Long-Term Results of Macrovascular Decompression Using Suture-Pexy Transposition Technique for the Treatment of Cranial Nerve and Brainstem Compression Syndromes

BACKGROUND AND OBJECTIVES: Macrovascular compression caused by a dolichoectatic vertebral or basilar artery represents a distinct subset of cranial nerve (CN) and brainstem compression disorders. Standard interpositional microvascular decompression (MVD) may not adequately decompress a large dolichoectatic vessel, necessitating vessel transposition. This study reports 2 decades of institutional experience with macrovascular decompression (MaVD) using a vascular mobilization and suture-pexy technique and evaluates long-term outcomes. METHODS: We retrospectively reviewed all patients undergoing MaVD for vertebrobasilar dolichoectasia-related brainstem or CN compression from 2005 to 2025. Demographics, clinical presentation, radiographic imaging, complications, and functional outcomes were analyzed. The operative technique involved mobilization of the offending large vessel and fixation to the clival dura using suture-pexy, and selective use of Teflon, fascia, or muscle interposition. Clinical outcomes were evaluated immediately postoperation, at 3 months, and/or at last follow-up. RESULTS: Among 144 patients treated for CN/brainstem compression syndromes, 22 (15%) had macrovascular causes. Patients (mean age 55 years; 73% men) presented mostly with hemifacial spasm (68%) or trigeminal neuralgia (23%). The vertebral artery was the offending vessel in 82% of patients, and compression occurred predominantly on the side of vertebral artery dominance. Brainstem compression was present in 32% (7/22). Complete symptom relief occurred in 86.5% (19/22) of patients immediately postoperation and 95% of patients at last follow-up (mean 1 year). There were no incidences of arterial dissection, stroke, or vessel occlusion. Complications included transient dysphagia (9%), taste disturbance (9%), hearing loss (5%), abducens palsy (5%), and pseudomeningocele (18%), two of which required cerebrospinal fluid diversion. CONCLUSION: MaVD using the suture-pexy technique is a safe and durable strategy for treating macrovascular CN and brainstem compression syndromes. This technique provides reliable decompression when standard MVD is inadequate.