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The efficacy and safety of revision microscopic microvascular decompression (microscopic MVD) for treating residual or recurrent hemifacial spasm (HFS) remain uncertain. We conducted a systematic review and meta-analysis to evaluate the benefits and risks associated with this reoperation, focusing primarily on spasm relief, facial palsy, and hearing impairment. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. We performed a comprehensive search of PubMed, Embase, Web of Science, and the Cochrane Library for eligible articles from their inception through June 2024. A total of 17 studies involving 719 patients were included in this meta-analysis. Among these patients, 668 experienced overall symptom relief following reoperation, resulting in a relief rate of 94% (95% CI: 92-96%). Complete relief was achieved in 603 patients, corresponding to a rate of 87% (95% CI: 80-93%). Transient facial palsy developed in 4% (95% CI: 1-8%) of patients, while persistent facial palsy was observed in 5% (95% CI: 2-8%) of patients following reoperation. Transient hearing impairment occurred in 1% (95% CI: 0-3%) of patients, while persistent hearing impairment was reported in 4% (95% CI: 1-7%) of patients. Patients with recurrent HFS have significantly lower overall and complete relief rates after reoperation compared to those with residual HFS and are at higher risk of long-term hearing loss. Our study suggests that reoperation for residual or recurrent HFS after microscopic MVD could be considered a safe and effective treatment option. Early reoperation may be indicated in specific cases, and the timing should be tailored to each patient's specific circumstances to optimize outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Objectives: Patients undergoing percutaneous rhizotomy for trigeminal neuralgia (TN) may require several procedures to manage their pain. However, it is not fully understood whether repeat procedures influence postoperative complication rates., Methods: We retrospectively reviewed patients undergoing rhizotomy at our institution from 2011 to 2022. Patients were included only if they had no history of prior interventions including microvascular decompression (MVD) or radiosurgery. We collected baseline patient information, pain characteristics, and postoperative complications for each patient. Patients were dichotomized into those undergoing primary rhizotomy versus those undergoing a repeat rhizotomy. Potential drivers of postoperative complications were included in a multivariate logistic regression model., Results: Of the 1904 cases reviewed, 965 met our inclusion criteria. 392 patients underwent primary rhizotomy, and 573 patients underwent repeat rhizotomies. The repeat rhizotomy group was significantly older, p<0.001. Patients in the repeat rhizotomy group expressed higher frequencies of bilateral pain, p=0.01. Patients in the repeat rhizotomy group demonstrated a significantly higher rate of preoperative numbness and postoperative numbness, p<0.001. There were no significant differences in any of the considered complications between the single rhizotomy and repeat rhizotomy groups. On multivariate logistic regression, repeat rhizotomy did not predict an increased risk of any postoperative complications, p=0.14., Conclusions: Patients undergoing repeat rhizotomy may be at risk of postoperative numbness but are not at increased risk for postoperative complications. These results are of use to patients who are poor surgical candidates, and thus may require multiple rhizotomies to effectively manage their pain over time., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Abstract: Trigeminal neuralgia (TN) is characterized by excruciating facial pain usually caused by neurovascular compression of the trigeminal nerve roots. TN can be treated medically or invasively. Microvascular decompression is the procedure of choice and usually results in complete symptom relief. During surgical decompression, Teflon can be placed between the offending vessel and the nerve root entry zone. In some cases, chronic Teflon-related inflammation can cause recurrent TN, which might lead to additional surgical intervention. We present imaging and histopathological correlation of a patient presenting with intractable recurrent TN approximately 2 years after microvascular decompression with Teflon implant., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

