Neuronavigated percutaneous gasserian radiofrequency thermorhizotomy for trigeminal neuralgia: how I do it.

BACKGROUND: Radiofrequency thermorhizotomy (TRZ) is an established treatment for trigeminal neuralgia (TN). TRZ can result risky and painful in a consistent subset of patients, due to the need to perform multiple trajectories, before a successful foramen ovale cannulation. Moreover, intraoperative x-rays are required. METHOD: TRZ has been performed by using a neuronavigated stylet, before trajectory planning on a dedicated workstation. CONCLUSION: Navigated-TRZ (N-TRZ) meets the expectations of a safer and more tolerable procedure due to the use of a single trajectory, avoiding critical structures. Moreover, N-TRZ is x-ray free. Efficacy outcomes are similar to those reported in literature.

Protocol for a systematic mapping review of surgical and pharmacological interventions for the treatment of trigeminal neuralgia.

Introduction: Trigeminal neuralgia is a painful neuropathic disorder characterized by sudden electric shock-like pain that significantly impacts patients' quality of life. Multiple treatment alternatives are available, including medical and surgical options but establishing the optimal course of action can be challenging. To enhance clinical decision-making for trigeminal neuralgia treatment, it is imperative to organize, describe and map the available systematic reviews and randomized trials. This will help identify the best treatment alternatives supported by evidence and acknowledge potential knowledge gaps where future research is needed. Objective: This systematic mapping review aims to provide up-to-date evidence on the different surgical and pharmacological treatment alternatives used for trigeminal neuralgia. Methods: A search will be systematically conducted on the Epistemonikos database to identify potentially eligible systematic reviews. Additionally, a search will be made in PubMed, CENTRAL, and EBSCO to identify randomized controlled trials assessing pharmacological and surgical treatment interventions for trigeminal neuralgia. Two independent reviewers will screen and select the studies. Data on the different treatment alternatives and reported outcomes in the included studies will be extracted using standardized forms. Following extraction, descriptive statistical methods will be used to analyze the data. The final output of this study will include an evidence map that will illustrate the connections between different treatments and their respective outcomes, providing a clear depiction of the evidence landscape. Expected results: This study expects to map, describe and assess the methodological quality of the available systematic reviews and trials on pharmacological interventions and neurosurgical procedures for treating trigeminal neuralgia. It will present the results in an evidence map that organizes the available evidence based on their different interventions and outcomes. This evidence map will serve as a visual tool to assist healthcare professionals and patients to understand evidence-based treatment options and their implications for managing this medical condition. Introducción: La neuralgia del trigémino es un trastorno neuropático doloroso caracterizado por un dolor súbito y agudo, similar a una descarga eléctrica, que impacta significativamente en la calidad de vida. Dada la variedad de tratamientos disponibles, médicos y quirúrgicos, es crucial organizar y mapear la evidencia proveniente de revisiones sistemáticas y ensayos clínicos para orientar las decisiones clínicas. Esto permite identificar tratamientos respaldados por evidencia y señalar áreas de investigación futura. Objetivo: El propósito de esta revisión sistemática de mapeo es proporcionar una visión actualizada de la evidencia existente en relación con las diversas opciones de tratamiento quirúrgico y farmacológico empleadas en el manejo de la neuralgia del trigémino. Métodos: Se realizará una búsqueda sistemática en la base de datos Epistemonikos para identificar potenciales revisiones sistemáticas. Adicionalmente, se buscará en PubMed, CENTRAL y EBSCO ensayos clínicos aleatorizados que evalúen intervenciones de tratamiento farmacológico y quirúrgico para la neuralgia del trigémino. Dos revisores independientes cribarán y seleccionarán los estudios. Se extraerán datos sobre las diferentes alternativas de tratamiento y los resultados reportados en los estudios incluidos utilizando formularios estandarizados. Tras la extracción, se utilizarán métodos estadísticos descriptivos para analizar los datos. El producto final de este estudio incluirá un mapa de evidencia que ilustrará las conexiones entre los diferentes tratamientos y sus respectivos resultados, proporcionando una representación clara del panorama de la evidencia. Resultados esperados: Los resultados que se extraerán de este mapeo sistemático incluyen identificar y describir las diferentes alternativas, tanto farmacológicas como quirúrgicas, que existen para el tratamiento de la neuralgia del trigémino. Además, se planea presentar un mapa de evidencia que se basará en los ensayos clínicos aleatorizados y revisiones sistemáticas, el cual mostrará la evidencia de manera organizada entre las diferentes intervenciones y sus desenlaces. Este mapa de evidencia servirá como una herramienta visual que ayudará a los profesionales de la salud y los pacientes a comprender mejor las opciones de tratamiento respaldadas por la evidencia y sus consecuencias en el manejo de esta condición médica.

