Neurovascular Compression in Patients With Trigeminal Neuralgia May Be Associated With Worse Outcomes After Primary Percutaneous Rhizotomy

Neurosurgery 94:1072–1078, 2024

Percutaneous rhizotomy may be an effective primary intervention in patients with trigeminal neuralgia who are poor candidates for microvascular decompression or those who desire a less invasive approach. However, the influence of neurovascular compression on pain-free survival after primary percutaneous rhizotomy is not well understood.

METHODS: We retrospectively reviewed all patients undergoing percutaneous rhizotomy at our institution from 1995 to 2022. Patients were included if they had no history of surgical intervention, available preoperative MRI imaging, and postoperative follow-up data. Barrow Neurological Institute pain scores were assigned at various time points. We collected baseline patient information, pain characteristics, and perioperative complications for each patient. In addition, we recorded evidence of pain recurrence. Patients were dichotomized into those with evidence of neurovascular compression on preoperative MRI vs those without. The effect of neurovascular compression on pain-free survival was assessed using Kaplan-Meier Cox proportional hazards analyses.

RESULTS: Of the 2726 patients reviewed, 298 met our inclusion criteria. Our study comprised 261 patients with no evidence of neurovascular compression on preoperative MRI vs 37 patients with evidence of neurovascular compression on preoperative MRI. Patients in the compression group had a shorter median duration to recurrence compared with those in the no compression group, P = .01. Kaplan-Meier survival analysis revealed that patients with preoperative evidence of neurovascular compression on MRI imaging demonstrated shorter pain-free survival compared with those without such evidence [hazard ratio = 1.57 (1.03-2.4), P = .037]. Cox proportional hazards analysis demonstrated that evidence of neurovascular compression was associated with poor pain-free survival [hazard ratio = 1.64 (1.06-2.53), P = .03].

CONCLUSION: Patients with neurovascular compression on preoperative MRI may experience reduced time to recurrence compared with those without after percutaneous rhizotomy. These patients should be counseled on potential reduced efficacy of percutaneous rhizotomy as a primary intervention for their pain.

Increase in Trigeminal Nerve Cross-Sectional Area on Immediate Postoperative MRI Predicts Favorable Outcome After Microvascular Decompression for Classical Trigeminal Neuralgia

Neurosurgery 92:283–292, 2023

Although distortion or indentation of a trigeminal nerve due to neurovascular compression (NVC) is associated with classical trigeminal neuralgia, whether morphological change in the trigeminal nerve is relieved by eliminating NVC has not been studied.

OBJECTIVE: To estimate morphological change in the trigeminal nerve after microvascular decompression (MVD).

METHODS: Fifty patients with classical trigeminal neuralgia who underwent MVD were included. Using coronal images in both preoperative and postoperative MRI, the trigeminal nerve cross-sectional area (CSA) was measured at 4 mm anterior to the nerve entry into the pons. Clinical outcomes were assessed using the Barrow Neurological Institute Pain Intensity Scale (BNI-PS) at the patient’s latest follow-up.

RESULTS: Forty-one patients achieved favorable outcomes without medication (BNI-PS I or II), and 9 patients had residual pain (BNI-PS ≥ 3A). The mean symptomatic trigeminal nerve CSA was increased by 51.47% after MVD in the favorable outcome group (pre-operative: 4.37 ± 1.64 mm 2 vs postoperative: 6.26 ± 1.76 mm2 , P < .01), whereas it was not significantly changed in the unfavorable outcome group (preoperative: 4.20 ± 1.19 mm2 vs postoperative: 4.43 ± 1.24 mm2 , P = .69). Kaplan–Meier survival analysis showed that the 3-year probability of maintaining a favorable outcome was 92.3 ± 7.4% and 56.1 ± 11.9%, for those whose symptomatic trigeminal nerve CSA was increased by over 20% and less than 20%, respectively (P < .01).

CONCLUSION: Morphological changes in the trigeminal nerve due to NVC could be recovered by MVD, and increases in the trigeminal nerve CSA predicted favorable outcomes.

