Microvascular Decompression for Treatment of Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: Three Surgical Approach Variations: Technical Note

Hitotsumatsu, Tsutomu; Matsushima, Toshio; Inoue, Tatsuo

doi:10.1227/01.neu.0000093431.43456.3b

Cited by 139 publications

(83 citation statements)

References 19 publications

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“…Limited exposure, deep working area, and the potencial severity of adverse outcomes that can result from postoperative infarction and swelling are all characteristics of operations in the posterior fossa 21 . The goal of MVD for treatment of these disorders is complete alleviation of the symptoms with minimization of those surgical complications 22 . Microvascular decompression has become the appropriate operative technique to relieve simple neurovascular compression syndromes.…”

Section: Discussionmentioning

confidence: 99%

Brainstem compression syndrome caused by vertebrobasilar dolichoectasia: microvascular repositioning technique

Pereira-Filho

Faria

Bleil

et al. 2008

Arq. Neuro-Psiquiatr.

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Vertebrobasilar dolichoectasia (VBD) is an anatomic variant that consists of enlargement and dilatation, often associated with a tortuous and elongated vessel 1 . The anomaly is probably due to a marked thinning of the internal elastica lamina and media, most likely as a consequence of prolonged systemic arterial hypertension 2 . It accounts for approximately 3 to 5% of all cerebellopontine mass lesions. A variety of clinical syndromes have been related due to pulsatile compression by the aberrant vessel: cerebellar dysfunction, hydrocephalus, ischemic stroke, transient or permanent motor deficits, central sleep apnea, trigeminal neuralgia, as well as brain stem compression syndrome 1,3,4 . Microvascular decompression surgery was introduced in the 1960s and was initially used to treat trigeminal neuralgia, hemifacial spasm and glossopharyngeal neuralgia 5 . Lately, it was used to treat brainstem dysfunction caused by an ectatic vessel 1 . Nowadays, microvascular decompression with repositioning of the ectatic vessel is a new technique that has been used successfully.The purpose of this study is to report and discuss a rare case of brain stem compression syndrome caused by vertebrobasilar dolichoectasia successfully treated with microvascular decompression repositioning technique and documented by computed tomography angiography (CTA) and magnetic resonance imaging (MRI). CASEA 60-years old man with a past medical history of diabete mellitus type 2 sought neurological treatment after experiencing mild progressive disartria for eight months. He did not have other complaints. The patient's neurologial examination revealed, besides the speech abnormality, left side pyramidal syndrome with hiperreflexia and Babinski´s sign. All the other aspects of the neurological examination were intact. Imaging investigationMRI and CTA showed an elongated and tortuous vertebrobasilar artery that crossed the ventral aspect of the medulla oblongata causing mechanial compression at the left side (Figs 1 and 2). Surgical techniqueThe patient was placed in the prone oblique (park bench) position, and a left far lateral suboccipitoretromastoidea approach was performed with left vertebral artery exposure. The dura was opened, and cerebrospinal fluid was released at the cisterna magna to provide a capacious working environment.Arachnoid dissection revealed a large vascular structure, identified as the basilar dolichoectatic artery, dislocating and compressing the brain stem (medulla oblongata) in its left ventral region. As soon as the neurovascular conflicting area was

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Section: Discussionmentioning

confidence: 99%

Brainstem compression syndrome caused by vertebrobasilar dolichoectasia: microvascular repositioning technique

Pereira-Filho

Faria

Bleil

et al. 2008

Arq. Neuro-Psiquiatr.

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Section: Discussionmentioning

confidence: 99%

“…4,12) This approach provided an excellent view of the lateral portion of the foramen magnum, PICA, VA, and lower cranial nerves, including the root entry zone of the glossopharyngeal nerve. 4) In addition, this approach allowed satisfactory access to the surgical field, reducing the risk of injury to the lower cranial nerves and perforating arteries. 12) Definitive diagnosis of GPN due to vascular compression is sometimes difficult, but balloon test occlusion can help to identify the responsible vessel(s) and confirm the selection of MVD surgery as the appropriate treatment modality in select patients with GPN.…”

