Internal Neurolysis (Nerve Combing) for Trigeminal Neuralgia without Neurovascular Compression

Objective The aim of the present study was to describe and evaluate the initial and the long-term clinical outcome of internal neurolysis (IN) for trigeminal neuralgia (TN) without neurovascular compression (NVC). Methods A total of 170 patients diagnosed with TN were treated by posterior fossa exploration, during the period between April 2012 and October 2019. The patients were divided into two groups: Group A (50 patients)was treated by IN and Group B (120 patients) received microvascular decompression (MVD). Surgical outcomes and postoperative complications were compared between the two groups. Pain intensity was assessed by the Barrow Neurological Institute (BNI) pain intensity score and BNI facial numbness score. Pain recurrence was statistically evaluated with Kaplan-Meier analysis. Results Pain was completely relieved in 44 patients (88%) who underwent IN (group A); 3 (6%) experienced occasional pain but did not require medication (BNI 2). In group B, 113 (94%) experienced immediate pain relief after MVD. The median duration of follow-ups was 4 years (6 months to 7.5 years). In Group A, there was a meantime recurrence of 27 months in 3 patients (6%). The recurrence in Group B was of 5.8% during the follow-up period. There were no statistically significant differences in the surgical outcomes between the two groups. All patients with IN experienced some degree of numbness, 88% of the cases resolved in 6 months, on average. Conclusion Internal neurolysis is an effective, safe and durable treatment option for trigeminal neuralgia when NVC is absent.

Applied value of vascular compression grading in prognosis evaluation of patients with trigeminal neuralgia / 中华神经医学杂志

Objective:To investigate the predictive value of trigeminal nerve vascular compression grading evaluated by preoperative magnetic resonance imaging (MRI) in patients with trigeminal neuralgia (TN) after microvascular decompression (MVD).Methods:Two hundred and seventy patients with TN accepted MVD in our hospital from January 2015 to December 2017 were chosen in our study; their clinical and MRI data were retrospectively analyzed. By referring to Sindou's method and Jannetta standard, these patients were divided into patients with mild vascular compression ( n=71) and patients with severe vascular compression ( n=199) according to preoperative MRI data; these patients were divided into typical TN patients ( n=219) and atypical TN patients ( n=51) according to their symptomatic characteristics; the differences in prognoses after one year of follow-up were compared among patients from different categories. Results:The degree of intraoperative vascular compression was basically consistent with the preoperative imaging evaluation results, and the intraoperative vascular compression in 256 patients was consistent with preoperative imaging evaluation grading, with a coincidence rate of 94.8% (256/270). The difference in prognosis between patients with mild vascular compression and patients with severe vascular compression was statistically significant ( Z=-3.420, P=0.001), and the mean rank indicated that the prognosis of patients with severe vascular compression was better than that of patients with mild vascular compression (142.01 vs. 117.25). The prognosis difference between typical TN patients and atypical TN patients was statistically significant ( Z=-5.810, P=0.000), and the mean rank indicated that the prognosis of typical TN patients was better than that of atypical TN patients (144.45 vs. 97.08). Conclusions:Preoperative MR imaging evaluation is a reliable method to assess the degree of vascular compression. Patients with severe vascular compression and typical TN have high postoperative pain relief rate after MVD.

Correlation between painful range of trigeminal neuralgia and location of neurovascular compression / 中华神经医学杂志