Retrogasserian trigeminal radiofrequency-thermorhizotmoy for trigeminal neuralgia.

Based on a personal experience of 4200 surgeries, radiofrequency thermocoagulation is useful lesional treatment for those trigeminal neuralgias (TNs) not amenable to microvascular decompression (idiopathic or secondary TNs). Introduced through the foramen ovale, behind the trigemnial ganglion in the triangular plexus, the needle is navigated by radiology and neurophysiological testing to target the retrogasserian fibers corresponding to the trigger zone. Heating to 55-75 °C can achieve hypoesthesia without anaesthesia dolorosa if properly controlled. Depth of anaesthesia varies dynamically sedation for cannulation and lesioning, and awareness during neurophysiologic navigation. Proper technique ensures long-lasting results in more than 75% of patients.

Efficacy and safety of microvascular decompression with or without partial sensory rhizotomy: a comprehensive meta-analysis and systematic review in treating trigeminal neuralgia.

Classical trigeminal neuralgia (TN), caused by vascular compression of the nerve root, is a severe cause of pain with a considerable impact on a patient's quality of life. While microvascular decompression (MVD) has lower recurrence rates when compared with partial sensory rhizotomy (PSR) alone, refractoriness can still be as high as 47%. We aimed to assess the efficacy and safety profile of MVD + PSR when compared to standalone MVD for TN. We searched Medline, Embase, and Web of Science following PRISMA guidelines. Eligible studies included those with ≥ 4 patients, in English, published between January 1980 and December 2023, comparing MVD vs. MVD + PSR for TN. Endpoints were pain cure, immediate post-operative pain improvement, long-term effectiveness, long-term recurrence, and complications (facial numbness, hearing loss, and intracranial bleeding). We pooled odds ratios (OR) with 95% confidence intervals with a random-effects model. I2 was used to assess heterogeneity, and sensitivity and Baujat analysis were conducted to address high heterogeneity. Eight studies were included, comprising a total of 1,338 patients, of whom 1,011 were treated with MVD and 327 with MVD + PSR. Pain cure analysis revealed a lower likelihood of pain cure in patients treated with MVD when compared to patients treated with MVD + PSR (OR = 0.30, 95% CI: 0.13 to 0.72). Immediate postoperative pain improvement assessment revealed a lower likelihood of improvement in the MVD group when compared with the MVD + PSR group (OR = 0.31, 95% CI: 0.10 to 0.95). Facial numbness assessment revealed a lower likelihood of occurrence in MVD alone when compared to MVD + PSR (OR = 0.08, 95% CI: 0.04 to 0.15). Long-term effectiveness, long-term recurrence, hearing loss, and intracranial bleeding analyses revealed no difference between both approaches. Our meta-analysis identified that MVD + PSR was superior to MVD for pain cure and immediate postoperative pain improvement for treating TN. However, MVD + PSR demonstrated a higher likelihood of facial numbness complications. Furthermore, identified that hearing loss and intracranial bleeding complications appear comparable between the two treatments, and no difference between long-term effectiveness and recurrence.

Intraoperative monitoring of trigeminal neuralgia: a technical note.

Trigeminal neuralgia causes excruciating pain in patients. Microvascular decompression is indicated for drug-resistant s trigeminal neuralgia. Unlike facial spasms, any part of the nerve can be the culprit, not only the root entry zone. Intraoperative monitoring does not yet exist for trigeminal neuralgia. We successfully used intermittent stimulation of the superior cerebellar artery during surgery and confirmed the disappearance of the trigeminal nerve motor branch reaction after the release of the compression. Intermittent direct stimulation of the culprit blood vessel using the motor branch of the trigeminal nerve may assist in intraoperative monitoring of decompression during trigeminal nerve vascular decompression surgery.

Predicting balloon shape in percutaneous microcompression : an observational comparative analysis of Meckel's cave imaging and balloon morphology.