We explored the impact of brainstem auditory evoked potentials monitoring, as well as anatomical characteristics, in relation to their influence on hearing deficits. A total of 851 patients diagnosed with idiopathic hemifacial spasm underwent microvascular decompression treatment were recruited in our study. A nomogram was developed based on the regression analysis. Nomogram performance was evaluated through receiver operating characteristic (ROC), decision curve analyses and calibration curve. The rate of positive wave V change was also higher in the hearing deficit group (71.8% vs no hearing deficit group, p < 0.001). Furthermore, greater retraction depth (0.78 ± 0.25 cm vs 0.55 ± 0.12 cm, p < 0.001), duration (74.43 ± 15.74 min vs 55.71 ± 7.01 min, p < 0.001) and retraction distance (4.38 ± 0.38 cm vs 4.17 ± 0.24 cm, p = 0.001) were evident in the hearing deficit patients. Multivariate logistic regression showed that positive wave V change (OR 5.43), greater retraction depth (OR 55.57) and longer retraction duration (OR 1.14) emerged as significant independent predictors of postoperative hearing deficit. The external validation cohort exhibited a favorable discrimination with an AUC of 0.88. The calibration curves further confirmed the reliability of the predicted outcome in relation to the observed outcome in the external validation cohort (p = 0.89). The decision curves demonstrated that the nomogram outperformed the All or None scheme when the threshold probability ranged from > 2% to < 60% in the external validation cohort. We constructed a nomogram, including wave V, retraction depth, and retraction duration, which can effectively predict the occurrence of hearing deficits and has good clinical applicability., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: This study aimed to investigate individualized treatment strategies and clinical outcomes in patients with recurrent trigeminal neuralgia after undergoing microvascular decompression (MVD)., Methods: One hundred forty-four patients with recurrent trigeminal neuralgia after MVD were retrospectively examined and grouped according to treatment. Surgical efficacy and pain recurrence were analyzed as outcomes., Results: Repeat craniotomy was performed in 31 patients (21.5 %), percutaneous balloon compression (PBC) in 67 (46.5 %), and radiofrequency thermocoagulation (RFT) in 46 (32.0 %). Effectiveness did not differ among the three types of treatment (P = 0.052). The incidence of postoperative complications, including trigeminal nerve cardiac reflex, facial numbness, and mastication weakness, was lower in the craniotomy group than the PBC and RFT groups (P < 0.001). The 5-year pain recurrence rate was significantly higher than the 1-year rate in all groups. Although the 1-year pain recurrence rate did not differ among the groups, the 5-year rate was significantly lower in the repeat craniotomy group than the other groups (P < 0.001)., Conclusion: Patients with recurrent trigeminal neuralgia after MVD should be treated based on imaging evaluation and general condition. Repeat craniotomy, PBC, and RFT are all effective. Incidence of postoperative complications and long-term pain recurrence-free survival are superior for repeat craniotomy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: The infrafloccular approach in microvascular decompression (MVD) surgery for hemifacial spasm (HFS) was investigated for the prevention of hearing complications., Methods: Retrospective analysis of 136 patients who underwent MVD for HFS in 2019. The infrafloccular approach for MVD was adopted to resolve the symptom and protect hearing function. Postoperative hearing function was evaluated subjectively and objectively within 30 postoperative days, and later mainly subjectively. Postoperative condition of mastoid air cells based on the CT scan of the following day was also recorded., Results: No final postoperative subjective hearing impairment was found in all patients. Mastoid air cells were opened in 105 patients, and subjective hearing impairment was recorded in 57 patients within 30 postoperative days, but all improved later. Increases in thresholds of greater than 10 dB in air conduction were observed in 28 patients, including 26 of transient conductive hearing loss (increases in the threshold of less than or equal to 10 dB). The other 2 patients with increases in the threshold of greater than 10 dB in both air and bone conduction had improvement confirmed by later audiometry., Conclusions: Infrafloccular approach in MVD for HFS provides a good hearing outcome. Inclusion of postoperative hearing conditions in the later period is ideal for a precise hearing evaluation.

