Prevention of Superior Petrosal Vein Injury during Microvascular Decompression for Trigeminal Neuralgia: Operative Nuances

2021 ◽  
Author(s):  
Minsoo Kim ◽  
Sang-Ku Park ◽  
Seunghoon Lee ◽  
Jeong-A Lee ◽  
Kwan Park
Keyword(s):  
Trigeminal Neuralgia ◽  
Microvascular Decompression ◽  
Patient Positioning ◽  
Vestibulocochlear Nerve ◽  
Neurophysiologic Monitoring ◽  
Petrosal Vein ◽  
Cerebrospinal Fluid Leaks ◽  
Superior Petrosal Vein ◽  
Surgical Corridor ◽  
Vein Injury

Abstract Background The superior petrosal vein (SPV) often obscures the surgical field or bleeds during microvascular decompression (MVD) for the treatment of trigeminal neuralgia. Although SPV sacrifice has been proposed, it is associated with multiple complications. We have performed more than 4,500 MVDs, including approximately 400 cases involving trigeminal neuralgia. We aimed to describe our operative technique and nuances to avoid SPV injury. Methods We have provided a detailed description of our institutional protocol, including the anesthesia technique, neurophysiologic monitoring, patient positioning, surgical approach, and SPV management. The surgical outcomes and treatment-related complications were retrospectively analyzed. Results No SPVs were sacrificed intentionally or accidentally during our MVD protocol for trigeminal neuralgia. In the 344 operations performed during 2006 to 2020, 269 (78.2%) patients did not require medication postoperatively, 58 (16.9%) tolerated the procedure with adequate medication, and 17 (4.9%) did not respond to MVD. Postoperatively, 35 (10.2%), 1 (0.3%), and 0 patients showed permanent trigeminal, facial, or vestibulocochlear nerve dysfunction, respectively. Wound infection occurred in five (1.5%) patients, while cerebrospinal fluid leaks occurred in three (0.9%) patients. Hemorrhagic complications appeared in four (1.2%) patients but these were unrelated to SPV injury. No surgery-related mortalities were reported. Conclusion MVD for the treatment of trigeminal neuralgia can be achieved safely without sacrificing the SPV. A key step is positioning the patient's vertex at a 10-degree elevation from the floor, which can ease venous return and loosen the SPV, making it less fragile to manipulation and providing a wider surgical corridor.

scholarly journals Bridging veins and veins of the brainstem in microvascular decompression surgery for trigeminal neuralgia and hemifacial spasm

2018 ◽  
Vol 45 (1) ◽  
pp. E2 ◽  
Author(s):  
Hiroki Toda ◽  
Koichi Iwasaki ◽  
Naoya Yoshimoto ◽  
Yoshihito Miki ◽  
Hirokuni Hashikata ◽  
...  
Keyword(s):  
Trigeminal Neuralgia ◽  
Hemifacial Spasm ◽  
Microvascular Decompression ◽  
Decompression Surgery ◽  
Vascular Compression ◽  
Petrosal Vein ◽  
Venous Compression ◽  
Bridging Veins ◽  
Superior Petrosal Vein ◽  
Microvascular Decompression Surgery

