Neurovascular Compression Syndrome Research Articles

Comparative study of CTA/CTV and MRTA for preoperative simulation of microvascular decompression in neurovascular compression syndromes.

Neurovascular compression syndrome (NVCS), characterized by cranial nerve compression due to adjacent blood vessels at the root entry zone, frequently presents as trigeminal neuralgia (TN), hemifacial spasm (HFS), or glossopharyngeal neuralgia (GN). Despite its prevalence in NVCS assessment, Magnetic Resonance Tomographic Angiography (MRTA)'s limited sensitivity to small vessels and veins poses challenges. This study aims to refine vessel localization and surgical planning for NVCS patients using a novel 3D multimodal fusion imaging (MFI) technique incorporating computed tomography angiography and venography (CTA/CTV). A retrospective analysis was conducted on 76 patients who underwent MVD surgery and were diagnosed with single-site primary TN, HFS, or GN. Imaging was obtained from MRTA and CTA/CTV sequences, followed by image processing and 3D-MFI using FastSurfer and 3DSlicer. The CTA/CTV-3D-MFI showed higher sensitivity than MRTA-3D-MFI in predicting responsible vessels (98.6% vs. 94.6%) and NVC severity (98.6% vs. 90.8%). Kappa coefficients revealed strong agreement with MRTA-3D-MFI (0.855 for vessels, 0.835 for NVC severity) and excellent agreement with CTA/CTV-3D-MFI (0.951 for vessels, 0.952 for NVC). Resident neurosurgeons significantly preferred CTA/CTV-3D-MFI due to its better correlation with surgical reality, clearer depiction of surgical anatomy, and optimized visualization of approaches (p < 0.001). Implementing CTA/CTV-3D-MFI significantly enhanced diagnostic accuracy and surgical planning for NVCS, outperforming MRTA-3D-MFI in identifying responsible vessels and assessing NVC severity. This innovative imaging modality can potentially improve outcomes by guiding safer and more targeted surgeries, particularly in cases where MRTA may not adequately visualize crucial neurovascular structures.

Application of Multimodal Reconstruction Technology and 3D Printing Technology in MVD Surgery.

Microvascular decompression (MVD) plays a pivotal role in the treatment of cranial neurovascular compression syndromes, yet the safety and precision of the surgery remain a focus of clinical attention. This article delves into the application of multimodal reconstruction and 3D printing technologies in MVD surgeries, evaluating their effectiveness in preoperative planning. Multimodal reconstruction, by integrating various imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT), provides high-resolution anatomical information, offering comprehensive data support for preoperative planning and intraoperative navigation. Complementing this, 3D printing technology presents patients' anatomical structures as individualized physical models, enabling surgeons to fabricate corresponding skin templates for surgical needs, offering intuitive and practical references. Case studies presented in this article demonstrate the application and efficacy of these technologies in actual MVD surgeries. The results suggest that multimodal reconstruction and 3D printing technologies aid surgical teams in better understanding patients' anatomical structures during preoperative planning, enhancing surgical accuracy, reducing operative time, and shortening hospital stays. Despite notable advancements in MVD surgeries, challenges such as data accuracy, technological complexity, and cost persist. Future research should aim to address these issues, further optimizing the technologies and promoting their widespread application in neurosurgical procedures. Through in-depth investigation and understanding of these advanced technologies, we hope to pave new paths for improving surgical outcomes and patients' quality of life.

Sling-technique for vertebral artery transposition in neurovascular conflicts caused by dolichoectasia

Vertebrobasilar dolichoectasia is rare but in symptomatic cases thoroughly reduce quality of life and is challenging for treatment. Current paper presentstwo cases of vertebral dolichoectasia that cause neurovascular compression syndromes. In both cases vertebral artery transposition performed using sling-technique. The aim of the study – to demonstrate special features and efficiency of sling-technique for neurovascular conflicts caused by dolichoectasia presented.Surgical video demonstrating particular technique also performed. Additionally, literature data on epidemiology, symptoms and surgical interventions for neurovascular conflicts caused by dolichoectasia presented.