Background: Dizziness often occurs after microvascular decompression (MVD), and therapeutic options are limited. The aim of this trial was to determine the potential efficacy of transcutaneous electrical acupoint stimulation (TEAS), against dizziness and its safety in patients undergoing MVD., Methods: Adult patients scheduled to undergo MVD for hemifacial spasm under total intravenous anesthesia were randomized at a 1:1 ratio to receive, after extubation, 30-min TEAS in the mastoid region as well as Fengchi acupoints (GB20) and Neiguan acupoints (PC6) or 30-min sham stimulation. The primary outcome was the incidence of dizziness at 2 h after surgery. Secondary outcomes included dizziness, postoperative nausea and vomiting (PONV) or headache severity, rescue medication, changes in intraocular pressure before and after surgery, length of stay, dizziness symptoms 4 weeks after discharge, and surgical complications., Results: A total of 86 patients (51.9 ± 9.4 years of age; 67 women) were enrolled. One patient (in the TEAS arm) was excluded from analysis due to conversion to sevoflurane anesthesia. The rate of dizziness at 2 h after surgery was 31.0 % (13/42) in the TEAS arm vs. 53.5 % (23/43) in the sham control arm (P = 0.036). TEAS was also associated with significantly lower severity of dizziness, based on a 10-point scale, during the first 24 h after surgery. None of the other secondary efficacy outcomes differed significantly between the two arms. All postoperative complications were Clavien-Dindo grade I or II. The rate of postoperative complications was 21.4 % (9/42) in the TEAS arm vs. 16.3 % (7/43) in the sham control arm (P = 0.544)., Conclusions: Compared with sham control, TEAS was associated with a lower incidence of dizziness within 2 h and lower severity of dizziness within 24 h post-operatively, but no improvement in other outcomes, in adult patients undergoing MVD for hemifacial spasm., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: While hearing loss is a well-known condition following microvascular decompression (MVD) for hemifacial spasm (HFS), tinnitus is an underreported one. This study aims to identify prevalence, characteristics, severity, and predictors of tinnitus following MVD for HFS., Methods: A single-center cohort of 55 HFS patients completed a questionnaire approximately 5 years following MVD. Data encompassed tinnitus presence, side, type, onset, and severity measured by a 10-point Visual Analogue Scale (VAS). Descriptive, correlation, and logistic regression analyses were conducted. RESULTS  : At surgery, participants' median age was 58 years (IQR 52-65). The median duration of HFS symptoms before surgery was 5 years (IQR 3-8), slightly predominant on the left (60%). Postoperative tinnitus was reported by 20 patients (36%), versus nine (16%) that reported preoperative tinnitus. Postoperative tinnitus was ipsilateral on the surgical side in 13 patients (65%), bilateral in six (30%), and contralateral in one (5%). Among patients with bilateral postoperative tinnitus, 33% did not have this preoperatively. Tinnitus was continuous in 70% of cases and pulsatile in 30%. Onset of new tinnitus was in 58% immediately or within days, in 25% within three months, and in 17% between three months and one year after surgery. The mean severity of postoperative tinnitus was 5.1 points on the VAS. Preoperative tinnitus and presence of arachnoid adhesions had suggestive associations with postoperative tinnitus in initial analyses (p = 0.005 and p = 0.065). However, preoperative tinnitus was the only significant predictor of postoperative tinnitus (p = 0.011)., Conclusion: Tinnitus is a common condition following MVD for HFS, with a moderate overall severity. Causes behind postoperative tinnitus remain obscure but could be related to those of postoperative hearing loss in this patient population. Clinicians should be aware of tinnitus following MVD and vigilantly monitor its occurrence, to facilitate prevention efforts and optimize outcome for HFS patients undergoing MVD., (© 2024. The Author(s).)

In this article, we will discuss a rare complication after microvascular decompression for trigeminal neuralgia: peripheral facial palsy.

Background and Objectives: Bone wax is a flexible hemostatic agent commonly used for surgery in the posterior cranial fossa to control bleeding from the mastoid emissary vein. A large amount of bone wax can migrate into the sigmoid sinus through the mastoid emissary canal (MEC). We aimed to identify clinical factors related to intraoperative bone wax migration through the MEC during microvascular decompression (MVD) surgery, which may result in sigmoid sinus thrombosis., Methods: We retrospectively collected the clinical data of patients with trigeminal neuralgia, hemifacial spasm, or trigeminal neuralgia accompanied by painful tic convulsif who underwent MVD. Basic information and the residual width and length (from the bone surface to the sigmoid sinus) of the MEC on computed tomography images were collected. We compared the collected clinical data between 2 groups of cases with and without intraoperative bone wax migration in the sigmoid sinus., Results: Fifty-four cases with intraoperative bone wax migration and 187 patients without migration were enrolled. The t -test revealed significant differences in the width and