Use of Superior Petrosal Venous Complex to Transpose the Superior Cerebellar Artery in Microvascular Decompression for Trigeminal Neuralgia: 2-Dimensional Operative Video.

Trigeminal neuralgia is a cause of severe facial pain, usually provoked by a neurovascular conflict, commonly involving the superior cerebellar artery (SCA). The superior petrosal venous complex is in the way toward the nerve through a retrosigmoid approach and can narrow the working area around trigeminal nerve. Nonetheless, instead an obstacle it can be faced in selected cases as an adjunct to help to transpose the offending arterial loop, avoiding undesired venous sacrifice. We present a case of a 64-year-old man with left-sided severe shock-like pain in the V3 territory suggestive of trigeminal neuralgia (Video 1). Preoperative imaging depicted a neurovascular conflict between SCA and trigeminal nerve root. A retrosigmoid approach was implemented, and stimulation of the compression point was consistent with the preoperative referred pain. Considering the thick superior petrosal vein (SPV), we transposed the offending artery and anchored it over a SPV tributary. In this way no prosthetic material was placed in contact with trigeminal nerve, minimizing chance of recurrence. No abnormality on neurophysiological monitoring was reported, and postoperative imaging demonstrated no edema or hemorrhage, as well successful displacement of SCA. Patient presented complete resolution of pain and no new neurological deficit after 1 year of follow-up. This case is an uncommon report depicting a helpful intraoperative decision to be considered in selected cases to avoid venous sacrifice and preclude prosthetic material in contact with the nerve. Anatomical pictures courtesy of the Rhoton Collection, American Association of Neurological Surgeons (AANS)/Neurosurgical Research and Educational Foundation (NREF).