Unilateral and Bilateral Axillary Arches in Male and Female Cadavers

Among sixteen donors (32 axillae) dissected in our gross anatomy lab, axillary arch was incidentally observed in three cases (five axillae). In three cases, the axillary arch was observed in five axillae-bilateral in one male and one female donor, and unilateral in one male donor. In all the three cases, the five arches consisted of muscular and connective tissue (aponeurotic/tendinous) parts. The muscular parts originated as slips from the lateral borders of the latissimus dorsi muscles and their connective tissue parts ascended and crossed anterior to the axillary neurovascular bundles to attach to various non-osseus structures on the proximal aspects of the arms. This created a canal dorsal to the axillary arch (designated here as axillobrachial canal or ABC) through which the axillary neurovascular bundles ran to enter the proximal aspect of the arms. The presence of such variant fibromuscular slip can be a cause of neurovascular compression syndrome of the upper limb and may complicate surgical procedures in the axillary region. Therefore, it should be considered in the differential diagnosis of neurovascular compression syndromes of the upper limb and axillary mass to avoid misdiagnosis and unintended damage or injury causing complications.

The Arterial Anatomy of the Cerebellum-A Comprehensive Review.

The cerebellum, a major feature of the hindbrain, lies posterior to the pons and medulla and inferior to the posterior part of the cerebrum. It lies beneath the tentorium cerebelli in the posterior cranial fossa and consists of two lateral hemispheres connected by the vermis. The cerebellum is primarily supplied by three arteries originating from the vertebrobasilar system: the superior cerebellar artery (SCA), the anterior inferior cerebellar artery (AICA), and the posterior inferior cerebellar artery (PICA). However, variations of the cerebellar arteries may occur, such as duplication of the SCA, SCA creating a common trunk with the posterior cerebral artery, triplication of the AICA, and agenesis of PICA, amongst others. Knowledge of the arterial anatomy of the cerebellum is crucial, as inadequate blood supply to this region can result in diminished motor functioning, significantly impacting the quality of life for patients. The present study demonstrated the importance of adequate anatomical knowledge of the arteries supplying the cerebellum. The PubMed and Embase databases were searched to gather articles on the anatomical characteristics and variations of the arterial supply of the cerebellum. It is the most comprehensive and up-to-date review available in the literature. The possible variations of these vessels may be clinically silent or present with clinical symptoms such as neurovascular compression syndromes of the cranial nerves and aneurysms. With a comprehensive understanding of the cerebellar arterial system, physicians can enhance their diagnostic and treatment capabilities, ultimately leading to more effective management of cerebellar vascular-related issues and other neurological deficits.

Microscope-Based Augmented Reality: A New Approach in Intraoperative 3D Visualization in Microvascular Decompression?

Neurovascular compression (NVC) syndromes such as trigeminal neuralgia (TN) are causally treated with microvascular decompression (MVD). Semiautomatic segmentation of high-resolution magnetic resonance imaging (MRI) data and constructive interference in steady state (CISS)/time-of-flight (TOF) sequences are utilized for the three-dimensional (3D) visualization of underlying causative vessels at the root entry zones of the relevant cranial nerves. Augmented reality (AR) of neurovascular structures was introduced especially in the resection of brain tumors or aneurysmatic operations. In this report, the potential feasibility of the implementation of microscope-based AR into the intraoperative microsurgical set-up of MVD was investigated. This article recommends the preoperative evaluation of 3D visualization besides the microscopical view of the surgeon. The implementation of multiple imaging data by AR into the operating microscope may afflict the experienced surgeon's view, which should be examined prospectively.

Clinical and Educational Aspects of Neuroimaging in Microsurgery of the Posterior Fossa: A Comprehensive Review.