length of the MEC ( P = .013 and P = .003, respectively). These variables were identified as significant factors in predicting intraoperative bone wax migration using multivariate logistic regression analysis., Conclusion: The large size of the MEC may be related to intraoperative bone wax migration into the sigmoid sinus in MVD. Neurosurgeons should be aware of these risks. Bone wax should be applied appropriately and hemostasis should be considered to control bleeding from the mastoid emissary vein in patients with a large MEC., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Microvascular decompression (MVD), radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS) are surgical techniques frequently used in the treatment of idiopathic trigeminal neuralgia (TN), although the results reported for each of these are diverse., Objective: This study aimed to compare long-term pain control obtained by MVD, SRS, and RFR in patients with idiopathic TN., Methods: To compare the results obtained by MVD, SRS, and RFR we chose a quasi-experimental, ambispective design with control groups but no pretest. A total of 52 participants (MVD n = 33, RFR n = 10, SRS n = 9) were included. Using standardized outcome measures, pain intensity, pain relief, quality of life, and satisfaction with treatment were assessed by an independent investigator. The TREND statement for reporting non-randomized evaluations was applied. Clinical outcomes were evaluated at the initial postoperative period and at 6 months, 1, 2, 3, 4, and 5 years postoperatively., Results: MVD has shown better results in pain scales compared to ablative procedures. Significant differences between groups were found regarding pain intensity and pain relief at the initial postoperative period (p < 0.001) and 6 months (p = 0.022), 1 year (p < 0.001), 2 years (p = 0.002), and 3 years (p = 0.004) after the intervention. Those differences exceeded the thresholds of the minimal clinically important difference. A higher percentage of patients free of pain was observed in the group of patients treated by MVD, with significant differences at the initial postoperative period (p < 0.001) and 6 months (p = 0.02), 1 year (p = 0.001), and 2 years (p = 0.04) after the procedure. Also, a higher risk of pain recurrence was observed in the RFR and SRS groups (HR 3.15, 95% CI 1.33-7.46; p = 0.009; and HR 4.26, 95% CI 1.77-10.2; p = 0.001, respectively) compared to the MVD group. No significant differences were found in terms of quality of life and satisfaction with treatment. A higher incidence of complications was observed in the MVD group., Conclusion: Concerning pain control and risk of pain recurrence, MVD is superior to RFR and SRS, but not in terms of quality of life, satisfaction with treatment, and safety profile., (© 2023 World Institute of Pain.)

Background and Objectives: Classical trigeminal neuralgia (cTN) is a painful disease. Microvascular decompression (MVD) provides immediate and durable relief in many patients. A variety of positive and negative prognostic biomarkers for MVD have been identified. The sagittal angle of the trigeminal nerve at the porus trigeminus (SATNaPT) is an MRI biomarker that can identify a subset of patients with cTN whose trigeminal nerve anatomy is different from normal controls. The purpose of this case-control study was to determine whether an abnormally hyperacute SATNaPT is a negative prognostic biomarker in patients with cTN undergoing MVD., Methods: Preoperative MRIs from 300 patients with cTN who underwent MVD were analyzed to identify patients with a hyperacute SATNaPT (defined as less than 3 SDs below the mean). The rate of surgical success (pain-free after at least 12 months) was compared between patients with a hyperacute SATNaPT and all other patients., Results: Patients without a hyperacute SATNaPT had an 82% likelihood of surgical success, whereas patients with a hyperacute SATNaPT had a 58% likelihood of surgical success ( P < .05). Patients with a hyperacute SATNaPT who also had no evidence of vascular compression on preoperative MRI had an even lower likelihood of success (29%, P < .05)., Conclusion: In patients with cTN being considered for MVD, a hyperacute SATNaPT is a negative prognostic biomarker that predicts a higher likelihood of surgical failure. Patients with a hyperacute SATNaPT, particularly those without MRI evidence of vascular compression, may benefit from other surgical treatments or a modification of MVD to adequately address the underlying cause of cTN., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objective: This study aimed to investigate the clinical characteristics of hemifacial spasm (HFS) after Bell's palsy and to evaluate the therapeutic efficacy of microvascular decompression (MVD)., Methods: A retrospective analysis was conducted on 18 patients who underwent MVD for HFS after Bell's palsy at our institution between January 1, 2017, and December 31, 2021. Clinical presentations, intraoperative findings, postoperative outcomes, and complications were comprehensively assessed., Results: Neurovascular compression (NVC) was identified in all the 18 patients. The offending vessels included anterior inferior cerebellar artery (AICA) in 6 patients (33.3%), posterior inferior cerebellar artery (PICA) in 7 patients (38.9%), vertebral artery (VA) combined with AICA in 3 patients (16.7%), and VA alongside PICA in 2 patients (11.1%). Notably, marked arachnoid membrane adhesion was evident in 11 patients (61.1%). 