Objective:To discuss the correlation between painful range of trigeminal neuralgia (TN) and location of neurovascular compression (NVC).Methods:A total of 165 patients with single branch TN enjoying complete clinical data and having definite offending vessels were enrolled into this study; these patients underwent microsurgical treatment in cerebellopontine angle (CPA) area via suboccipital retrosigmoid approach in our hospital from March 2017 and June 2019; 22 patients had branch I TN, 84 patients had branch II TN, and 59 patients had branch III TN. The cistern part of trigeminal sensory root (CPA cistern part) was divided into four directions: cephalic, caudal, ventral and dorsal sides. The root entry zone (REZ) of trigeminal nerves was divided into four quadrants: cephalic-ventral, cephalic-dorsal, caudal-ventral and caudal-dorsal quadrants.Results:(1) In patients with branch I TN, 8 patients had location of NVC in the cistern part of CPA, including 5 in the cephalic side, two in the ventral side and one in the dorsal side; main offending vessels were superior cerebellar artery (SCA, n=7), mainly with cephalic compression. Another 14 patients had location of NVC in the REZ, including 11 in the cephalic-ventral quadrant, 2 in the cephalic-dorsal quadrant and one in the caudal-ventral quadrant; main offending vessels were SCA ( n=11), mainly with cephalic-ventral compression ( n=8). (2) In patients with branch II TN, 29 patients had location of NVC in the cistern part of CPA, including 16 in the ventral side, 10 in the dorsal side, 2 in the cephalic side and one in the caudal side; main offending vessels were SCA ( n=22), mainly with ventral and dorsal compression. Another 55 patients had location of NVC in REZ, including 26 patients in the cephalic-dorsal quadrant, 20 in the cephalic-ventral quadrant, 6 in caudal-dorsal quadrant and 3 in the caudal-ventral quadrant; main offending vessels were SCA ( n=41), mainly with cephalic-dorsal compression ( n=23) and cephalic-ventral compression ( n=17). (3) In patients with branch III TN, 26 patients had location of NVC in the cistern part of CPA, including16 in the caudal side and 10 in the dorsal side; main offending vessels were SCA ( n=7), mainly with dorsal compression. Another 33 patents had location of NVC in the REZ, including 25 in the cephalic-dorsal quadrant, 6 in the the caudal-dorsal quadrant and 2 in the caudal-ventral quadrant; main offending vessels were SCA ( n=22), mainly with cephalic-dorsal compression. Conclusions:The location of NVC in patients with branch I TN is mainly in the cephalic direction of the cistern part of CPA and the cephalic-ventral quadrant of REZ. The location of NVC in patients with branch II TN is mainly in the ventral and dorsal direction of the cistern part of CPA, and cephalic-dorsal and cephalic-ventral quadrant of REZ. The NVC in patients with branch III TN only locates in the caudal and dorsal direction of the cistern part of CPA, and mainly in the cephalic-dorsal quadrant of REZ. In the REZ or cistern part of CPA, SCA is always the main offending vessel.

Bilateral water sign: a new imaging sign for evaluating neurovascular compression in primary trigeminal neuralgia / 中华神经医学杂志

Objective:To evaluate a new imaging sign, named" bilateral water sign" (BWS), which can evaluate the neurovascular compression of primary trigeminal neuralgia (TN).Methods:A prospective study was conducted on 85 primary TN patients admitted to our hospital from March 2017 to March 2019. All patients accepted magnetic resonance 3D-T2W-DRIVEN sequence examination and multiplanar reconstruction (MPR) for post-processing. The sequential nerve (low signal)-cerebrospinal fluid (high signal)-vessel (low signal)-cerebrospinal fluid (high signal)-nerve (low signal) signs on the recombination plane were named as "BWS". The sensitivity, specificity, positive predictive value and negative predictive value of BWS in evaluating the neurovascular compression were calculated respectively, by combining with intraoperative situation of microvascular decompression (MVD).Results:In 85 TN patients, 46 patients (54.12%) had BWS. The sensitivity was 57.14%, the specificity was 75.00%, the positive predictive value was 95.65% and the negative predictive value was 15.38%. There was a statistically significant difference in the degree of neurovascular compression between patients with and without BWS ( P<0.05); and degree of neurovascular compression was severer in patients with BWS. Conclusion:BWS can evaluate the relation of neurovascular compression in TN patients and suggest the degree of neurovascular compression.

Neurovascular Compression Confirmed by 3D T2-Weighted Volume Isotropic Turbo Spin-Echo Acquisition Sequence in Trigeminal Neuralgia

No abstract available.

Paroxismia vestibular: reporte de un caso / Vestibular paroxysmia: case report

Presentamos el caso de un paciente joven quien presenta 4 a 5 crisis diarias de vértigo espontáneo de segundos de duración, todos o casi todos los días desde hace 9 meses. Estas crisis no tienen gatillo posicional, y hay completa ausencia de sintomatologia entre crisis. Como discutimos en el artículo, este cuadro coíncide con los recientemente publicados criterios para una paroxismia vestibular, entidad supuestamente secundaria a la compresión neurovascular del nervio vestibular. El paciente respondió de forma inmediata y completa a carbamazepina a dosis bajas, el tratamiento de elección en la paroxismia vestibular.

We present the case of a young patient, with a 9-month long history of 4 to 5 daily spells of spontaneous vertigo, each lasting only seconds. There is no positional trigger, and there is a complete lack of symptoms between attacks. As is discussed in the article, this matches the recently published criteria for Vestibular Paroxysmia, an entity allegedly secondary to neurovascular compression of the vestibular nerve. The patient responded immediately and completely to carbamazepine at low dosage, the preferred treatment for vestibular paroxysmia.