The clinical and educational value of modern high-resolution magnetic resonance imaging (MRI) and image processing in neurovascular diseases of the posterior fossa with regard to preoperative planning and intraoperative comparison with the actual anatomical situation was consecutively evaluated. Patients with trigeminal neuralgia (TN), hemifacial spasm (HFS), glossopharyngeal neuralgia (GN) and arterial hypertension (HTN) were analyzed. The high-resolution MRI data was segmented and visualized three-dimensionally using computer graphics methods. New anatomical insights were gained, such as the classification of neurovascular compression (NVC) in HFS and GN. It was also possible to visualize the pathognomonic cerebrospinal fluid signal in patients with TN for the first time. Using the new imaging methods, pregnant hypertensive patients were examined and the existence of NVC was confirmed for the first time, and the findings were compared to other studies dealing with NVC syndromes. This review gives an overview on the established methods of neuroimaging and image processing of neurovascular structures in the posterior fossa with the focus on clinical and educational aspects.

Prevalence of Anterior Inferior Cerebellar Artery Vascular Loop in Cerebellopontine Angle With Three-Dimensional Constructive Interference in Steady State (CISS) Sequence MRI.

Background The cerebellopontine angle (CPA) cistern houses vital neurovascular structures such as cranial nerves V, VII, and VIII and the anterior inferior cerebellar artery (AICA), often leading to neurovascular compression syndromes due to its complex anatomy. Although vascular compression is a recognized cause of certain neuralgias, its association with otologic symptoms such as tinnitus, hearing loss, and dizziness remains uncertain. Hence, this study aims to determine the prevalence of the AICA vascular loop in the CPA cistern on MRI in patients with asymptomatic audiovestibular symptoms. Methodology Adult patients who underwent MRI, including the posterior fossa's high-resolution volumetric T2 sequence (three-dimensional constructive interference in steady state (3D-CISS)), were assessed. Patients with a history of audiovestibular symptoms (tinnitus/dizziness/vertigo/sensorineural hearing loss), intracranial tumor, vascular lesions, intracranial surgery, brain radiation therapy, traumatic brain injury, poor image quality, and MRI scans without 3D-CISS sequences were excluded. Two radiologists independently reviewed 114 (228 sides) MRI studies for the vascular loop of AICA in the CPA cistern and the extension of the AICA loop into the ipsilateral internal acoustic meatus which was graded by Chavda's classification. Results The prevalence of vascular loop of AICA in the CPA cistern was as high as 47.6% in asymptomatic patients. Grade I Chavda vascular loop was the most common type followed by type II, with type III being the least common type. Conclusions Knowledge regarding the high prevalence of the AICA loop in the asymptomatic population and the lack of significant correlation between the presence of the AICA loop and otovestibular symptoms should be considered in preoperative planning for decompression procedures.

A case of cerebellopontine angle meningioma presenting as neurovascular compression syndrome of the 8th cranial nerve

A 54-year-old female patient presented with paroxysmal tinnitus and vertigo for 2 years, which have repeatedly occurred while rotating her neck, and lasted about 10 seconds. An anticonvulsant medication was prescribed with a diagnosis of microvascular compression syndrome on the 8th cranial nerve and audiovestibular evaluation and magnetic resonance imaging (MRI) scan were appointed a week later. In her next visit, she reported the disappearance of paroxysmal audiovestibular symptoms after medication. In the left ear, canal paresis and abnormal auditory brainstem response were observed. In MRI, a large meningioma in the cerebellopontine angle in the vicinity of the internal auditory canal orifice was detected, that was surgically resected by a neurosurgeon. After surgical removal of the tumor, she reported continuous dizziness due to vestibular nerve injury, but the paroxysmal attack of tinnitus and vertigo disappeared without anticonvulsant medication. This case suggests that an imaging study is mandatory when diagnosing microvascular compression syndrome on the 8th cranial nerve.

The Anterior Inferior Cerebral Artery Variability in the Context of Neurovascular Compression Syndromes: A Narrative Review.