Achieving a pear-shaped balloon holds pivotal significance in the context of successful percutaneous microcompression procedures for trigeminal neuralgia. However, inflated balloons may assume various configurations, whether it is inserted into Meckel's cave or not. The absence of an objective evaluation metric has become apparent. To investigate the relationship between the morphology of Meckel's Cave and the balloon used in percutaneous microcompression for trigeminal neuralgia and establish objective criteria for assessing balloon shape in percutaneous microcompression procedures. This retrospective study included 58 consecutive patients with primary trigeminal neuralgia. Data included demographic, clinical outcomes, and morphological features of Meckel's cave and the balloon obtained from MRI and Dyna-CT imaging. MRI of Meckel's cave and Dyna-CT of intraoperative balloon were modeled, and the morphological characteristics and correlation were analyzed. The reconstructed balloon presented a fuller morphology expanding outward and upward on the basis of Meckel's cave. The projected area of balloon was strongly positively correlated with the projected area of Meckel's cave. The Pearson correlation coefficients were 0.812 (P<0.001) for axial view, 0.898 (P<0.001) for sagittal view and 0.813 (P<0.001) for coronal view. Similarity analysis showed that the sagittal projection image of Meckel's cave and that of the balloon had good similarity. This study reveals that the balloon in percutaneous microcompression essentially represents an expanded morphology of Meckel's cave, extending outward and upward. There is a strong positive correlation between the volume and projected area of the balloon and that of Meckel's cave. Notably, the sagittal projection image of Meckel's cave serves as a reliable predictor of the intraoperative balloon shape. This method has a certain generalizability and can help providing objective criteria for judging balloon shape during percutaneous microcompression procedures.

Three-dimensional CT reconstruction-guided percutaneous balloon compression for trigeminal neuralgia.

OBJECTIVE: To study the value of three-dimensional CT (3D-CT) reconstruction by comparing the surgical effects of C-arm and 3D-CT in the treatment of trigeminal neuralgia (TN) by percutaneous balloon compression (PBC). METHODS: A total of 136 patients were included from May 2018 to February 2019. Among them, 65 patients underwent PBC treatment with 3D-CT and others with C-arm. During 3D-CT-guided operation, 3D-CT reconstruction software was used to analyze and measure the distances from the internal orifice of Foramen ovale (FO-I) and the external orifice of Foramen ovale (FO-E) to the top of the balloon (BT) and the petrous bone ridge (PR). The data, including the angle between the puncture needle direction and the zygomatic arch, petrous bone ridge, and slope, were used to assist the puncture and balloon plasty. Postoperative follow-up for more than five years was performed to evaluate the efficacy and pain recurrence. RESULTS: The distance from FO-E to PR was (2.10 ± 0.16)cm, the average distance from FO-I to BT was (2.39 ± 0.07)cm, and the average angles between the puncture needle and zygomatic arch, slope, and petrous bone ridge were (56.19 ± 5.59)°, (69.12 ± 6.92)°, and (104.49 ± 6.46)°, respectively. One (1.5 %) patient in the 3D-CT group and three (4.2 %) patients in the C-arm group failed to receive PBC treatment because of failure of FO puncture (P = 0.032).In terms of postoperative pain improvement, 3D-CT group achieved better results than the C-arm group (P = 0.043). There were no significant differences in the rates of major complications and short-term recurrence (P = 0.926) between the two groups after surgery, but the five-year recurrence rate in the 3D-CT group was lower than that in the C-arm group (P = 0.032). CONCLUSION: By guiding the angle and depth of puncture, the intraoperative application of 3D-CT reconstruction technology can improve the accuracy of foramen ovale puncture and alleviate postoperative pain, and also maintain long-term postoperative pain relief, which can be used as a potentially better guidance method to improve the surgical efficacy of PBC.

A novel indicator to predict the outcome of percutaneous stereotactic radiofrequency rhizotomy for trigeminal neuralgia patients: diffusivity metrics of MR-DTI.

