Ruiz-Juretschke F, Guzmán-de-Villoria J G, García-Leal R, Sañudo J R
Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España.
Servicio de Neurorradiología, Hospital General Universitario Gregorio Marañón, Madrid, España.
Neurologia (Engl Ed). 2019 Oct;34(8):510-519. doi: 10.1016/j.nrl.2017.03.007. Epub 2017 May 23.
Microvascular decompression (MVD) is accepted as the only aetiological surgical treatment for refractory classic trigeminal neuralgia (TN). There is therefore increasing interest in establishing the diagnostic and prognostic value of identifying neurovascular compressions (NVC) using preoperative high-resolution three-dimensional magnetic resonance (MRI) in patients with classic TN who are candidates for surgery.
This observational study includes a series of 74 consecutive patients with classic TN treated with MVD. All patients underwent a preoperative three-dimensional high-resolution MRI with DRIVE sequences to diagnose presence of NVC, as well as the degree, cause, and location of compressions. MRI results were analysed by doctors blinded to surgical findings and subsequently compared to those findings. After a minimum follow-up time of six months, we assessed the surgical outcome and graded it on the Barrow Neurological Institute pain intensity score (BNI score). The prognostic value of the preoperative MRI was estimated using binary logistic regression.
Preoperative DRIVE MRI sequences showed a sensitivity of 95% and a specificity of 87%, with a 98% positive predictive value and a 70% negative predictive value. Moreover, Cohen's kappa (CK) indicated a good level of agreement between radiological and surgical findings regarding presence of NVC (CK 0.75), type of compression (CK 0.74) and the site of compression (CK 0.72), with only moderate agreement as to the degree of compression (CK 0.48). After a mean follow-up of 29 months (range 6-100 months), 81% of the patients reported pain control with or without medication (BNI score i-iiiI). Patients with an excellent surgical outcome, i.e. without pain and off medication (BNI score i), made up 66% of the total at the end of follow-up. Univariate analysis using binary logistic regression showed that a diagnosis of NVC on the preoperative MRI was a favorable prognostic factor that significantly increased the odds of obtaining an excellent outcome (OR 0.17, 95% CI 0.04-0.72; P=.02) or an acceptable outcome (OR 0.16, 95% CI 0.04-0.68; P=.01) after MVD.
DRIVE MRI shows high sensitivity and specificity for diagnosing NVC in patients with refractory classic TN and who are candidates for MVD. The finding of NVC on preoperative MRI is a good prognostic factor for long-term pain relief with MVD.
微血管减压术（MVD）被公认为是治疗难治性经典三叉神经痛（TN）的唯一病因性外科手术。因此，对于那些适合手术的经典TN患者，利用术前高分辨率三维磁共振成像（MRI）来确定神经血管压迫（NVC）的诊断和预后价值的兴趣日益浓厚。
这项观察性研究纳入了74例连续接受MVD治疗的经典TN患者。所有患者均接受了术前带有驱动序列的三维高分辨率MRI检查，以诊断NVC的存在以及压迫的程度、原因和位置。由对手术结果不知情的医生分析MRI结果，随后将其与手术结果进行比较。在至少随访6个月后，我们评估了手术结果，并根据巴罗神经学研究所疼痛强度评分（BNI评分）对其进行分级。使用二元逻辑回归估计术前MRI的预后价值。
术前驱动MRI序列显示敏感性为95%，特异性为87%，阳性预测值为98%，阴性预测值为70%。此外，科恩kappa系数（CK）表明，在NVC的存在（CK 0.75）、压迫类型（CK 0.74）和压迫部位（CK 0.72）方面，影像学和手术结果之间具有良好的一致性，而在压迫程度方面只有中等一致性（CK 0.48）。平均随访29个月（范围6 - 100个月）后，81%的患者报告无论是否用药疼痛均得到控制（BNI评分I - III）。在随访结束时，手术结果极佳（即无疼痛且无需用药，BNI评分I）的患者占总数的66%。使用二元逻辑回归进行的单因素分析表明，术前MRI诊断为NVC是一个有利的预后因素，显著增加了MVD后获得极佳结果（OR 0.17，95%CI 0.04 - 0.72；P = 0.02）或可接受结果（OR 0.16，95%CI 0.04 - 0.68；P = 0.01）的几率。
驱动MRI在诊断难治性经典TN且适合MVD的患者的NVC方面显示出高敏感性和特异性。术前MRI发现NVC是MVD长期缓解疼痛的良好预后因素。