Significance of degree of neurovascular compression in surgery for trigeminal neuralgia

J Neurosurg 133:411–416, 2020

The aim of this study was to identify preoperative imaging predictors of surgical success in patients with classic trigeminal neuralgia (cTN) undergoing microvascular decompression (MVD) via retrospective multivariate regression analysis.

METHODS All included patients met criteria for cTN and underwent preoperative MRI prior to MVD. MR images were blindly graded regarding the presence and severity (i.e., mild or severe) of neurovascular compression (NVC). All patients were contacted by telephone to determine their postoperative pain status.

RESULTS A total of 79 patients were included in this study. Sixty-two patients (78.5%) were pain-free without medication following MVD. The following findings were more commonly observed with the symptomatic nerve when compared to the contralateral asymptomatic nerve: NVC (any form), arterial compression alone, NVC along the proximal trigeminal nerve, and severe NVC (p values < 0.0001). The only imaging variable that was a statistically significant predictor of being pain-free without medication following MVD was severe NVC. Patients with severe NVC were 6.36 times more likely to be pain-free following MVD compared to those without severe NVC (p = 0.007).

CONCLUSIONS In patients with cTN undergoing MVD, severe NVC on preoperative MRI is a strong predictor of an excellent surgical outcome.


Sex-dependent posterior fossa anatomical differences in trigeminal neuralgia patients with and without neurovascular compression: a volumetric MRI age- and sex-matched case-control study

J Neurosurg 132:631–638, 2020

The pathophysiology of trigeminal neuralgia (TN) in patients without neurovascular compression (NVC) is not completely understood. The objective of this retrospective study was to evaluate the hypothesis that TN patients without NVC differ from TN patient with NVC with respect to brain anatomy and demographic characteristics.

METHODS Six anatomical brain measurements from high-resolution brain MR images were tabulated; anterior-posterior (AP) prepontine cistern length, cerebellopontine angle (CPA) cistern volume, nerve-to-nerve distance, symptomatic nerve length, pons volume, and posterior fossa volume were assessed on OsiriX. Brain MRI anatomical measurements from 232 patients with either TN type 1 or TN type 2 (TN group) were compared with measurements obtained in 100 age- and sex-matched healthy controls (control group). Two-way ANOVA tests were conducted on the 6 measurements relative to group and NVC status. Bonferroni adjustments were used to correct for multiple comparisons. A nonhierarchical k-means cluster analysis was performed on the TN group using age and posterior fossa volume as independent variables.

RESULTS Within the TN group, females were found to be younger than males and less likely to have NVC. The odds ratio (OR) of females not having NVC compared to males was 2.7 (95% CI 1.3–5.5, p = 0.017). Patients younger than 30 years were much less likely to have NVC compared to older patients (OR 4.9, 95% CI 1.3–18.4, p = 0.017). The mean AP prepontine cistern length and symptomatic nerve length were smaller in the TN group than in the control group (5.3 vs 6.5 mm and 8.7 vs 9.7 mm, respectively; p < 0.001). The posterior fossa volume was significantly smaller in TN patients without NVC compared to those with NVC. A TN group cluster analysis suggested a sex-dependent difference that was not observed in those without NVC. Factorial ANOVA and post hoc testing found that findings in males without NVC were significantly different from those in controls or male TN patients with NVC and similar to those in females (female controls as well as female TN patients with or without NVC).

CONCLUSIONS Posterior fossa volume in males was larger than posterior fossa volume in females. This finding, along with the higher incidence of TN in females, suggests that smaller posterior fossa volume might be an independent factor in the pathophysiology of TN, which warrants further study.

Trigeminal Nerve Atrophy Predicts Pain Recurrence After Gamma Knife Stereotactic Radiosurgery for Classical Trigeminal Neuralgia

Neurosurgery 84:927–934, 2019

Trigeminal nerve atrophy and neurovascular compression (NVC) are frequently observed in classical trigeminal neuralgia (CTN).

OBJECTIVE: To determine whether nerve characteristics contribute to Gamma Knife (ElektaAB, Stockholm, Sweden) surgery (GKS) outcomes in unilateral CTN without previous surgery.