Magnetic resonance-diffusion tensor imaging (MR-DTI) has been used in the microvascular decompression and gamma knife radiosurgery in trigeminal neuralgia (TN) patients; however, use of percutaneous stereotactic radiofrequency rhizotomy (PSR) to target an abnormal trigeminal ganglion (ab-TG) is unreported. Fractional anisotropy (FA), mean and radial diffusivity (MD and RD, respectively), and axial diffusivity (AD) of the trigeminal nerve (CNV) were measured in 20 TN patients and 40 healthy control participants immediately post PSR, at 6-months, and at 1 year. Longitudinal alteration of the diffusivity metrics and any correlation with treatment effects, or prognoses, were analyzed. In the TN group, either low FA (value < 0.30) or a decreased range compared to the adjacent FA (dFA) > 17% defined an ab-TG. Two-to-three days post PSR, all 15 patients reported decreased pain scores with increased FA at the ab-TG (P < 0.001), but decreased MD and RD (P < 0.01 each). Treatment remained effective in 10 of 14 patients (71.4%) and 8 of 12 patients (66.7%) at the 6-month and 1-year follow-ups, respectively. In patients with ab-TGs, there was a significant difference in treatment outcomes between patients with low FA values (9 of 10; 90%) and patients with dFA (2 of 5; 40%) (P < 0.05). MR-DTI with diffusivity metrics correlated microstructural CNV abnormalities with PSR outcomes. Of all the diffusivity metrics, FA could be considered a novel objective quantitative indicator of treatment effects and a potential indicator of PSR effectiveness in TN patients.

Efficacy and Challenges: Minimally Invasive Procedures for Trigeminal Neuralgia Treatment in Multiple Sclerosis - A Systematic Review and Meta-Analysis.

INTRODUCTION: Trigeminal neuralgia (TGN) poses a therapeutic challenge, particularly within the context of multiple sclerosis (MS). This study aimed to conduct a comprehensive meta-analysis and systematic review of four less-invasive treatment modalities for TGN in MS patients, namely, gamma knife radiosurgery (GKRS), glycerol rhizotomy (GR), balloon compression (BC), and radiofrequency ablation (RFA). METHODS: Single-armed meta-analyses were employed to assess the overall efficacy of each treatment, while double-armed analyses compared the efficacy between different treatment options in double-armed studies. Outcome evaluations included acute pain relief (within 1 month post-procedure), recurrence rates throughout 18 months of follow-up, and reported complication rates. RESULTS: The meta-analysis revealed diverse outcomes for each intervention. GKRS demonstrated favorable outcomes, achieving a 77% success rate in alleviating pain among a pooled cohort of 863 patients, reinforcing its status as a viable therapeutic option. Additionally, GR, BC, and RFA exhibited efficacy, with success rates of 77%, 71%, and 80%, respectively, based on outcomes observed in 611, 385, and 203 patients. Double-armed analyses highlighted distinctions between the treatments, providing nuanced insights for clinical decision-making. CONCLUSION: This meta-analysis provides a comprehensive overview of less-invasive treatments for TGN in MS patients. GKRS emerges as a leading option with comparable efficacy and fewer complications. However, the study underscores the nuanced efficacy and considerations associated with GR, BC, and RFA. The findings offer valuable insights for clinicians navigating treatment choices in this challenging patient population, considering acute pain relief, recurrence rates, and complication profiles.

Neurorehabilitation strategies: Assessing the impact on postoperative psychological state, pain, and complications in trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia is a difficult clinical situation marked by excruciating pain that requires efficient postoperative measures. In patients with trigeminal neuralgia, this study sought to investigate the effects of ongoing rehabilitation intervention on postoperative outcomes, including psychological state, pain, and complications. The aim was to provide new perspectives and treatment strategies for the management of this crippling illness. NEW METHOD: Between January 2021 and December 2022, 120 patients receiving treatment for trigeminal neuralgia were randomized to either the observation or control groups. The observation group received a continuous and comprehensive rehabilitation intervention that included elements of the control group's regimen, while the control group received standard health education and dietary guidance interventions through the use of a digital table method. The assessment of pain scales (VAS), self-rating depression scales (SDS), self-rating anxiety scales (SAS), and complication rates were all part of the postoperative follow-up. RESULTS: At seven days following surgery, there were no appreciable variations in the observation and control groups' VAS, SAS, and SDS scores (P > 0.05). Nevertheless, the observation group showed significantly lower VAS and SAS scores than the control group at 6 months and 1 year following surgery (P < 0.05). The observation group's SDS score was significantly lower than the control group's one year after surgery (P < 0.001). In comparison to the control group, the observation group also showed a lower overall complication rate (P < 0.05), especially in the cases of facial herpes and vertigo. COMPARISON WITH EXISTING METHODS: Our ongoing, all-encompassing rehabilitation approach demonstrated better results than current approaches in terms of long-lasting pain alleviation, enhanced mental health, and lower rates of complications in patients with trigeminal neuralgia following surgery. This implies that, in comparison to traditional methods, incorporating rehabilitation strategies may provide greater therapeutic benefits. CONCLUSION: Continuous comprehensive rehabilitation intervention can effectively reduce the degree of postoperative pain in patients with trigeminal neuralgia, help to regulate their psychological state, and reduce the occurrence of complications, which has certain clinical application value.

