). However, surgical difficulties due to complex anatomy or revision surgery can endanger the functional integrity of the brainstem. We describe surgically challenging cases and provide operative guidance that may be helpful for neurosurgeons who perform MVDs. Of 3028 patients with HFS who underwent MVDs consecutively by a single neurosurgeon, complex or unusual cases associated with surgical difficulty were selected. Medical charts and images were reviewed, with the primary focus being intraoperative findings, operative techniques, and clinical outcomes. All MVDs were performed using the interposition method. Surgically difficult cases were categorized into six types: tandem, perforator, atypical location, encircling, revision, and penetrating types. During the follow-up period (11.5-42.7 months; median 24.9 months), the spasm-free rate was 88.4%. Intraoperative changes in brainstem auditory evoked potentials were observed in 31.5% of patients. Immediate postoperative facial palsy and deafness were observed in 6.0% and 1.5% of patients, respectively. Revision surgery showed the highest surgical morbidity among the unusual HFS types. Detailed illustrations and descriptions of MVD in patients with surgically challenging HFS are provided. Complex or unusual HFS types carry higher surgical risks in MVD. Neurosurgeons performing MVDs need to be prepared to manage complex HFS cases in order to achieve favorable clinical outcomes.

Virtual reality-based evaluation of neurovascular conflict for the surgical planning of microvascular decompression in trigeminal neuralgia patients.

Trigeminal neuralgia (TN) is a lightning bolt of violent, electrifying, and stinging pain, often secondary to the neurovascular conflict (NVC). The vessels involved in NVC are mostly arteries and rarely veins. Evaluation of NVC in the deep infratentorial region is inseparably connected with cranial imaging. We retrospectively analyzed the potential influence of three-dimensional (3D) virtual reality (VR) reconstructions compared to conventional magnetic resonance imaging (MRI) scans on the evaluation of NVC for the surgical planning of microvascular decompression in patients with TN. Medical files were retrospectively analyzed regarding patient- and disease-related data. Preoperative MRI scans were retrospectively visualized via VR software to detect the characteristics of NVC. A questionnaire of experienced neurosurgeons evaluated the influence of VR visualization technique on identification of anatomical structures involved in NVC and on surgical strategy. Twenty-four patients were included and 480 answer sheets were evaluated. Compared to conventional MRI, image presentation using 3D-VR modality significantly influenced the identification of the affected trigeminal nerve (p = 0.004), the vascular structure involved in the NVC (p = 0.0002), and the affected side of the trigeminal nerve (p = 0.005). In patients with TN caused by NVC, the reconstruction of conventional preoperative MRI scans and the spatial and anatomical presentation in 3D-VR models offers the possibility of increased understanding of the anatomy and even more the underlying pathology, and thus influences operation planning and strategy.

Long-term pain outcomes in elderly patients with trigeminal neuralgia: comparison of first-time microvascular decompression and stereotactic radiosurgery.

Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and stereotactic radiosurgery (SRS). The use of MVD in elderly patients has been described but has yet to be prospectively compared to SRS, which is well-tolerated and noninvasive. The authors aimed to directly compare long-term pain control and adverse event rates for first-time surgical treatments for idiopathic TN in the elderly. A prospectively collected database was reviewed for TN patients who had undergone treatment between 1997 and 2017 at a single institution. Standardized collection of preoperative demographics, surgical procedure, and postoperative outcomes was performed. Data analysis was limited to patients over the age of 65 years who had undergone a first-time procedure for the treatment of idiopathic TN with at least 1 year of follow-up. One hundred ninety-three patients meeting the study inclusion criteria underwent surgical procedures for TN during the study period (54 MVD, 24 MVD+Rhiz, 115 SRS). In patients in whom an artery was not compressing the trigeminal nerve during MVD, a partial sensory rhizotomy (MVD+Rhiz) was performed. Patients in the SRS cohort were older than those in the MVD and MVD+Rhiz cohorts (mean ± SD, 79.2 ± 7.8 vs 72.9 ± 5.7 and 70.9 ± 4.8 years, respectively; p < 0.0001) and had a higher mean Charlson Comorbidity Index (3.8 ± 1.1 vs 3.0 ± 0.9 and 2.9 ± 1.0, respectively; p < 0.0001). Immediate or short-term postoperative pain-free rates (Barrow Neurological Institute [BNI] pain intensity score I) were 98.1% for MVD, 95.8% for MVD+Rhiz, and 78.3% for SRS (p = 0.0008). At the last follow-up, 72.2% of MVD patients had a favorable outcome (BNI score I-IIIa) compared to 54.2% and 49.6% of MVD+Rhiz and SRS patients, respectively (p = 0.02). In total, 0 (0%) SRS, 5 (9.3%) MVD, and 1 (4.2%) MVD+Rhiz patients developed any adverse event. Multivariate Cox proportional hazards analysis demonstrated that procedure type (p = 0.001) and postprocedure sensory change (p = 0.003) were statistically significantly associated with pain control. In this study cohort, patients who had undergone MVD had a statistically significantly longer duration of pain freedom than those who had undergone MVD+Rhiz or SRS as their first procedure. Fewer adverse events were seen after SRS, though the MVD-associated complication rate was comparable to published rates in younger patients. Overall, the results suggest that both MVD and SRS are effective options for the elderly, despite their advanced age. Treatment choice can be tailored to a patient's unique condition and wishes.

Efficacy of microvascular decompression in patients with trigeminal neuralgia with negative neurovascular relationship shown by magnetic resonance tomography

ObjectiveTo explore the surgical efficacy of microvascular decompression(MVD) when the recent magnetic resonance tomography angiography(MRA) is unable to determine the relationship between blood vessels and nerves in patients with trigeminal neuralgia(TN). Materials and methodsThe MRI images of 146 patients with TN who underwent MVD from January 2016 to December 2019 were analyzed retrospectively. The relationship between nerves and vessels was categorized as no contact, suspicious contact, and clear contact. Suspicious contact and clear contact were both defined as positive neurovascular relationship, whereas no contact was defined as negative neurovascular relationship. The efficacy of MVD in positive and negative groups was compared. Results1. A total of 146 TN patients underwent MVD. Intraoperative examination revealed that out of 146, 143 patients exhibited contacts, including 110 cases with arterial contact, 22 cases with combined arterial and venous contact, and 11 cases with venous contact. Considering the surgical result as a gold standard, the sensitivity of three-dimensional time leap angiography (3D-TOF-MRA) in assessing vascular compression in TN was 74.0 %; and the sensitivity of three-dimensional steady-state precession rapid imaging sequence (3D-FIESTA) in determining vascular compression was 82.2 %. Out of a total of 17 cases demonstrating negative neurovascular relationship by 3D-TOF-MRA together with 3D-FIESTA, 14 cases were found to have vascular contact during the surgery, and the sensitivity was determined to be 88.4 %. 2.Among the 38 patients with a negative neurovascular relationship demonstrated by 3D-TOF, postoperative efficacy was noted as a cure: 30 cases, improved: 5 cases, no effect: 3 cases. 3D-FIESTA showed 26 cases of negative neurovascular relationship, among them, cured: 20 cases, improved: 3 cases, no effect: 3 cases. A total of 17 patients with negative neurovascular relationships were established by 3D-TOF-MRA together with 3D-FIESTA, and the postoperative effects were found to be cure: 13 cases, improvement: 2 cases, and no effect: 2 cases. There was no statistically significant difference between the negative group and the positive group (x2 test; p > 0.05). ConclusionTo conclude, 3D-TOF-MRA, together with 3D-FIESTA, can illustrate the large blood vessels surrounding the trigeminal nerve efficiently, and determine whether it is the offending blood vessel. The interpretation would help reproduce the local anatomical spatial structure of the site before surgery, yet it is impossible to assess the peripheral anatomical relationship of the trigeminal nerve cistern comprehensively and accurately. This hints that a perfect prediction of the surgical effect of MVD is not possible at present. Thus, typical symptoms of TN are the most critical indicators for MVD surgery.