Section: Discussionmentioning

confidence: 99%

Usefulness of Balloon Test Occlusion in the Diagnosis of Glossopharyngeal Neuralgia -Case Report-

Hasegawa

Morioka

Kai

et al. 2008

Neurol. Med. Chir.(Tokyo)

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A 67-year-old man presented with glossopharyngeal neuralgia (GPN) manifesting as severe paroxysmal pharyngeal and retroauricular pain not controlled by medical treatment. Constructive interference in steady state magnetic resonance imaging suggested that the responsible vessel was the right vertebral artery (VA). As carbamazepine had some limited effect, we reviewed the appropriateness of microvascular decompression surgery. Balloon test occlusion of the VA was performed to confirm that the GPN was due to right VA pulsation. The neuralgia disappeared and reappeared with balloon inflation and deflation. Therefore, the VA was moved to decompress the glossopharyngeal nerve. The patient was pain-free after surgery. Balloon test occlusion may be useful in the diagnosis of GPN and the selection of the most appropriate surgical treatment.

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“…11,13,14,18 The root exit zone of CN VII or a nearby area is a common site for vascular compression syndrome; thus, we have recommended the lateral suboccipital infrafloccular approach, 3,7,8,11 in which the root exit zone is approached between CN IX and the flocculus. The flocculus is gent ly retracted in a caudorostral direction perpendicular to CN VIII to avoid stretching that nerve and causing auditory nerve damage.…”

mentioning

confidence: 99%

“…2,4,17 In this approach, the first steps performed under the operating microscope include resection of the arachnoid membrane around the jugular foramen and separation of CN IX from the choroid plexus. 3,7,8,10,11 During these procedures, we sometimes encounter the rhomboid lip, a thick membranous structure distinct from the arachnoid membrane. 1,5 The rhomboid lip is a sheetlike layer of neural tissue forming the ventral wall of the lateral recess of the fourth ventricle and part of the foramen of Luschka.…”

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confidence: 99%

Importance of awareness of the rhomboid lip in microvascular decompression surgery for hemifacial spasm

Nakahara

Matsushima

Hiraishi

et al. 2013

JNS

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Object. The authors adopted the infrafloccular approach for microvascular decompression (MVD) surgery to treat hemifacial spasm (HFS). The inferior portion of the flocculus is retracted to observe the root exit zone of cranial nerve (CN) VII between CN IX and the flocculus. During the procedure, the rhomboid lip, a sheetlike layer of neural tissue forming the lateral recess of the fourth ventricle, is sometimes encountered. The existence of the rhomboid lip in cases of HFS was reviewed to determine the importance of the structure during MVD surgery.Methods. Preoperative imaging and intraoperative observations in 34 consecutive cases of HFS treated in the period from October 2008 through September 2011 were used to assess the frequency of encountering the rhomboid lip.Results. The rhomboid lip was observed during MVD surgery in 9 (26.5%) of the 34 cases but had been demonstrated on preoperative MR images in only 3 cases (8.8%). On T2weighted images, it appeared as a highintensity nonstructural area on the ventral side of the flocculus and continued into the fourth ventricle via the foramen of Luschka.Conclusions. A large rhomboid lip presents an impediment to MVD surgery in a significant minority of patients with HFS. It is seldom observed on preoperative MR images. Proper dissection of the rhomboid lip away from the arachnoid membrane and/or the lower CNs during MVD surgery provides good visualization of the root exit zone of CN VII and reduces injury of CNs IX and X, avoiding postoperative deficits like dysphagia.

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Microvascular Decompression for Treatment of Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: Three Surgical Approach Variations: Technical Note

Abstract: The greatest advantage of the differential selection of the surgical approach is increased ability to reach the destination in the CPA accurately, with minimal risk of postoperative cranial nerve palsy.

Cited by 139 publications

References 19 publications

Brainstem compression syndrome caused by vertebrobasilar dolichoectasia: microvascular repositioning technique

Brainstem compression syndrome caused by vertebrobasilar dolichoectasia: microvascular repositioning technique

Usefulness of Balloon Test Occlusion in the Diagnosis of Glossopharyngeal Neuralgia -Case Report-

Importance of awareness of the rhomboid lip in microvascular decompression surgery for hemifacial spasm

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