A novel surgical strategy for trigeminal neuralgia associated with vertebrobasilar dolichoectasia: nerve rerouting via the anterior transpetrosal approach. Illustrative case.

BACKGROUND

Microvascular decompression for trigeminal neuralgia (TN) caused by vertebrobasilar dolichoectasia is challenging due to severe arteriosclerosis of the offending vessel, and is often associated with poor improvement of the symptoms, recurrence, and increased risk of complications. The authors describe a novel method of treatment: rerouting the trigeminal nerve and not manipulating the offending vessels.

OBSERVATIONS

A 50-year-old male presented with a 7-year history of TN. MRI showed that the anterior inferior cerebellar artery (AICA) was strongly compressing the trigeminal nerve from the inferomedial direction. Given the severe dolichoectatic changes, mobilization of the offending vessels was considered extremely risky. Therefore, decompression was performed by mobilizing the trigeminal nerve instead of manipulating the offending vessels. The surgery was performed via an anterior transpetrosal approach. Meckel's cave was opened to allow sufficient mobilization of the trigeminal nerve. A GORE-TEX sling was used to lift and decompress the trigeminal nerve by separation from the AICA. The patient's facial pain completely disappeared immediately after surgery, and no new neurological deficits were observed.

LESSONS

The relative mobility of the trigeminal nerve allows rerouting by opening Meckel's cave. This technique may help reduce surgical risk by avoiding direct manipulation of severely atherosclerotic arteries. https://thejns.org/doi/10.3171/CASE25474.