Comparative study of MR 3 D-SPACE and 3 D-TOF sequences in diagnosis of intracranial neurovascular compression syndrome / 实用放射学杂志

Objective To investigate the value of fused 3D-SPACE and 3D-TOF images in diagnosis of intracranial neurovascular compression syndrome.Methods 26 patients with intracranial neurovascular compression syndrome were examined using 3D-SPACE sequence and 3D-TOF sequence.After 3D-SPACE and 3D-TOF were fused by different times,the quality of image as well as the ability of j udging the relationship between nerves and blood vessels was analyzed and compared between the original images and the fused images.Results In this study,the fused images by adding one 3D-SPACE sequence and one 3D-TOF sequence showed the highest accurate than others(2 1 cases),and the j udgement of the relationship between the responsible blood vessels and nerve accor-ded with the surgical results to the highest extent (P<0.05).Conclusion The fusion image of 3D-SPACE sequence and 3D-TOF se-quence can improve the diagnostic ability of the intracranial neurovascular compression syndrome,and the appropriate proportion of the fusion image can show the relationship between the nerve and blood vessel.

Vestibular Paroxysmia Mimicking Benign Parxysmal Positional Vertigo / 대한평형의학회지

Vestibular paroxysmia is the name given to the syndrome caused by vascular compression of the vestibulocochlear nerve. The main symptoms of vestibular paroxysmia are recurrent, spontaneous, brief attacks of spinning, non-spinning vertigo or positional vertigo that generally last less than one minute, with or without ear symptoms (tinnitus and hypoacusis). Prior to attributing a patient's symptoms to vestibular paroxysmia, however, clinicians must exclude common conditions like benign paroxysmal positional vertigo, Menière's disease, vestibular neuritis and vestibular migraine. This is usually possible with a thorough history and bedside vestibular/ocular motor examination. Herein, we describe a patient with vestibular paroxysmia that mimicked resolved BPPV with a literature review.

Clinical and functional significance of accessory brachialis muscle: an unique anatomical variant / Significado clínico y funcional del músculo braquial accesorio: una variante anatómica única

A thorough knowledge of the variations in the patterns of muscle insertion and the consequent neurovascular entrapment due to them is important for orthopedic and plastic surgeons. During routine dissection, we encountered a unique occurrence of an accessory brachialis muscle (acBr) blending with the medial aspect of bicipital aponeurosis in the cubital fossa. It also entrapped the median nerve and brachial artery due to its superficial position. The abnormality reported here might result in neurovascular compression symptoms in the upper limb and possible mechanical advantages or disadvantage in the flexion of elbow joint. To the best of our knowledge, the brachialis variant insertion we present here is rare in the list of its anomalies. We also discuss in this report the embryological background and the clinical application of the variation that can abet clinicians in evaluating symptoms involving the upper limb.

Es importante para los cirujanos ortopédicos y plásticos, el conocimiento integral de las variaciones en los patrones de inserción de los músculos y el consiguiente atrapamiento neurovascular. Durante una disección de rutina, encontramos un caso único de un músculo accesorio braquial con aponeurosis bicipital en el lado medial de la fosa cubital. También cubre la arteria braquial y nervio mediano debido a su posición superficial. La anomalía informada aquí podría resultar en síntomas de compresión neurovascular en el miembro superior y las posibles ventajas o desventajas mecánicas de flexión de la articulación del codo. De acuerdo a lo estudiado, la inserción variante braquial que presentamos aquí es un caso raro dentro de la lista de sus variaciones. También se discuten en este informe la base embriológica y la aplicación clínica de la variación que puede ser útil para los clínicos en la evaluación de los síntomas relacionados con el miembro superior.

Magnetic resonance tomographic angiography in cranial neurovascular compression syndrome / 中华神经医学杂志

Objective To investigate the clinical diagnostic value of magnetic resonance tomographic angiography (MRTA) on cranial neurovascular compression syndrome,and evaluate the ability of 3D-FIESTA and 3D-TOF-SPGR sequences in demonstrating the relation of three-dimensional space between cranial nerves and blood vessels.Methods The data of 41 patients with cranial neurovascular compression syndrome,admitted to our hospital from May 2007 to May 2009,were analyzed.These patients were planed to perform micro vasular decompression (MVD).Before the operation,MRTA,3D-FIESTA and 3D-TOF-SPGR sequence scanning were performed to observe the relation of three-dimensional space between cranial nerves and blood vessels;these results were compared with the intraoperative results to evaluate the advantages and disadvantages of 3D-FIESTA and 3D-TOF-SPGR sequence scanning.Results MRTA could demonstrate such cranial nerves as trigeminal nerve,facial nerve and glossopharyngeal nerve,and responsible blood vessels clearly and simultaneously.The 3D-FIESTA imaging showed high signal in the cerebrospinal fluid and moderate signal in the nerves and blood vessels.The 3D-TOF-SPGR imaging showed low signal in the cerebrospinai fluid,moderate signal in the nerves and brain parenchyma,and high signal in the blood vessels.Closed relation between the nerves and the blood vessels in the lesion side were found in 34 patients (82.9%) by 3D-FIESTA sequence scanning,and that was found in 35 patients by 3D-TOF-SPGR sequence scanning; no significant difference between 3D-FIESTA and 3D-TOF-SPGR sequence scanning was found in displaying the relation of nerves and blood vessels (P>0.05).Conclusion MRTA technology may clearly show the relation of cranial nerves and responsible blood vessels;combined application of 3D-FIESTA and 3D-TOF-SPGR sequence scanning can help making the preoperative diagnosis and determining the surgical indications in patients with cranial neurovaseular compression syndrome.