METHODS: From 2006 to 2012, 67 patients with unilateral CTN without previous surgery received GKS with a maximal dose of 90 Gy delivered to the trigeminal nerve juxta brainstem. Two evaluators, blinded to the side of pain, analyzed the magnetic resonance images before GKS to obtain the parameters, including nerve cross-sectional area (CSA), vessel type of NVC, and site of NVC along the nerve. Correlations of the parameters with pain relief (Barrow Neurological Institute [BNI] grades I-IIIb) and recurrence (BNI grades VIV) were made by using Cox regression and Kaplan–Meier analyses.

RESULTS: The median CSA of the symptomatic nerves was significantly smaller than that of the asymptomatic nerves (4.95 vs 5.9 mm2, P < .001). After adjustment for age and sex, larger nerve CSA was associated with lower initial pain relief (hazard ratio 0.81, P=.03) and lower pain recurrence after initial response (hazard ratio 0.58, P= .02). Patients with nerve atrophy (CSA of ≤ 4.4 mm2 after receiver operating characteristic curve analysis) had a lower 5-yr probability of maintaining pain relief after initial response than those without nerve atrophy (65% vs 86%, P= .04).

CONCLUSION: Trigeminal nerve atrophy may predict pain recurrence in patients with initial post-GKS relief of CTN.Arterial and proximalNVCare not predictive ofGKS outcomes. Future studies are required to determine optimal treatments for long-term pain relief in patients with CTN and trigeminal nerve atrophy.

The relationship of dose to nerve volume in predicting pain recurrence after stereotactic radiosurgery in trigeminal neuralgia

J Neurosurg 128:891–896, 2018

Approximately 75%–92% of patients with trigeminal neuralgia (TN) achieve pain relief after Gamma Knife surgery (GKS), although a proportion of these patients will experience recurrence of their pain. To evaluate the reasons for durability or recurrence, this study determined the impact of trigeminal nerve length and volume, the nerve dose-volume relationship, and the presence of neurovascular compression (NVC) on pain outcomes after GKS for TN.

METHODS Fifty-eight patients with 60 symptomatic nerves underwent GKS for TN between 2013 and 2015, including 15 symptomatic nerves secondary to multiple sclerosis (MS). High-resolution MRI was acquired the day of GKS. The median maximum dose was 80 Gy for initial GKS and 65 Gy for repeat GKS. NVC, length and volume of the trigeminal nerve within the subarachnoid space of the posterior fossa, and the ratio of dose to nerve volume were assessed as predictors of recurrence.

RESULTS Follow-up was available on 55 patients. Forty-nine patients (89.1%) reported pain relief (Barrow Neurological Institute [BNI] Grades I–IIIb) after GKS at a median duration of 1.9 months. The probability of maintaining pain relief (BNI Grades I–IIIb) without requiring resumption or an increase in medication was 93% at 1 year and 84% at 2 years for patients without MS, and 68% at 1 year and 51% at 2 years for all patients. The nerve length, nerve volume, target distance from the brainstem, and presence of NVC were not predictive of pain recurrence. Patients with a smaller volume of nerve (< 35% of the total nerve volume) that received a high dose (≥ 80% isodose) were less likely to experience recurrence of their TN pain after 1 year (mean time to recurrence: < 35%, 32.2 ± 4.0 months; > 35%, 17.9 ± 2.8 months, log-rank test, c2 = 4.3, p = 0.039).

CONCLUSIONS The ratio of dose to nerve volume may predict recurrence of TN pain after GKS. Prospective studies are needed to determine the optimal dose to nerve volume ratio and whether this will result in longer pain-free outcomes.

Trigeminal neuralgia due to neurovascular conflicts from venous origin: an anatomical-surgical study

Trigeminal neuralgia due to neurovascular conflicts from venous origin- an anatomical-surgical study-1

Acta Neurochir (2015) 157:455–466

Veins as the source of trigeminal neuralgias (TN) lead to controversies. Only a few studies have specifically dealt with venous implication in neurovascular conflicts (NVC). The aim of this study was the anatomical-surgical description of the compressive veins found during microvascular decompression (MVD).

Methods Patients retained were those in whom a vein was considered compressive, alone, or in association with an artery. The study defined the type of vein involved, its situation along, the location around the root, and management. For this study, denomination of veins in relation with the root was revisited.