15(83.3%) patients were cured immediately after MVD, delayed relief was found in 3 (16.7%) patients. During the follow-up period, recurrence was not documented. Surgical complications were limited to facial paralysis in 3 patients and auditory impairment in 1 patient. No additional surgical complications were recorded., Conclusions: In patients manifesting HFS after Bell's palsy, NVC predominantly underlies the etiology. MVD is a reliably safe and efficacious therapeutic intervention., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Fully endoscopic microvascular decompression (MVD) of the facial nerve is the main surgical treatment for hemifacial spasm. However, the technique presents distinct surgical challenges. We retrospectively analyzed prior cases to consolidate surgical insights and assess clinical outcomes. Clinical data from 16 patients with facial nerve spasms treated at the Department of Neurosurgery in the First Affiliated Hospital of Bengbu Medical College, between August 2020 and July 2023, were retrospectively examined. Preoperatively, all patients underwent magnetic resonance angiography to detect any offending blood vessels; ascertain the relationship between offending vessels, facial nerves, and the brainstem; and detect any cerebellopontine angle lesions. Surgery involved endoscopic MVD of the facial nerve using a mini Sigmoid sinus posterior approach. Various operative nuances were summarized and analyzed, and clinical efficacy, including postoperative complications and the extent of relief from facial paralysis, was evaluated. Fully endoscopic MVD was completed in all patients, with the offending vessels identified and adequately padded during surgery. The offending vessels were anterior inferior cerebellar artery in 12 cases (75%), vertebral artery in 3 cases (18.75%), and posterior inferior cerebellar artery in 1 case (6.25%). Intraoperative electrophysiological monitoring revealed that the lateral spread response of the facial nerve vanished in 15 cases and remained unchanged in 1 case. Postoperative facial spasms were promptly alleviated in 15 cases (93.75%) and delayed in 1 case (6.25%). Two cases of postoperative complications were recorded-one intracranial infection and one case of tinnitus-both were resolved or mitigated with treatment. All patients were subject to follow-up, with no instances of recurrence or mortality. Fully endoscopic MVD of the facial nerve is safe and effective. Proficiency in endoscopy and surgical skills are vital for performing this procedure., (© 2024. The Author(s).)

Objective: Postoperative nausea and vomiting (PONV) occurs frequently after microvascular decompression (MVD). Fentanyl, an opioid, is strongly related to the development of PONV, and ketorolac, a nonsteroidal anti-inflammatory drug, has been approved for postoperative pain management. However, how ketorolac-based patient-controlled analgesia (PCA) causes PONV or how its efficacy differs from that of fentanyl-based PCA after MVD is unclear. In this study, the authors compared ketorolac-based with fentanyl-based PCA in terms of the incidence and severity of PONV and analgesia after MVD., Methods: This prospective, double-blind, single-center, randomized controlled trial conducted from December 2021 to February 2023 included patients with MVD who were randomly allocated to the ketorolac- or fentanyl-based PCA group postoperatively. The incidence (primary outcome) and severity of PONV and rescue antiemetic requirements were determined during the first 48 hours postoperatively. Additionally, postoperative pain scores, rescue analgesic requirement, PCA usage, and satisfaction scores were assessed during the study period. PONV severity and postoperative pain scores were assessed using an 11-point numeric rating scale (0 = none, 10 = extremely). Satisfaction scores for PONV and pain were determined (0 = very dissatisfied, 10 = very satisfied). Categorical variables were analyzed using the chi-square or Fisher's exact test. Continuous variables were analyzed using the Student t-test or Mann-Whitney U-test based on normal distribution., Results: Of 185 screened patients, 91 were excluded based on predetermined exclusion criteria; 87 patients (43 in the ketorolac group and 44 in the fentanyl group) were analyzed and showed no significant differences in demographic data between groups. PONV incidence (48.8% vs 79.5%, p = 0.003) and severity (p = 0.004) were lower in the ketorolac-based PCA group than in the fentanyl-based PCA group. In the ketorolac group, there was a significant reduction in rescue antiemetic requirements compared with the fentanyl group (p = 0.049). The number of discontinuations was lower in the ketorolac-based PCA group than in the fentanyl-based PCA group (p = 0.001), whereas no significant differences in postoperative pain were found between the two groups., Conclusions: In patients with MVD, ketorolac-based PCA resulted in a decrease in PONV incidence and severity compared with fentanyl-based PCA, with analgesic effects similar to those of fentanyl-based PCA. This study provides clinical evidence that ketorolac-based PCA may be a valid alternative to fentanyl-based PCA in postoperative care.

