Long-term effectiveness of an ad hoc tailored titanium implant as a spacer for microvascular decompression in the treatment of trigeminal neuralgia caused by megadolichoectatic basilar artery anomaly: 9-year follow-up

Case report

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An enlarged, elongated, ectatic, and sclerotic aberration of the vertebrobasilar system is known as a megadolichoectatic basilar artery (BA) anomaly. The anomaly is often involved in the pathological process of trigeminal neuralgia by compressing and distorting the trigeminal nerve. First-line medical treatment includes drug therapy, but a second-line surgical procedure could be effective in medication-resistant cases. The authors report the case of a 65-year-old man with a 12-year history of progressing trigeminal neuralgia who underwent microvascular decompression after the first-line drug treatment had failed. This case is unique because an in situ tailored titanium microplate was used as a spacer to alleviate compression by the BA on the trigeminal nerve. The titanium implant provided durable and sufficient retraction for the sclerotic arterial complex when the trigeminal nerve was placed in the tunnel of the implant.

The 9-year follow-up examination proves the safety and long-term efficacy of titanium implants in the treatment of trigeminal neuralgia caused by a megadolichoectatic BA anomaly. The method applied in this case was not intended to be and certainly is not an alternative to routine microvascular decompression—this surgical solution may be reserved for some extreme cases.

Abbreviations used in this paper:AICA = anterior inferior cerebellar artery; BA = basilar artery; CTA = CT angiography; MVD = microvascular decompression; SCA = superior cerebellar artery; TN = trigeminal neuralgia; VA = vertebral artery.

Article Information

Address correspondence to: Péter Banczerowski, M.D., Ph.D., National Institute of Neurosurgery and Semmelweis University Faculty of Medicine, Department of Neurosurgery, Amerikai út 57, Budapest 1145, Hungary. email: bancpet@gmail.com.

Please include this information when citing this paper: published online September 26, 2014; DOI: 10.3171/2014.8.JNS132445.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Preoperative axial T2-weighted (left) and T1-weighted contrast-enhanced MRI (right) studies showing compression of the trigeminal nerve caused by an atherosclerotic megadolichoectatic BA anomaly on the left side.

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    Illustration showing compression of the trigeminal nerve against the tentorium caused by an atherosclerotic megadolichoectatic BA. a. = artery; ant. inf. = anterior inferior; n. = nerve; v. = vein. Copyright Péter Banczerowski. Published with permission.

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    Intraoperative photographs showing compression of the trigeminal nerve (A); the spacer in place, providing a protective tunnel for the trigeminal nerve (B); and muscle flap squeezed between the implant and the BA (C). A = AICA; B = megadolichoectatic BA; I = implant; M = muscle flap; T = tentorium; V = trigeminal nerve; VII = facial nerve; VIII = cochlear nerve.

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    Photograph of the rosette-like titanium microplate before it was bent to form a tunnel.

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    Illustration showing decompression of the trigeminal nerve after insertion of the makeshift spacer. Copyright Péter Banczerowski. Published with permission.

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    Postoperative anteroposterior skull fluoroscopy (left) and axial T1-weighted MR (right) images showing the position of the tailored titanium implant.

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    Postoperative coronal CT reconstruction (A) showing the titanium implant in situ, and 3D CT reconstruction (CTA) images (B and C) demonstrating the artificial tunnel containing the fifth cranial nerve (black star) in relation to vascular structures 9 years after surgery.

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