The anterior inferior cerebellar artery (AICA) is situated within the posterior cranial fossa and typically arises from the basilar artery, usually at the pontomedullary junction. AICA is implicated in various clinical conditions, encompassing the development of aneurysms, thrombus formation, and the manifestation of lateral pontine syndrome. Furthermore, owing to its close proximity to cranial nerves within the middle cerebellopontine angle, AICA's pulsatile compression at the root entry/exit zone of cranial nerves may give rise to specific neurovascular compression syndromes (NVCs), including hemifacial spasm (HFS) and geniculate neuralgia concurrent with HFS. In this narrative review, we undertake an examination of the influence of anatomical variations in AICA on the occurrence of NVCs. Significant methodological disparities between cadaveric and radiological studies (CTA, MRA, and DSA) were found, particularly in diagnosing AICA's absence, which was more common in radiological studies (up to 36.1%) compared to cadaver studies (less than 5%). Other observed variations included atypical origins from the vertebral artery and basilar-vertebral junction, as well as the AICA-and-PICA common trunk. Single cases of arterial triplication or fenestration have also been documented. Specifically, in relation to HFS, AICA variants that compress the facial nerve at its root entry/exit zone include parabola-shaped loops, dominant segments proximal to the REZ, and anchor-shaped bifurcations impacting the nerve's cisternal portion.

Posterior Fossa Anatomy for Microvascular Decompression Surgery

In most microvascular decompression surgeries, surgical maneuvers are performed within normal anatomical structures without any neoplasms. Thus, detailed anatomical knowledge is essential to perform safe and efficient procedures. "Rule of 3" by Rhoton AL Jr. is helpful for understanding not only the anatomy of the posterior fossa but also the three neurovascular compression syndromes. The cerebellar arteries and posterior fossa veins have substantial variability, but a basic understanding of their typical patterns is useful to explore individual cases. To use adequate surgical approaches through the cerebellar tentorial or petrosal surface in individual trigeminal neuralgia surgeries, anatomical knowledge of the bridging veins on the tentorial(the bridging veins into the tentorial sinus)and petrosal surfaces(the superior petrosal vein)is crucial. Fissure openings help to minimize cerebellar retraction, similarly to the sylvian fissure dissection in supratentorial surgeries.

Fully endoscopic microvascular decompression for the treatment of hemifacial spasm, trigeminal neuralgia, and glossopharyngeal neuralgia: a retrospective study

BackgroundMicrovascular decompression (MVD) is already the preferred surgical treatment for medically refractory neurovascular compression syndromes (NVC) such as hemifacial spasm (HFS), trigeminal neuralgia (TN), and glossopharyngeal neuralgia (GPN). Endoscopy has significantly advanced surgery and provides enhanced visualization of MVD. The aim of this study is to analyze the efficacy and safety of fully endoscopic microvascular decompression (E-MVD) for the treatment of HFS, TN, and GPN, as well as to present our initial experience.Materials and methodsThis retrospective case series investigated fully E-MVD performed in 248 patients (123 patients with HFS, 115 patients with TN, and 10 patients with GPN ) from December 2008 to October 2021 at a single institution. The operation duration, clinical outcomes, responsible vessels, intra- and postoperative complications, and recurrences were recorded. Preoperative and immediate postoperative magnetic resonance imaging (MRI) and computerized tomography (CT) were performed for imageological evaluation. The Shorr grading and Barrow Neurological Institute (BNI) pain score were used to evaluate clinical outcomes. The efficacy, safety, and risk factors related to the recurrence of the operation were retrospectively analysed, and the surgical techniques of fully E-MVD were summarised.ResultsA total of 248 patients (103 males) met the inclusion criteria and underwent fully E-MVD were retrospectively studied. The effective rate of 123 patients with HFS was 99.1%, of which 113 cases were completely relieved and 9 cases were significantly relieved. The effective rate of 115 patients with TN was 98.9%, of which 105 cases had completely pain relieved after surgery, 5 cases had significant pain relieved, 4 cases had partial pain relieved but still needed to be controlled by medication. The effective rate of 10 patients with GPN was 100%, 10 cases of GPN were completely relieved after surgery. As for complications, temporary facial numbness occurred in 4 cases, temporary hearing loss in 5 cases, dizziness with frequent nausea and vomiting in 8 cases, headache in 12 cases, and no cerebral hemorrhage, intracranial infection, and other complications occurred. Follow-up ranged from 3 to 42 months, with a mean of 18.6 ± 3.3 months. There were 4 cases of recurrence of HFS and 11 cases of recurrence of TN. The other effective patients had no recurrence or worsening of postoperative symptoms. The cerebellopontine angle (CPA) area ratio (healthy/affected side), the length of disease duration, and the type of responsible vessels are the risk factors related to the recurrence of HFS, TN, and GPN treated by fully E-MVD.ConclusionsIn this retrospective study, our results suggest that the fully E-MVD for the treatment of NVC such as HFS, TN, and GPN, is a safe and effective surgical method. Fully E-MVD for the treatment of NVC has advantages and techniques not available with microscopic MVD, which may reduce the incidence of surgical complications while improving the curative effect and reducing the recurrence rate.