The Primary Afferents of Trigeminal Autonomic Reflex May not be Nociceptive: A Case Report.

Autonomic symptoms have been long noticed coming along with pain in the head, e.g. Trigeminal Neuralgia, trigeminal autonomic cephalalgias. The symptoms show up during pain attacks, so they are assumed to be activated by the nociceptive afferents of the trigeminal nerve. Here, we present a case with hypersalivation as the complication after percutaneous balloon compression for trigeminal neuralgia, although the patient was pain-free after the treatment. A 71-year-old female with excessive salivation on the affected side after percutaneous balloon compression is described. The patient underwent microvascular decompression several years ago, and both the microvascular decompression and the preoperative imaging examination confirmed that there was no offending vessel at the root entry zone of the trigeminal nerve. After the percutaneous balloon compression, the patient was free of pain, but the autonomic symptoms (hypersalivation) still showed up. The autonomic symptoms which usually came along with pain presented solely as post-percutaneous balloon compression complication in the case. Contrary to popular belief, for the patient who was pain-free after percutaneous balloon compression, the transiently overactivated nerve fibers that led to hypersalivation were not nociceptive afferents of the trigeminal nerve.

Comparison of initial percutaneous balloon compression versus radiofrequency thermocoagulation followed by percutaneous balloon compression in the treatment of trigeminal neuralgia. / 首次经皮球囊压迫术与射频热凝术后再行经皮球囊压迫术治疗三叉神经痛的比较.

OBJECTIVES: There are a variety of minimally invasive interventional treatments for trigeminal neuralgia, and the efficacy evaluation is different. The preferred treatment scheme is still controversial. This study aims to investigate the differences in treatment effects between patients with primary trigeminal neuralgia (PTN) treated with percutaneous balloon compression (PBC) for the first intervention and patients with pain recurrence after radiofrequency thermocoagulation (RT) who then received PBC for PTN, and to offer clinicians and patients more scientifically grounded and precise treatment alternatives. METHODS: We retrospectively analyzed 103 patients with PTN admitted to the Department of Pain Management of the Second Affiliated Hospital of Guangxi Medical University from January 2020 to December 2021, including 49 patients who received PBC for the first time (PBC group) and 54 patients who received PBC for pain recurrence after RT (RT+PBC group). General information, preoperative pain score, intraoperative oval foramen morphology, oval foramen area, balloon volume, duration of compression, and postoperative pain scores and pain recurrence at each time point on day 1 (T1), day 7 (T2), day 14 (T3), 1 month (T4), 3 months (T5), and 1 year (T6) were collected and recorded for both groups. The differences in treatment effect, complications and recurrence between the 2 groups were compared, and the related influencing factors were analyzed. RESULTS: The differences of general information, preoperative pain scores, foramen ovale morphology, foramen ovale area, T1 to T3 pain scores between the 2 groups were not statistically different (all P>0.05). The balloon filling volume in the PBC group was smaller than that in the RT+PBC group, the pain scores at T4 to T6 and pain recurrence were better than those in the RT+PBC group (all P<0.05). Pain recurrence was positively correlated with pain scores of T2 to T6 (r=0.306, 0.482, 0.831, 0.876, 0.887, respectively; all P<0.01). CONCLUSIONS: The choice of PBC for the first intervention in PTN patients is superior to the choice of PBC after pain recurrence after RT treatment in terms of treatment outcome and pain recurrence.

Letter to the editor: "A nomogram based on radiomics and clinical information to predict prognosis in percutaneous balloon compression for the treatment of trigeminal neuralgia: a retrospective cohort study of published cases".

This critique evaluates a recent study on a nomogram based on radiomics and clinical data to predict the prognosis of percutaneous balloon compression (PBC) for trigeminal neuralgia (TN), focusing on its strengths, weaknesses, and suggestions for future research. It acknowledges the innovative approach's potential to personalize treatment and improve outcomes, but raises concerns about the study's retrospective nature, sample size limitations, and challenges in implementing radiomics in clinical practice. Overall, although the nomogram offers promise, further validation in larger cohorts is essential to confirm its utility and reliability. Future research should prioritize prospective multicenter studies with standardized protocols, collaborative efforts among institutions, and innovative techniques to advance our understanding and management.