Results Of the 326 consecutive patients who underwent MVD from 2005 to 2013, 124 (38.0 %) had a venous conflict, alone in 29 (8.9 %), or in association with an artery in 95 (29.1 %). The compressive veins belonged to one of the two venous systems described: the superficial or the deep superior petrosal venous system (sSPVS or dSPVS). A vein from sSPVS was found compressive in 81 cases (59.6 %), for the major part it was the pontine affluent of the superior petrosal vein (48 cases). The conflict was situated at TREZ in 28.4 %, midcisternal portion in 50.6 %, and porus in 8.6 %. The dSPVS was found compressive in 55 cases (40.4 %), almost always a transverse vein at porus (51 cases). Decompression was coagulation-division of the conflicting vein in 36.8 % and simple cleavage in the other.

Conclusions The study shows the frequent implication of veins in NVC as the source of TN. NVC are not only at TREZ but also at mid-cisternal portion and porus of Meckel cave.

Trigeminal nerve atrophy caused by neurovascular compression

Atrophic changes in the trigeminal nerves of patients with trigeminal neuralgia due to neurovascular compression and their association with the severity of compression and clinical outcomes

J Neurosurg 120:1484–1495, 2014

The aim of this study was to prospectively evaluate atrophic changes in trigeminal nerves (TGNs) using measurements of volume (V) and cross-sectional area (CSA) from high-resolution 3-T MR images obtained in patients with unilateral trigeminal neuralgia (TN), and to correlate these data with patient and neurovascular compression (NVC) characteristics and with clinical outcomes.

Methods. Anatomical TGN parameters (V and CSA) were obtained in 50 patients (30 women and 20 men; mean age 56.42 years, range 22–79 years) with classic TN before treatment with microvascular decompression (MVD). Parameters were compared between the symptomatic (ipsilateralTN) and asymptomatic (contralateralTN) sides of the face. Twenty normal control subjects were also included. Two independent observers blinded to the side of pain separately analyzed the images. Measurements of V (from the pons to the entrance of the nerve into Meckel’s cave) and CSA (at 5 mm from the entry of the TGN into the pons) for each TGN were performed using imaging software and axial and coronal projections, respectively. These data were correlated with patient characteristics (age, duration of symptoms before MVD, side of pain, sex, and area of pain distribution), NVC characteristics (type of vessel involved in NVC, location of compression along the nerve, site of compression around the circumference of the root, and degree of compression), and clinical outcomes at the 2-year follow-up after surgery. Comparisons were made using Bonferroni’s test. Interobserver variability was assessed using the Pearson correlation coefficient.

Results. The mean V of the TGN on the ipsilateralTN (60.35 ± 21.74 mm3) was significantly smaller (p < 0.05) than those for the contralateralTN and controls (78.62 ± 24.62 mm3 and 89.09 ± 14.72 mm3, respectively). The mean CSA of the TGN on the ipsilateralTN (4.17 ± 1.74 mm2) was significantly smaller than those for the contralateralTN and controls (5.41 ± 1.89 mm2 and 5.64 ± 0.85 mm2, respectively). The ipsilateralTN with NVC Grade III (marked indentation) had a significantly smaller mean V than the ipsilateralTN with NVC Grade I (mere contact), although it was not significantly smaller than that of the ipsilateralTN with NVC Grade II (displacement or distortion of root). The ipsilateralTN with NVC Grade III had a significantly smaller mean CSA than the ipsilateral TN with NVC Grades I and II (p < 0.05). The TGN on the ipsilateralTN in cured patients had a smaller mean CSA than that on the ipsilateralTN of patients with partial pain relief or treatment failure (p < 0.05). The same finding was almost found in relation to measurements of V, but the p value was slightly higher at 0.05.

Conclusions. Results showed that TGN atrophy in patients with TN can be demonstrated by high-resolution imaging. These data suggest that atrophic changes in TGNs, which significantly correlated with the severity of compression and clinical outcomes, may help to predict long-term prognosis after vascular decompression.