Microanatomy of the central myelin portion and transitional zone of the oculomotor and abducens nerves.

The microanatomy of the central myelin portion and transitional zone of several cranial nerves including trigeminal, facial, vestibulocochlear, glossopharyngeal, and vagus nerves have been clearly demonstrated to provide information for neurovascular compression syndrome such as trigeminal neuralgia and hemifacial spasm. However, the study of oculomotor and abducens nerve is limited. Oculomotor and abducens nerves were harvested with a portion of brainstem and embedded in paraffin. Longitudinal and serial sections from ten of each cranial nerve were stained and a photomicrograph was taken to make the following observations and measurements: 1) patterns of central myelin portion, 2) length of central myelin portion, and 3) depth of central myelin- peripheral myelin transitional zone. For oculomotor nerve, the longest central myelin bundle was always seen on the first nerve bundle and that the length of central myelin decreased gradually. For abducens nerve, morphological patterns were classified into four types based on number of nerve rootlets emerging from the brainstem and number of nerve bundles in each rootlet. Length of central myelin portion was between 0.36-6.10 mm (2.75 ± 0.83 mm) and 0.13-5.01 mm (1.66 ± 1.39 mm) for oculomotor and abducens nerves, respectively. The oculomotor nerve transitional zone depth was 0.07-058 mm (0.23 ± 0.07 mm), while for abducens nerve, depth was 0.05-0.40 mm (0.16 ± 0.07 mm). Positive weak correlations between central myelin and depth of TZ were found in oculomotor nerve (r +0.310, p < 0.05) and abducens nerves (r +0.413, p < 0.05). Detailed microanatomy of the central myelin and transitional zone might be beneficial for locating the site of compression in neurovascular conflicts at oculomotor and abducens nerves.

P.099 A novel electrophysiologic reflex in neurovascular compression syndromes serving as a marker of pain resolution

Background: Radiofrequency rhizotomy is a commonly used percutaneous technique for treatment of trigeminal neuralgia especially in cases not eligible for microvascular decompression. This technique is usually performed with the patient under conscious sedation. We devised a method for performance of this technique under general anesthetic with neurophysiology monitoring. Methods: The patient is put under general anaesthetic and EMG monitoring is set up. Needles are placed in temporalis muscle, masseter and mylohyoid or anterior belly of digastric. Resting activityis monitored. Rhizotomy is then performed under fluoroscopic guidance, with monitoring of EMG potentials pre- and post-lesioning, with specific attention paid to presence of an abnormal electrophysiologic reflex. Results: A total of 38 procedures were performed in 23 patients. Of these, 15 were revision procedures. Patients had improvement from BNI pain scale 3.8 ±0.8 to 1.3 ±1.5, and had a reduction in number of medications from 1.9 ±1.0 to 0.8 ±0.9. Survey results indicate greater practitioner satisfaction with this technique. Conclusions: Radiofrequency rhizotomy can be performed under GA with IONM guidance with good results. We present a novel method for EMG-based monitoring. Further study is required to validate this technique.

