Demonstration of neurovascular compression in trigeminal neuralgia with magnetic resonance imaging

Comparison with surgical findings in 52 consecutive operative cases

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✓ Until recently, the inability to demonstrate neurovascular compression of the trigeminal nerve preoperatively resulted in surgery being offered only in cases of severe trigeminal neuralgia (TGN), frequently after a prolonged trial of medical treatment and following less invasive procedures, despite the fact that posterior fossa microvascular decompression gives long-term pain relief in 80% to 90% of cases. To assess whether vascular compression of the nerve could be demonstrated preoperatively, high definition magnetic resonance tomographic angiography (MRTA) was performed in 50 consecutive patients, five of whom had bilateral TGN, prior to posterior fossa surgery. The imaging results were compared with the operative findings in all patients, including two patients who underwent bilateral exploration.

Vascular compression of the trigeminal nerve was identified in 42 of 45 patients with unilateral symptoms and on both sides in four patients with bilateral TGN. In the last patient with bilateral TGN, neurovascular compression was identified on one side, and on the other side the compressing superior cerebellar artery was separated from the nerve by a sponge placed during previous surgery. There was full agreement regarding the presence or absence of neurovascular compression demonstrated by MRTA in 50 of 52 explorations, but MRTA misclassified four vessels compressing the trigeminal nerve as arteries rather than veins. In two cases, there was disagreement between the surgical and MRTA findings. In the first of these cases, surgery revealed distortion of the nerve at the pons by a vein that MRTA had predicted to lie 6 mm remote from this point. In the second patient, venous compression was missed; however, this patient was investigated early in the series and did not have gadolinium-enhanced imaging.

In nine cases, MRTA correctly identified neurovascular compression of the trigeminal nerve by two arteries. Moreover, MRTA successfully guided surgical reexploration in one patient in whom a compressing vessel was missed during earlier surgery and also prompted exploration of the posterior fossa in two patients with multiple sclerosis and one patient with Charcot-Marie-Tooth syndrome, in whom neurovascular compression was identified preoperatively.

It is concluded that MRTA is an extremely sensitive and specific method for demonstrating vascular compression in TGN. As a result, open surgical procedures can be recommended with confidence, and microvascular decompression is now the treatment of choice for TGN at the authors' unit. They propose MRTA as the definitive investigation in such patients in whom surgery is contemplated.

Article Information

Address reprint requests to: James F. M. Meaney, F.R.C.R., Department of Radiology, Walton Centre for Neurology and Neurosurgery, Rice Lane, Liverpool L9 1AE, England.

© AANS, except where prohibited by US copyright law.

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    Imaging in a 67-year-old patient with right trigeminal neuralgia. Left: Magnetic resonance tomographic angiogram (MRTA). Both trigeminal nerves are indicated by curved arrows on this coronal reconstruction. Note compression of the right trigeminal nerve (which appears semilunar in cross-section due to grooving) in the axilla by the superior cerebellar artery (SCA) (curved open arrow). Note a clear separation of the left SCA (straight arrow) from the left trigeminal nerve. Center: Sagittal MRTA reconstruction along the right trigeminal nerve confirming compression of the nerve (solid arrow) by the SCA (open arrow). Right: Maximum intensity projection angiogram showing caudal looping of the right SCA. The site at which the vessel compressed the nerve is indicated (arrow).

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    Imaging in a 78-year-old patient with right trigeminal neuralgia. Left: Magnetic resonance tomographic angiogram (MRTA). Axial slice at the level of mid pons showing the left (curved arrow) but not the right trigeminal nerve. At the expected site of the right trigeminal nerve there is a small artery (straight arrow) behind the basilar artery, which is deviated to the right side at approximately the site of the axilla of the nerve. As the symptomatic nerve is not seen, neurovascular compression cannot be confirmed or excluded. Center: Coronal MRTA reconstruction showing elevation, distortion, and grooving of the right trigeminal nerve (compare both nerves, curved arrows) by an upwardly looping anterior inferior cerebellar artery (AICA) (open arrow). A further vessel is seen medial to the nerve (solid straight arrow). Further slices (not shown) confirmed the presence of compression of the nerve between two vessels. Right: Maximum intensity projection angiogram (rotated 30° to right anterior oblique position) shows a caudally looping superior cerebellar artery (arrowheads) and cranially looping AICA (short arrows), which approximate one another in the prepontine cistern. The site at which the nerve was compressed between these two vessels is indicated by the long straight arrow.

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    Imaging in a 45-year-old patient with right trigeminal neuralgia. Left: Magnetic resonance tomographic angiogram, sagittal reconstruction, along the right trigeminal nerve showing compression of the nerve (straight solid arrow) at the pons by the superior cerebellar artery (SCA) above (open arrow) and a further small vessel inferiorly (curved arrow). Right: Maximum intensity projection angiogram showing the SCA (open arrows) and confirming that the second vessel inferiorly (straight arrows) represents a second small branch of the SCA rather than the anterior inferior cerebellar artery.

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    Magnetic resonance tomographic angiograms in a 53-year-old patient with left-sided trigeminal neuralgia. A: Unenhanced axial slice showing no definite evidence of vascular compression of the left trigeminal nerve (arrow). B: Unenhanced coronal reconstruction showing what appear to be normal trigeminal nerves bilaterally (right trigeminal nerve, solid curved arrow; left trigeminal nerve, open curved arrow). Both superior cerebellar arteries are quite small (open straight arrows). On the left side note the presence of unopacified blood within the petrosal vein (straight arrow) above the nerve. C: Enhanced axial slice at same level as A, showing the presence of an enhancing vascular structure compressing the nerve (arrow) in the axilla. Further slices confirmed that this represents the petrosal vein. D: Enhanced coronal reconstruction at the same level as B. There is no evidence of compression of the right trigeminal nerve (curved solid arrow). On the left side there is compression of the trigeminal nerve (open curved arrow) by the enhancing petrosal vein (straight arrows). The nerve is considerably reduced in size confirming the presence of grooving. The enhanced scan confirms that what appeared to represent the left trigeminal nerve on the unenhanced coronal image (B) actually represented a combination of the grooved trigeminal nerve and the petrosal vein. In retrospect the “nerve” in B has a slightly dumb-bell appearance consistent with a vein—nerve composite opacity.

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