Sacrificing the superior petrosal vein during microvascular decompression. Is it safe? Learning the hard way. Case report and review of literature

Abstract

Background:Venous infarction as a complication of microvascular decompression (MVD) is a recognized but extremely rare occurrence in an otherwise standard neurosurgical procedure. Sacrificing one or more veins is considered safe by majority of experienced surgeons and authors. However, in the recent years, there has been growing debate about the management of venous trigeminal compression and/or superior petrosal complex (separation vs. coagulation and cutting of the vein), with few papers describing mild to severe complications related to venous sacrifice.Case Description:We report our dramatic experience during re-exploration for MVD on a male who developed massive cerebellar, brainstem, and brain infarction. Extensive analysis of surgical planning and literature debate about this topic is also reported.Conclusion:Despite rare, venous infarction after venous sacrifice in MVD is possible and can have catastrophic consequences. We would advise: (1) To try preserving the vein anytime this is possible, especially if it is large in size; (2) if it is decided to sacrifice the vein temporary occlusion while observing changed in the neurophysiology might be safer; (3) when planning an MVD for suspected venous compression, possible alternative forms of treatment should also be considered.

Individual variations of the superior petrosal vein complex and their microsurgical relevance in 50 cases of trigeminal microvascular decompression

“…Fifty of 55 patients met the inclusion criteria (age range, 34-86 years; mean, 67.18 years). Women and a right-sided operation bFFE balanced fast field echo, FIESTA fast imaging employing steady-state acquisition, MRI magnetic resonance imaging, 3D CISS three-dimensional constructive interference in steady state 1 Data were missing in 21 of 50 cases (42%). The mean was calculated based on the available data only 2 Missing data in 2 cases (4%).…”

“…Twelve of the later 13 cases had inadequate MRI acquisition rostrally (mostly the cuts did not reach the level of the midbrain), and artifacts disturbed the upper cuts in 1 case. Because this interconnection was not possible to assess intraoperatively, the bFFE balanced fast field echo, PTv pontotrigeminal vein, SPVC superior petrosal vein complex 1 The number of cases with non-assessable petrosal-galenic anastomosis due to technical shortcomings of the bFFE magnetic resonance imaging examinations certainty of this MRI observation was evaluated; it was felt to be certain in 41 cases (82%) and unsure in the remaining 9 (18%). The unsure findings involved different observations of this interconnectivity, without a certain tendency toward one of them.…”

“…Herein, bFFE helped to overcome such pitfalls. An unspecific definition of SPVC components is frequent in the literature [1,12,15,16,21,25,27,33]. We suggested thorough and practical definitions of SPVC components, and differentiated between direct and the surgically irrelevant indirect tributaries to avoid confusion.…”

“…Injury of a part of the SPV complex (SPVC) has been frequently reported in large case series, with an incidence ranging from 55 to 84% of cases [16,25,34]. However, serious complications range from 0.01 to 7% of cases [1,9,13,16,17,23,24,27,28], while minor events are probably common but underreported [5]. Lesions on magnetic resonance imaging (MRI) may be detected even in asymptomatic patients [30].…”

Evaluation of Venous Drainage Patterns for Skull Base Meningioma Surgery

“…24) Mizutani et al reported that the basal vein via the pontotrigeminal vein serves as a collateral route for the superior petrosal vein in PCM. 25) The risk of sacrificing the superior petrosal veins is well established and can lead to venous complications; 23,26–38) however, there is a very low rate of serious complications related to microvascular decompression (MVD) procedures, in part due to the established practice of coagulating the vein for decompression and/or to achieve better exploration of the nerve. 39) Several authors have reported the importance of preserving venous flow via the petrosal vein during the petrosal approach.…”