Preoperative Frailty Predicts Worse Outcomes after Microvascular Decompression for Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: A Multicenter Analysis of 1,473 Patients from a Prospective Surgical Registry

Introduction: Microvascular decompression (MVD) is an efficacious neurosurgical intervention for patients with medically intractable neurovascular compression syndromes. However, MVD may occasionally cause life-threatening or altering complications, particularly in patients unfit for surgical operations. Recent literature suggests a lack of association between chronological age and surgical outcomes for MVD. The Risk Analysis Index (RAI) is a validated frailty tool for surgical populations (both clinical and large database). The present study sought to evaluate the prognostic ability of frailty, as measured by RAI, to predict outcomes for patients undergoing MVD from a large multicenter surgical registry. Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2011–2020) was queried using diagnosis/procedure codes for patients undergoing MVD procedures for trigeminal neuralgia (n = 1,211), hemifacial spasm (n = 236), or glossopharyngeal neuralgia (n = 26). The relationship between preoperative frailty (measured by RAI and 5-factor modified frailty index [mFI-5]) for primary endpoint of adverse discharge outcome (AD) was analyzed. AD was defined as discharge to a facility which was not home, hospice, or death within 30 days. Discriminatory accuracy for prediction of AD was assessed by computation of C-statistics (with 95% confidence interval) from receiver operating characteristic (ROC) curve analysis. Results: Patients undergoing MVD (N = 1,473) were stratified by RAI frailty bins: 71% with RAI 0–20, 28% with RAI 21–30, and 1.2% with RAI 31+. Compared to RAI score 19 and below, RAI 20 and above had significantly higher rates of postoperative major complications (2.8% vs. 1.1%, p = 0.01), Clavien-Dindo grade IV complications (2.8% vs. 0.7%, p = 0.001), and AD (6.1% vs. 1.0%, p < 0.001). The rate of primary endpoint was 2.4% (N = 36) and was positively associated with increasing frailty tier: 1.5% in 0–20, 5.8% in 21–30, and 11.8% in 31+. RAI score demonstrated excellent discriminatory accuracy for primary endpoint in ROC analysis (C-statistic: 0.77, 95% CI: 0.74–0.79) and demonstrated superior discrimination compared to mFI-5 (C-statistic: 0.64, 95% CI: 0.61–0.66) (DeLong pairwise test, p = 0.003). Conclusions: This was the first study to link preoperative frailty to worse surgical outcomes after MVD surgery. RAI frailty score predicts AD after MVD with excellent discrimination and holds promise for preoperative counseling and risk stratification of surgical candidates. A risk assessment tool was developed and deployed with a user-friendly calculator: https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression.

Correlation of Preoperative High-Resolution Neurovascular Imaging and Surgical Success in Neurovascular Compression Syndromes.

Neurovascular compression syndromes (NVCSs) are a group of neurological disorders characterized by compression of a cranial nerve and include trigeminal neuralgia (TN), hemifacial spasm, geniculate neuralgia, glossopharyngeal neuralgia, vestibular paroxysmia, and trochlear palsy. The European Academy of Neurology recommends constructive interference in steady-state/fast imaging employing steady-state (CISS/FIESTA) magnetic resonance imaging (MRI) in the evaluation of medically intractable TN, but similar recommendations do not exist for the remaining NVCSs. We conducted a retrospective chart review of 300 patients with an NVCS who underwent microvascular decompression (MVD) by a single neurosurgeon from 2004 to 2021. Data were collected on preoperative diagnosis, pre- and postoperative symptoms, presence/absence of preoperative high-spatial-resolution CISS/FIESTA MRI, and intraoperative findings. Rates of symptomatic improvement were used as a correlate of surgical success. The rate of symptomatic improvement in the patients with a preoperative CISS/FIESTA MRI was 5.8% greater than those without preoperative high-spatial-resolution neuroimaging (98.8% vs. 93%, respectively; P= 0.008). Stratified by diagnosis, patients with TN had the greatest difference in surgical success between the 2 groups (99.3% vs. 92.9%, n= 268; P= 0.006). No statistically significant differences were observed in the other NVCSs, although positive trends were noted. Preoperative CISS/FIESTA MRI correlated with greater rates of surgical success in cases of medically intractable TN; however, definitive conclusions could not be made regarding the remaining NVCSs. We support the recommendation that this imaging modality be included as part of the standard of practice for the evaluation and management of TN and encourage future studies to further elucidate this relationship for the less common NVCSs using a larger cohort.

