Acta Neurochirurgica. 2026. DOI: 10.1007/s00701-026-07055-3
Arterial variants can make microvascular decompression more demanding without necessarily precluding favorable outcomes. Kawano and colleagues identify the trigeminocerebellar artery as particularly relevant: its relationship to the trigeminal root may involve penetrating vessels, encircling loops or perforators that restrict mobilization. The practical message is to anticipate these configurations before surgery, rather than assume every offending artery can be displaced in the same way.
Study and key findings
This retrospective single-center study included 170 adults, aged 19-84 years, undergoing first-time microvascular decompression for drug-resistant classical trigeminal neuralgia: 172 operated sides, including two bilateral cases. Preoperative assessment combined high-resolution MR angiography, heavily T2-weighted imaging and three-dimensional reconstruction.
Among 168 patients with unilateral symptoms, the trigeminocerebellar artery was more frequent on the affected than the contralateral side: 10.7% versus 4.8% (P=.033). Early bifurcation of the superior cerebellar artery showed no significant side difference.
Of 19 operated sides with an offending trigeminocerebellar artery, four showed root penetration, four encircling loops and five multiple perforators. All four penetration configurations were identified preoperatively. Recurrence occurred in 28/172 sides overall (16.3%), including 3/19 in this subgroup (15.8%); comparisons did not demonstrate significant recurrence differences between arterial groups.
Interpretation and limitations
The technical distinction is between an artery passing between sensory and motor roots and one penetrating the sensory root itself. Transposition predominated; nerve splitting was used only in the two cases with direct sensory-root penetration. These observations do not justify routine nerve splitting or establish superiority over alternative decompression techniques.
The retrospective design, selected surgical population and small variant subgroups limit inference. Contralateral comparisons demonstrate association, not causality. MRI-based classification cannot always distinguish a trigeminocerebellar artery from a duplicated superior cerebellar artery. Nonsignificant outcome comparisons do not establish equivalent safety, particularly for uncommon neurological complications.
Clinical takeaway
Preoperative imaging should inform how the artery relates to the root and perforators, not merely identify vascular contact. This series supports anatomy-specific planning and cautious mobilization, while leaving the comparative benefits and risks of individual maneuvers unresolved.
You must be logged in to post a comment.