Trigeminal neuralgia occurs and recurs in the absence of neurovascular compression


J Neurosurg 120:1048–1054, 2014

Vascular compression of the trigeminal nerve is the most common factor associated with the etiology of trigeminal neuralgia (TN). Microvascular decompression (MVD) has proven to be the most successful and durable surgical approach for this disorder. However, not all patients with TN manifest unequivocal neurovascular compression (NVC). Furthermore, over time patients with an initially successful MVD manifest a relentless rate of TN recurrence.

Methods. The authors performed a retrospective review of cases of TN Type 1 (TN1) or Type 2 (TN2) involving patients 18 years or older who underwent evaluation (and surgery when indicated) at Oregon Health & Science University between July 2006 and February 2013. Surgical and imaging findings were correlated.

Results. The review identified a total of 257 patients with TN (219 with TN1 and 38 with TN2) who underwent high-resolution MRI and MR angiography with 3D reconstruction of combined images using OsiriX. Imaging data revealed that the occurrence of TN1 and TN2 without NVC was 28.8% and 18.4%, respectively. A subgroup of 184 patients underwent surgical exploration. Imaging findings were highly correlated with surgical findings, with a sensitivity of 96% for TN1 and TN2 and a specificity of 90% for TN1 and 66% for TN2.

Conclusions. Magnetic resonance imaging detects NVC with a high degree of sensitivity. However, despite a diagnosis of TN1 or TN2, a significant number of patients have no NVC. Trigeminal neuralgia clearly occurs and recurs in the absence of NVC.

Vascular compression of the trigeminal nerve in asymptomatic individuals

Vascular compression of the trigeminal nerve in asymptomatic individuals

Acta Neurochir (2014) 156:577–580

Neurovascular compression (NVC) of the trigeminal nerve is associated with trigeminal neuralgia (TN), but also occurs in many asymptomatic individuals. The purpose of this study was to investigate the possible microstructural tissue changes of trigeminal nerves (TGN) in asymptomatic individuals with NVC by using axial diffusivity (AD) and radial diffusivity (RD) of MR imaging and to discuss its underlying mechanisms.

Methods Twenty asymptomatic individuals with unilateral NVC and 18 healthy controls (HCs) were divided into three groups (compressed, uncompressed side in asymptomatic individuals and HCs). Three groups were imaged with a 3.0-T MR system using three-dimensional fast imaging employing steady-state acquisition (3D FIESTA) and diffusion tensor imaging (DTI).We placed a region of interest over the root entry zone of the TGN and measured fractional anisotropy (FA), AD and RD. The mean values of FA, AD and RD were compared among the three groups.

Results No significant changes in any of the diffusion metrics (FA, RD and AD) were found among the three groups (compressed, uncompressed side in asymptomatic individuals and HCs).

Conclusions Our study demonstrated that neither demyelination nor axonal injury is found in asymptomatic individuals with NVC.

The role of the cerebellopontine angle cistern area and trigeminal nerve length in the pathogenesis of trigeminal neuralgia

Role of CPA cistern and TN

Acta Neurochir (2013) 155:863–868

The aim of this prospective study was to evaluate whether the cerebellopontine angle (CPA) cistern area and trigeminal nerve cisternal length play a role in the pathogenesis of trigeminal neuralgia (TN).

Methods High-resolution 1.5 T magnetic resonance imaging of the posterior fossa was performed in 26 patients with TN and 18 age-matched healthy controls. Axial T2- weighted, three-dimensional constructive interference in steady-state (3D-CISS) was used to measure bilaterally the cross-sectional area of the CPA cistern and trigeminal nerve cisternal length.

Results In patients, the cross-sectional area of the CPA cistern and trigeminal nerve cisternal length was smaller on the affected side (p=0.04). Healthy controls tended to have larger cisternal areas and longer trigeminal nerve lengths than patients (p=0.059, p=0.071, respectively). Larger CPA cisternal areas tended to be seen in older patients. There was a strong correlation between the crosssectional area of the CPA cistern and the length of the trigeminal nerve (p=0.000).

Conclusions Smaller CPA cisterns and short cisternal trigeminal nerves impact the pathogenesis of essential TN by facilitating the neurovascular conflict, especially in younger patients. Trigeminal nerve cisternal measurement provides an easy and direct estimation of the CPA area. This information can be used for surgical planning and potentially for outcome prediction.