Neurovascular Compression Syndromes: A Pictorial Essay

Neurovascular compression syndromes are typically brought on by arteries that come into contact with a cranial nerve’s (CN) cisternal section. Neurovascular contact does not always present with clinical symptoms. The most susceptible area for symptomatic neurovascular compression syndromes is the transitional zone between the peripheral and central myelin. Individual CN functional abnormalities are the clinical hallmark of neurovascular compression disorders. We present a series of four cases of patients presenting to a tertiary care center in Central India with symptoms and signs of neurovascular compression syndrome.

Suprafloccular transhorizontal fissure approach to the cerebellopontine angle: an anatomical study with case series.

The suprafloccular transhorizontal fissure approach is a modified variant of the classical retrosigmoid approach option to be chosen for cerebellopontine angle lesions. In this study, we aimed to demonstrate a previously described but not widely used method, the suprafloccular transhorizontal fissure approach with anatomical dissection on the cadaver, accompanied by a case presentation with the largest clinical series in the literature. Klingler's protocol was used to prepare 8 silicone injected and 8 non-silicone injected human hemispheres. A total of 210 patients who underwent surgery in the cerebellopontine angle between 2019 and 2022 were evaluated in our clinic. Of these, the suprafloccular transhorizontal fissure approach was applied in 33 patient, and it was successful in 26 patient, but this approach could not be achieved in 7 patients. The transhorizontal fissure is a fissure in the cerebellum located between the superior semilunar lobule and the inferior semilunar lobule. In the 26 patients we operated with the suprafloccular transhorizontal fissure approach, there was no need for retraction and no complications developed. However, in 7 patients, this fissure could not be dissected due to adhesions. Suprafloccular approach is an alternative to the classical retrosigmoid approach in tumours smaller than 2 cm, medially localised with little cerebellar oedema and neurovascular compression syndrome. Because in this approach, no cerebellum retraction is required, vascular structures are better preserved and the surgical time is shortened. This approach can be applied in smaller tumours than 2 cm when the sulcal anatomy is appropriate.

Combined four neurovascular compression syndromes: the first case report and literature review

BackgroundNeurovascular compression syndromes (NVCs) are cranial nerve syndromes caused by direct contact or compression of vascular structures on the cranial nerves at the root exit/entry zone. Cases of combined NVCs are extremely rare.CaseWe reported the first case of a 41-year-old woman with combined four NVCs presenting with left hemifacial spasm followed by simultaneous left glossopharyngeal neuralgia, left type-writer tinnitus and vestibular paroxysmia due to the left posterior inferior cerebellar artery compression at the root exit/entry of the left facial, vestibulocochlear and glossopharyngeal nerves. All the symptoms resolved immediately after microvascular decompression without recurrence in a period of follow-up for one year. In addition, we presented a literature review of combined three or more NVCs.ConclusionWe discussed the hypothesis of combined three or more NVCs development, especially the central hyperactivity of the cranial nerve nuclei mechanism.

PICA ischemic stroke

The posterior inferior cerebellar artery (PICA) has a unique anatomical complexity, which is of great clinical importance and is involved in many pathologies, such as aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM) and brain tumour (1).&#x0D; PICA has a sinuous and variable trajectory, divided into 5 segments. PICA infarction usually manifests lateral bulbar syndrome and is more likely to cause mass effects. PICA frequently compresses the bulb and cranial nerves, resulting in various neurovascular compression syndromes (NVCS) (2).&#x0D; The ischemic stroke caused by thromboembolism in the PICA segment is accounted for more than 2% of all cases of ischemic stroke (3). Moreover, it tends to be underdiagnosed due to the symptomatology, represented usually by vertigo which mimics a possible peripheral vestibulopathy (4).