Preoperative visualization of neurovascular anatomy in trigeminal neuralgia

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Object

The authors report on a novel technique to identify neurovascular compression in trigeminal neuralgia (TN). Using 3D reconstructed high-resolution balanced fast-field echo (BFFE) images fused with 3D time-of-flight (TOF) magnetic resonance (MR) angiography and Gd-enhanced 3D spoiled gradient recalled sequence, it is possible to objectively visualize the trigeminal nerve and nearby arteries and veins.

Methods

Magnetic resonance imaging was performed in 18 patients with unilateral TN using 3 sequences: BFFE, 3D TOF angiography, and 3D Gd-enhanced imaging. The images were imported into OsiriX imaging software; after their fusion, a 3D false-color reconstruction was produced using surface rendering. The reconstructed images objectively differentiate nerves and vessels and can be viewed from any angle, including the anticipated surgical approach.

Results

Fifteen patients were predicted to have neurovascular compression on the symptomatic side (9 arterial and 6 venous compressions). All patients had a vascular structure that was identical in location and configuration to that predicted on preoperative analysis. The 3 patients without predicted compression underwent surgical exploration because they manifested the classic symptoms. As expected, exploration in 2 of these patients revealed no offending vessel. The third patient had a small vein embedded in the trigeminal nerve that was beyond the resolution of the 3D Gd-enhanced study.

Conclusions

Combining BFFE with MR angiography and Gd-enhanced MR images capitalizes on the advantages of both techniques, enabling MR angiography and contrast-enhanced MR imaging discrimination of vascular structures at BFFE resolution. This results in an unambiguous 3D image that can be used to identify the neurovascular compression and plan the surgical approach.

Abbreviations used in this paper: BFFE = balanced fast-field echo; CPA = cerebellopontine angle; CSF = cerebrospinal fluid; MR = magnetic resonance; MVD = microvascular decompression; TN = trigeminal neuralgia; TOF = time-of-flight.

Article Information

Address correspondence to: Kim J. Burchiel, M.D., Department of Neurological Surgery, Mail Code: CH8N, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, Oregon 97239. email: burchiek@ohsu.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Images obtained in the patients in Case 5 (I), 12 (II), and 16 (III). Source BFFE (A) and MR angiography (B) images demonstrate arterial compression. Reconstruction of fused MR angiography and BFFE (C) demonstrates the expected surgeon's view, with neural anatomy in white and arterial anatomy in red. In each case, arterial contact was confirmed at surgery (intraoperative view, D).

  • View in gallery

    Images obtained in the patients in Case 2 (I), 4 (II), 17 (III) and 6 (IV). Source BFFE (A) and 3D Gd-enhanced (B) images demonstrate venous compression. Reconstruction of fused 3D Gd-enhanced and BFFE images (C) demonstrates neural anatomy in white and venous anatomy in purple, showing compression of the trigeminal nerve by a vein. This was confirmed at surgery (intraoperative view, D). In the patient in Case 6 (IV): source BFFE (A) and 3D Gd-enhanced (B) images demonstrate no obvious compression of the trigeminal nerve. Reconstruction of fused 3D Gd-enhanced and BFFE images (C) demonstrates neural anatomy in white and venous anatomy in purple, and shows a very small vein running near the nerve but not clearly touching it. At surgery, a very small vein was seen running along the course of the nerve (intraoperative view, D).

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