Visualization of Vascular Compression of the Trigeminal Nerve With High-Resolution 3T MRI: A Prospective Study Comparing Preoperative Imaging Analysis to Surgical Findings in 40 Consecutive Patients Who Underwent Microvascular Decompression for Trigeminal Neuralgia

Neurosurgery 69:15–26, 2011 DOI: 10.1227/NEU.0b013e318212bafa

High-resolution three-dimensional (3D) magnetic resonance imaging (MRI) has demonstrated its ability to predict fine trigeminal neurovascular anatomy.

OBJECTIVE: To address the predictive value of 3-Tesla (3T) MRI in detecting and assessing features of neurovascular compression (NVC), particularly regarding the degree of compression exerted on the root, in patients who underwent microvascular decompression (MVD) for classic primary trigeminal neuralgia.

METHODS: This prospective study includes 40 consecutive patients who underwent MVD for classic primary trigeminal neuralgia. All patients underwent a preoperative 3T MRI with 3D T2-weighted driven equilibrium (DRIVE), 3D time-of-flight (TOF) magnetic resonance angiography (MRA), and 3D T1-weighted gadolinium-enhanced sequences in combination. Evaluations were performed by 2 independent observers and compared with the operative findings.

RESULTS: For prediction of NVC, image analysis corresponded with surgical findings in 39 cases. Of the 3 patients in whom image analysis did not show NVC, 2 did not have NVC at the time of intraoperative observation. MRI sensitivity was 97.4% (37/38), and specificity was 100% (2/2). The kappa coefficients (k) for predicting the offending vessel, its location, and the site of compression were 0.882, 0.813, and 0.942, respectively. Image analysis correctly defined the severity of the compression in 31 of the 37 cases. The k coefficients predicting the degree of compression were 0.813, 0.833, and 0.852, respectively, for Grades 1 (simple contact), 2 (distortion), and 3 (marked indentation).

CONCLUSION: 3T MRI using 3D T2-weighted DRIVE in combination with 3D TOF-MRA and 3D T1-weighted gadolinium-enhanced sequences proved to be reliable in detecting NVC and in predicting the degree of root compression, the outcome being correlated with the latter.

Preoperative demonstration of the neurovascular compression characteristics with special emphasis on the degree of compression, using high-resolution magnetic resonance imaging: a prospective study, with comparison to surgical findings, in 100 consecutive patients who underwent microvascular decompression for trigeminal neuralgia

Acta Neurochir (2010) 152:817–825. DOI 10.1007/s00701-009-0588-7

Surgical outcome after microvascular decompression (MVD) for primary trigeminal neuralgia (TN) has been demonstrated as being related to the characteristics of the neurovascular compression (NVC), especially to the degree of compression exerted on the root. Therefore, preoperative determination of the NVC features could be of great value to the neurosurgeon, for evaluation of conflicting nature, exact localization, direction and degree of compression. This study deals with the predictive value of MRI in detecting and assessing features of vascular compression in 100 consecutive patients who underwent MVD for TN.

Methods. The study included 100 consecutive patients with primary TN who were submitted to a preoperative 3D MRI 1.5 T with T2 high-resolution, TOF-MRA, and T1-Gadolinium. Image analysis was performed by an independent observer blinded to the operative findings and compared with surgical data.

Findings. In 88 cases, image analysis showed NVC features that coincided with surgical findings. There were no false-positive results. Among 12 patients that did not show NVC at image analysis, nine did not have NVC at intraoperative observation, resulting in three false-negative cases. MRI sensitivity was 96.7% (88/91) and specificity 100% (9/9). Image analysis correctly identified compressible vessel in 80 of the 91 cases and degree of compression in 77 of the 91 cases. Kappa-coefficient predicting degree of root compression was 0.746, 0.767, and 0.86, respectively, for Grades I (simple contact), II (distortion), and III (marked indentation; p<0.01).

Conclusion. 3D T2 high-resolution in combination with 3D TOF-MRA and 3D T1-Gadolinium proved to be reliable in detecting NVC and in predicting the degree of the root compression