OBJECTIVEIn microvascular decompression surgery for trigeminal neuralgia and hemifacial spasm, the bridging veins are dissected to provide the surgical corridors, and the veins of the brainstem may be mobilized in cases of venous compression. Strategy and technique in dissecting these veins may affect the surgical outcome. The authors investigated solutions for minimizing venous complications and reviewed the outcome for venous decompression.METHODSThe authors retrospectively reviewed their surgical series of microvascular decompression for trigeminal neuralgia and hemifacial spasm in patients treated between 2005 and 2017. Surgical strategies included preservation of the superior petrosal vein and its tributaries, thorough dissection of the arachnoid sleeve that enveloped these veins, cutting of the inferior petrosal vein over the lower cranial nerves, and mobilization or cutting of the veins of the brainstem that compressed the nerve roots. The authors summarized the patient characteristics, operative findings, and postoperative outcomes according to the vascular compression types as follows: artery alone, artery and vein, and vein alone. They analyzed the data using chi-square and 1-way ANOVA tests.RESULTSThe cohort was composed of 121 patients with trigeminal neuralgia and 205 patients with hemifacial spasm. The superior petrosal vein and its tributaries were preserved with no serious complications in all patients with trigeminal neuralgia. Venous compression alone and arterial and venous compressions were observed in 4% and 22%, respectively, of the patients with trigeminal neuralgia, and in 1% and 2%, respectively, of those with hemifacial spasm (p < 0.0001). In patients with trigeminal neuralgia, 35% of those with artery and venous compressions and 80% of those with venous compression alone had atypical neuralgia (p = 0.015). The surgical cure and recurrence rates of trigeminal neuralgias with venous compression were 60% and 20%, respectively, and with arterial and venous compressions the rates were 92% and 12%, respectively (p < 0.0001, p = 0.04). In patients with hemifacial spasm who had arterial and venous compressions, their recurrence rate was 60%, and that was significantly higher compared to other compression types (p = 0.0008).CONCLUSIONSDissection of the arachnoid sleeve that envelops the superior petrosal vein may help to reduce venous complications in surgery for trigeminal neuralgia. Venous compression may correlate with worse prognosis even with thorough decompression, in both trigeminal neuralgia and hemifacial spasm.

Absence of Ischemic Injury after Sacrificing the Superior Petrosal Vein during Microvascular Decompression

2019 ◽  
Author(s):  
Yuanxuan Xia ◽  
Timothy Y Kim ◽  
Leila A Mashouf ◽  
Kisha K Patel ◽  
Risheng Xu ◽  
...  
Keyword(s):  
Microvascular Decompression ◽  
Ischemic Injury ◽  
Petrosal Vein ◽  
Superior Petrosal Vein

Arteriovenous Micromalformation of the Trigeminal Root: Intraoperative Diagnosis With Indocyanine Green Videoangiography: Case Report

2010 ◽  
Vol 67 (3) ◽  
pp. onsE309-onsE310 ◽  
Author(s):  
Paolo Ferroli ◽  
Francesco Acerbi ◽  
Morgan Broggi ◽  
Giovanni Broggi
Keyword(s):  
Trigeminal Neuralgia ◽  
Indocyanine Green ◽  
Microvascular Decompression ◽  
Single Case ◽  
Preoperative Evaluation ◽  
Vascular Compression ◽  
Contrast Administration ◽  
Intraoperative Diagnosis ◽  
Petrosal Vein ◽  
Trigeminal Root

Abstract BACKGROUND AND IMPORTANCE: To report on a single case of arteriovenous micromalformation (micro-AVM) of the trigeminal root that was diagnosed during microvascular decompression for trigeminal neuralgia with the use of indocyanine green (ICG) videoangiography. CLINICAL PRESENTATION: A 52-year-old woman with drug-resistant trigeminal neuralgia underwent a key hole suboccipital cerebellopontine angle exploration after the usual magnetic resonance imaging (MRI) screening had raised the suspicion of a vascular compression. In surgery, the petrosal vein was found to be bigger than usual and arterialized; the trigeminal root was embedded in a tangle of abnormal arterialized vessels. Intraoperative ICG videoangiography showed that the direction of flow in the arterialized petrosal vein was anterograde, thus allowing for the differential diagnosis between micro-AVM and tentorial dural fistula. It was possible to achieve only a partial nerve decompression because of the intimate relationship between the trigeminal root and the pathological vessels. Postoperative angiography and MRI with contrast administration confirmed the intraoperative diagnosis of micro-AVM. The patient was discharged neurologically intact on postoperative day 4. One month after surgery, she remains pain-free despite a 50% reduction in antiepileptic drugs. CONCLUSION: Surgeons performing microvascular decompression should be aware that a diagnosis of vascular compression based on MRI without contrast administration could not exclude the presence of a pontine micro-AVM. ICG videoangiography provides an elegant means of showing the flow dynamics of these pathological vessels. An MRI protocol that is suitable to avoid this kind of intraoperative drawback should be defined and systematically used in the preoperative evaluation of all such surgical candidates.