Radiosurgical Decompression of Trigeminal Nerve and Its Correlation with Functional Outcome in Tumor-Related Trigeminal Neuralgia.

BACKGROUND: Target selection during Gamma Knife radiosurgery (GKRS) in cases of tumor-related trigeminal neuralgia is always debatable. We analyzed the correlation of regression of tumor size and degree of release of the nerve with long-term pain control. METHODS: Between March 2012 and March 2023, 50 cases of tumor-related trigeminal neuralgia were treated with GKRS (tumor was targeted). Radiological findings after GKRS were categorized into 3 types: 1) tumor volume remained same or decreased, additional segment of nerve not seen; 2) tumor volume decreased, additional segment of trigeminal nerve seen, but tumor still adherent to the nerve; 3) tumor volume decreased, adjacent nerve seen completely separated from tumor. Pain score before and after GKRS (Barrow Neurological Institute I-III: good; Barrow Neurological Institute IV and V: poor) was correlated with these subgroups. RESULTS: At median follow-up of 46.5 months, 18 cases showed type 1 radiological response, 23 showed type 2 response, and 9 showed type 3 response. Good pain control was achieved in 10 (55.5%) patients with type 1, 15 (65.21%) with type 2, and 7 (77.8%) with type 3 responses. The outcome differences among these 3 groups were not statistically significant (P = 0.519). Five patients with type 3 radiological response were off medication, which was statistically better than type 1 and type 2 radiological responses, with 3 patients (P = 0.012) and 2 patients (P = 0.002), respectively, still receiving medication. CONCLUSIONS: Tumor volume reduction after GKRS may be associated with good pain control in tumor-related trigeminal neuralgia. Further, this allows visualization of additional segment of nerve that can be targeted in a second session for treating recurrent or failed cases.

Riveting technique in percutaneous balloon compression for trigeminal neuralgia remedy.

BACKGROUND: The percutaneous balloon compression (PBC) is a safe and simple treatment for trigeminal neuralgia. It works by compressing the Gasserian ganglion to block pain signals from the trigeminal nerve. To ensure effectiveness, it is important to focus the compression on the lower part of the balloon. OBJECTIVE: To validate the efficacy of a riveting technique, specifically pulling an inflated balloon, in order to apply enhanced compression on the ganglion. METHODS: To compare this novel technique with the conventional approach, a retrospective investigation was conducted on consecutive PBCs performed in our department between 2019 and 2022. For postoperative outcome assessment, efficacy was defined as achieving a VAS score of 0 or an improvement exceeding 5 points. Postoperative numbness was graded as none, mild, or severe based on its impact on daily life and tolerance level. RESULTS: Excluding cases with missed follow-up, a total of 179 participants were included in the study, and their follow-up period ranged up to 40 months. Postoperatively, symptomatic remission was achieved by 98.1% (52/53) of patients in the riveting technique group compared to 87.3% (110/126) in the conventional group (P<0.05). At the last follow-up period, with recurrence observed over time, the long-term efficacy of riveting and conventional groups were 94.3% and 74.6%, respectively (P<0.05). The majority of cases in both groups experienced ipsilateral facial numbness immediately following PBC, which appeared to diminish after 3 months in both groups without significant difference between them (P>0.05).

Surgical Strategy for Petroclival Meningioma-Related Trigeminal Neuralgia: The Role of Porus Trigeminus Opening.