Diagnostic Usefulness of CISS Image in Preoperative Evaluation of Trigeminal Neuralgia and Hemifacial Spasm

OBJECTIVES: Trigeminal neuralgia and hemifacial spasm are caused by vascular compression of the REZ(root entry or exit zone) of the 5th and the 7th cranial nerve. Preoperative detection of neurovascular compression is essential for accurate diagnosis, appropriate treatment, and the good operative results. Three dimensional Fourier Transformation-Constructive Interference in Steady State(3DFT-CISS) images are known to give good contrast between CSF, nerve, and vessels. We applied a 3DFT-CISS imaging technique for the preoperative evaluation of patients with these diseases and estimated the diagnostic accuracy and usefulness of this study. METHODS: A series of 71 patients with trigeminal neuralgia and hemifacial spasm were treated by microvascular decompression. Among them 34 patients with trigeminal neuralgia and 24 patients with hemifacial spasm had preoperative CISS images. We compared the radiologic finding with the operative finding, and analysed the diagnostic usefulness of 3DFT-CISS imaging. RESULTS: The sensitivity of CISS images of detecting the neurovascular compression was 90.3% in trigeminal neuralgia and 100% in hemifacial spasm. There were one false-positive and three false-negative cases in trigeminal neuralgia, and one false-positive case in hemifacial spasm. The accuracy in diagnosing the causative vessel was 73.5% in trigeminal neuralgia and 83.3% in hemifacial spasm. CONCLUSION: CISS image is very useful diagnostic tool for preoperative evaluation of neurovascular compression in patients with trigeminal neuralgia and hemifacial spasm. No additional neuroradiologic examination other than CISS image and MRA is needed for preoperative evaluation of patients with trigeminal neuralgia and hemifacial spasm.

Microvascular Decompression for Essential Hypertension

Idiopathic arterial hypertension, termed "essential" or "neurogenic", is a common generalized cardiovascular syndrome comprised of a sequence of pathologic changes and accommodations. Although an extensive literature exists concerning that, the primary etiology has been unclear yet. However, Jannetta and coworkers have reported a possible etiological connection between essential hypertension and intraoperatively observed neurovascular compression of the ventrolateral medulla at the level of the root entry zone of the ninth and tenth cranial nerves on the left, recently. They have also introduced one of new therapeutical concept for essential hypertension by microvascular decompression(MVD) of offending vessels. Based on Jannetta and coworker's hypothesis, the authors have made some operations for the control of hypertension. Seven essential hypertensive patients have been underwent retromastoid craniectomy and MVD in the left ventrolateral medulla between July 1992 and June 1993. Five of them showed multiple episodes of intracerebral hemorrhages, one was an intractable hypertension case and the other one had a left hemifacial spasm with essential hypertension. The most common offending vessel was the posterior inferior cerebellar artery and it had been confirmed during operation. Postoperatively, in three cases, blood pressure was lowered to normal without medications. Of remaining four cases, blood pressure was significantly improved in one and slightly improved in three. There were no major complications in patients with surgery and no poor outcomes. These results indicate that the MVD for essential hypertension is relatively safe procedure and alternative choice as one of the management of intractable essential hypertension, repeated hypertensive intracerebral hemorrhages and left cranial nerve hyperfunction disorders combined with essential hypertension.

Surgical Treatment of Spasmodic Torticollis by Microvascular Decompression with Selective Dorsal Cervical Phizotomy: Case Report

A case of spasmodic torticollis in a 48-year-old man cured by micovascular decompression of the spinal accessory nerve with selective dorsal cervical rhizotomy of the first and second cervical nerves. The 11th nerve was compressed by the posterior inferior cerebellar artery originating from the vertebral artery at the C1 level. After intraoperative identification of each posterior rootlets of C1 and C2 nerves exclusively related with the involved sternocleidomastoid muscle(SCM) using the monopolar electric nerve stimulator, microvascular decompression with selective dorsal cervical rhizotomy was done using the Teflon felt and electrobipolar coagulator. The patient was significantly relieved from symptoms 1 week after operation.