scholarly journals 106 Sacrificing the Superior Petrosal Vein During Microvascular Decompression Does Not Increase Vascular Complications: Experience From One Institution

Neurosurgery ◽  
2018 ◽  
Vol 65 (CN_suppl_1) ◽  
pp. 82-82
Author(s):  
Yuanxuan Xia ◽  
Timothy Y Kim ◽  
Leila A Mashouf ◽  
Kisha K Patel ◽  
Risheng Xu ◽  
...  
Keyword(s):  
Microvascular Decompression ◽  
Vascular Complications ◽  
Petrosal Vein ◽  
Superior Petrosal Vein

scholarly journals The hanging technique using the superior petrosal vein in surgical transposition for trigeminal neuralgia

2020 ◽  
Vol 22 ◽  
pp. 100795
Author(s):  
Keisuke Onoda ◽  
Ai Kawaguchi ◽  
Yoshinori Takaya ◽  
Yuzo Saito ◽  
Hisashi Ishikawa ◽  
...  
Keyword(s):  
Trigeminal Neuralgia ◽  
Petrosal Vein ◽  
Superior Petrosal Vein

scholarly journals Suprafloccular approach via the petrosal fissure and venous corridors for microvascular decompression of the trigeminal nerve: technique notes and clinical outcomes

2018 ◽  
Vol 129 (2) ◽  
pp. 324-333 ◽  
Author(s):  
Hao Wang ◽  
Xiang Ying ◽  
Wen H. Yu ◽  
Qiang Zhu ◽  
Xiao Q. Dong ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Trigeminal Nerve ◽  
Morbidity Rate ◽  
Consecutive Series ◽  
Vestibulocochlear Nerve ◽  
Petrosal Vein ◽  
Working Space ◽  
Large Patient ◽  
Patient Series ◽  
Superior Petrosal Vein

OBJECTIVESurgical exposure and decompression of the entire trigeminal nerve in a conventional lateral supracerebellar approach can be challenging because of blockages from the superior petrosal vein complex, cerebellum, and vestibulocochlear nerve. The authors demonstrate a novel suprafloccular approach via the petrosal fissure and venous corridors that can be used as a substitute for the conventional route used to treat trigeminal neuralgia and present a consecutive series of patients and their clinical outcomes.METHODSPreoperative and postoperative clinical data from 420 patients who underwent this modified approach at Hangzhou First People’s Hospital between March 2012 and May 2014 were reviewed. The technique expands the working space by opening the petrosal fissure and dissecting adhesions between the vein of the cerebellopontine fissure and the simple lobule as needed. Via 3 surgical corridors, the entire trigeminal nerve is exposed and decompressed thoroughly with minimal retraction of the surrounding vital structures.RESULTSThe medial one-third of the trigeminal nerve accounted for the majority (275 [65.5%] cases) of neurovascular conflict sites. The lateral corridor was used in 219 (52.1%) cases, the medial corridor was used in 175 (41.7%) cases, and the intermediate corridor was used in 26 (6.2%) cases. The entire trigeminal nerve in each patient was accessed directly and decompressed properly. At the end of the 24-month follow-up period, the rate of excellent results (Kondo score of T0 or T1) was stable at approximately 90.5%. No complications were related directly to petrosal vein or vestibulocochlear nerve injury.CONCLUSIONSBased on data from the large patient series, the authors found this suprafloccular approach via the petrosal fissure and venous corridors provides full exposure and decompression of the entire trigeminal nerve, a high cure rate, and a low neurovascular morbidity rate.

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