OBJECTIVE: Petroclival meningiomas invade Meckel's cave through the porus trigeminus, leading to secondary trigeminal neuralgia. Microsurgery and stereotactic radiosurgery (SRS) are the typical treatment options. This study investigated symptom control, outcomes, and surgical strategies for PC meningioma-induced TN. METHODS: We retrospectively analyzed 28 TN patients with PC meningiomas who underwent microsurgical nerve decompression between January 2021 and February 2023. In all patients undergoing a transpetrosal approach, the porus trigeminus was opened to enable the removal of the entire tumor within Meckel's cave. Clinical outcomes were assessed using the Barrow Neurologic Institute (BNI) pain intensity scale. Risk factors for poor TN outcomes and poor facial numbness were analyzed. RESULTS: Among 28 patients, 21 (75%) underwent the transpetrosal approach, 5 (17.9%) underwent the retrosigmoid approach, and 2 (7.1%) underwent the Dolenc approach. Following microsurgery, 23 patients (82.1%) experienced TN relief without further medication (BNI I or II). TN recurrence occurred in 2 patients (7.1%), and 3 patients (10.7%) did not achieve TN relief. Cavernous sinus invasion was significantly correlated with poor TN outcomes (P = 0.047). A history of previous SRS (P = 0.011) and upper clivus type tumor (P = 0.018) were significantly associated with poor facial numbness. CONCLUSIONS: Microsurgical nerve decompression is effective in improving BNI scores in patients with TN associated with PC meningiomas. Considering the results of our study, the opening of the porus trigeminus can be considered as a suggested procedure in the treatment of PC meningiomas, especially in cases accompanied by TN.

Benchtop and in Vitro Experiments of Novel Transform Stents for Trigeminal Neuralgia Treatment.

BACKGROUND: Trigeminal neuralgia (TN) is a debilitating condition characterized by sudden, excruciating facial pain due to neurovascular compression of the trigeminal nerve. Stent deployment can change the course of the superior cerebellar artery upwards, possibly releasing the root entry zone of the trigeminal nerve. We developed a novel stent, the Transform stent, for TN treatment, and evaluated its mechanical properties using benchtop and in vitro hemocompatibility tests. METHODS: We compared the performance of Transform and Enterprise stents in treating TN because they share similar self-expanding closed-cell features in the manufacturing process, are derived from nitinol tubes, and are fabricated through a laser-cutting process, but also because only the safety of Enterprise stents deployed in intracranial arteries has been reported clinically. All benchtop measurements, including radial force, trackability, bending stiffness, and conformability, were performed thrice for each stent model, and their average values are presented. RESULTS: Transform stents showed higher radial forces in vessels of diameters ranging from 1.0 mm than Enterprise stents. The trackability of the Transform stent was better than that of the Enterprise stent in a neurovascular model. Bending stiffness was stronger in the Transform stent whereas conformability was superior in the Enterprise stent. No significant thrombogenic issues were observed in the in vitro hemocompatibility tests. CONCLUSIONS: This study demonstrated the Transform stent as a potential option and paved the way for innovative endovascular approaches for the future TN treatment. Namely, the study confirmed that the characteristics of Transform stents at benchtop and in vitro evaluations may be used as a first step for studies such as in vivo pre- and clinical studies.

Revisiting the Efficacy of Redo Microvascular Decompression for Trigeminal Neuralgia.

BACKGROUND: Microvascular decompression (MVD) is an effective nondestructive neurosurgical procedure for trigeminal neuralgia (TN). However, some patients may undergo surgery failure or experience pain recurrence, sparking debates on the need for reoperation. METHODS: We conducted a retrospective analysis of 103 cases of patients with primary TN who underwent redo MVD at our center between January 2020 and December 2022. Comparative prognostic assessments were performed by comparing these cases against a cohort of 348 patients who underwent primary MVD during the same study period. RESULTS: During the redo MVD cases, arachnoid membranes adhesions (80.6%) and Teflon adhesions with/without granuloma (86.4%) as well as remaining vascular compression (36.9%) were observed. After the reoperation, an immediate relief rate of 94.2% was observed. During a mean follow-up period of 17.4 ± 4.4 months, a long-term relief rate of 89.3% was achieved. Postoperative complications included 3 cases of persistent paresthesia, 1 case each of hearing loss, cerebrospinal fluid leak, and facial palsy. Ten cases without evident compression received nerve combing and all experienced immediate complete relief, with only 1 patient experiencing recurrence 9 months after surgery. Compared to the primary MVD group, the reoperation group had a higher average age, longer disease duration, and operating time (P < 0.05). However, there were no significant differences in immediate relief rate, long-term relief rate, or complications between the 2 groups. The main cause of persistent symptom was inadequate decompression, such as missing the offending vessel; while the recurrent was primarily due to Teflon adhesion or granuloma formation. CONCLUSIONS: The redo MVD for TN is equally efficacious and safe compared to the primary procedure, with an emphasis on meticulous dissection and thorough decompression. Additionally, nerve combing proves to be an effective supplementary option for patients without obvious compression.