Multiple Vessel Compression of the Trigeminal Nerve Is Associated With Worse Outcomes in Trigeminal Neuralgia After Microvascular Decompression

Neurosurgery 92:1029–1034, 2023

Whether the total number of compressive vessels in trigeminal neuralgia (TN) affects outcomes after microvascular decompression (MVD) is unknown.

OBJECTIVE: To investigate whether the number of compressive vessels is associated with outcomes after MVD.

METHODS: We retrospectively reviewed all patients with TN who underwent MVDs at our institution from 2007 to 2020. The number and identity of compressive vessels on the trigeminal nerve were recorded. Preoperative and postoperative pain and numbness Barrow Neurological Institute scores were compared. Factors associated with pain recurrence were assessed using survival analyses and multivariate regressions.

RESULTS: We identified 496 patients with a single vessel and 381 patients with multiple vessels compressing the trigeminal nerve. Compared with patients with a single compressive vessel, patients with multiple sources of compression exhibited increased Barrow Neurological Institute pain scores preoperatively (P = .01). In addition, pain recurrence was more frequent (P < .001) and occurred after a significantly shorter pain-free duration (P < .001) for the multiple compression group. Using multivariate ordinal regression, a greater number of arteries (P = .03) and veins (P = .03) were both significantly associated with higher pain scores at final follow-up. Furthermore, the number of arteries (P = .01) and of veins (P = .01) was significantly associated with a higher risk for pain recurrence.

CONCLUSION: TN patients with a single compressive vessel exhibited better pain outcomes after an MVD. Patients with multiple compressive vessels exhibited higher pain scores preoperatively and incurred a higher risk for pain recurrence, which occurred after a shorter pain-free interval compared with the single compression cohort.

Transdural arterial recruitment to brain arteriovenous malformation

J Neurosurg 127:51–58, 2017

The occurrence of transdural arterial recruitment (TDAR) in association with brain arteriovenous malformation (bAVM) is uncommon, and the reason for TDAR is not understood. The aim of this cohort study was to examine patient and bAVM characteristics associated with TDAR and the implications of TDAR on management.

METHODS A prospective surgical database of bAVMs was examined. Cases previously treated elsewhere or incompletely examined by digital subtraction angiography (DSA) assessment were excluded. Three studies of this cohort were performed, as follows: characteristics associated with TDAR, the relationship between TDAR and neurological deficits unassociated with hemorrhage (NDUH), and the impact of TDAR on outcome from surgery. Regression models were performed.

RESULTS Of 769 patients with complete DSA who had no previous treatment, 51 (6.6%) were found to have TDAR. The presence of TDAR was associated with increasing age (p < 0.01; OR 1.05; 95% CI 1.02–1.07); presentation with NDUH (p < 0.01; OR 2.71; 95% CI 1.29–5.71); increasing size of the bAVM (p < 0.01; OR 1.57; 95% CI 1.29–1.91); and combined supply from both anterior and posterior circulations (p = 0.02; OR 2.37; 95% CI 1.17–4.78). Further analysis of TDAR cases comparing those with and without NDUH found an association of larger size (6.6 cm [2.9 SD] compared with 4.7 cm [1.8 SD]; p < 0.01) and combined supply from both anterior and posterior circulations (relative risk 2.5; 95% CI 1.0–6.2; p = 0.04) to be associated with an NDUH presentation. For the 632 patients undergoing surgery there was an increased risk of complications (where this produced a new permanent neurological deficit at 12 months represented by a modified Rankin Scale score of > 1) with the following variables: size; location in eloquent brain; deep venous drainage; increasing age; and no presentation with hemorrhage. The presence of TDAR was not associated with an increased risk of complications from surgery.

CONCLUSIONS The authors found that TDAR occurs in older patients with larger bAVMs, and that TDAR is also more likely to be associated with bAVMs presenting with NDUH. The likely explanation for the presence of TDAR is a secondary recruitment arising as a consequence of shear stress, rather than a primary vascular supply present from the earliest development of the bAVM.

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