Successful Microvascular Decompression For Trigeminal Neuralgia Secondary to a Persistent Trigeminal Artery

BACKGROUND AND IMPORTANCE: Persistent trigeminal artery (PTA) is a rare but important anatomic variant that contributes to trigeminal neuralgia (TN). Microvascular decompression (MVD) of the responsible vessel(s) away from the trigeminal nerve provides the most complete and durable relief from TN. The role and technique of MVD for TN associated with a PTA has not been fully defined in the literature. Furthermore, assessment of PTA anatomy intraoperatively with a microscope is challenging. We report the first 3-dimensional (3D) microscopic video and first intraoperative endoscopic video of a successful MVD of the trigeminal nerve in a patient who suffered TN from a tortuous, compressive PTA. CLINICAL PRESENTATION: A 66-yr-old right-handed female presented with right facial pain in V2 and V3 distributions with a clinical picture of TN. Imaging demonstrated trigeminal nerve compression secondary to a PTA and MVD was performed with a 3D operative microscope and an endoscope. The PTA appeared to compress the nerve directly at the trigeminal porus and also had compressive superior cerebellar artery variant branches. The nerve was decompressed at all points of compression with Teflon pledgets along its entire cisternal length. Postoperatively, she is free with trigeminal pain episodes at 4-mo follow-up. CONCLUSION: In cases of TN associated with a PTA, we recommend decompression along the entire length of the nerve wherever there is compression. Furthermore, we find both the operative microscope and particularly the endoscope useful to assess vascular anatomy intraoperatively.