Objective: Microvascular decompression (MVD) is a well-accepted treatment modality for trigeminal neuralgia (TN) with high initial success rates. The causes for recurrence of TN after previously successful MVD have not been fully clarified, and its treatment is still a matter of debate. Here, we present the surgical findings and the clinical outcome of patients with recurrent TN after MVD who underwent posterior fossa re-exploration., Methods: Microsurgical posterior fossa re-exploration was performed in 26 patients with recurrent TN (mean age 59.1 years) who underwent MVD over a period of 10 years. The trigeminal nerve was exposed, and possible factors for recurrent TN were identified. Arachnoid scars and Teflon granulomas were dissected meticulously without manipulating the trigeminal nerve. Outcome of posterior fossa re-exploration was graded according to the Barrow Neurological Institute (BNI) pain intensity score. Follow-up was analyzed postoperatively at 3, 12, and 24 months and at the latest available time point for long-term outcome., Results: The mean duration of recurrent TN after the first MVD was 20 months. Pain relief was achieved in all patients with recurrent TN on the first postoperative day. Intraoperative findings were as follows: arachnoid scar tissue in 22/26 (84.6%) patients, arterial compression in 1/26 (3.8%), venous contact in 8/26 (30.8%), Teflon granuloma in 14/26 (53.8%), compression by an electrode in Meckel's cave used for treatment of neuropathic pain in 1/26 (3.8%), evidence of pulsations transmitted to the trigeminal nerve through the Teflon inserted previously/scar tissue ("piston effect") in 15/26 (57.7%), and combination of findings in 18/26 (69.2%). At long-term follow-up (mean 79.5 months; range, 29-184 months), 21/26 (80.8%) patients had favorable outcome (BNI I-IIIa). New hypaesthesia secondary to microsurgical posterior fossa re-exploration occurred in 5/26 (19.2%) patients., Conclusions: Posterior fossa re-exploration avoiding manipulation to the trigeminal nerve, such as pinching or combing, may be a useful treatment option for recurrent TN after previously successful MVD providing pain relief in the majority of patients with a low rate of new hypaesthesia., (© 2023. The Author(s).)

Background: To examine the factors contributing to persistent and recurrent hemifacial spasms (HFS) following a microvascular decompression (MVD) procedure and to suggest technical improvements to prevent such failures., Methods: A retrospective review was conducted on fifty-two cases of repeat surgery. The extent of the previous craniotomy and the location of neurovascular compression (NVC) were investigated. The operative findings were categorized into two groups: "Missing Compression" and "Teflon Contact". The analysis included long-term outcomes and operative complications after repeat MVD procedures., Results: Missing compression was identified in 29 patients (56%), while Teflon contact was observed in 23 patients (44%). Patients with missing compression were more likely to experience improper craniotomy (66%) compared to those with Teflon contact (48%). Medially located NVC was a frequent finding in both groups, mainly due to compression by the anterior inferior cerebellar artery. In the missing compression group, during the repeat MVD, Teflon sling retraction was utilized in 79% of cases, while in the Teflon contact group, the most common procedure involved removing the Teflon in contact (65%). After the repeat MVD procedure, immediate spasm relief was achieved in 42 patients (81%), with six (12%) experiencing delayed relief. After a median follow-up of 54 months, 96% of patients were free from spasms. Delayed facial palsy, facial weakness, and hearing impairment were more frequently observed in the Teflon contact group., Conclusions: A proper craniotomy that provides adequate exposure around the REZ is crucial to prevent missing the culprit vessel during the initial MVD procedure. Teflon contact on the REZ should be avoided, as it poses a potential risk of procedure failure and recurrence., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Introduction: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression., Methods: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome., Results: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief., Conclusions: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment., (Copyright © 2021 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.)

Glossopharyngeal neuralgia (GPN) is an uncommon facial pain syndrome and is characterized by paroxysms of excruciating pain in the distributions of the auricular and pharyngeal branches of cranial nerves IX and X. Glossopharyngeal neuralgia characterized by otalgia alone is rare. Herein, the authors analyzed 2 patients with GPN with otalgia as the main clinical manifestation. The clinical features and prognosis of this rare group of patients with GPN were discussed. They both presented with paroxysmal pain in the external auditory meatus and preoperative magnetic resonance imaging suggested the vertebral artery were closely related to the glossopharyngeal nerves. In both patients, compression of the glossopharyngeal nerve was confirmed during microvascular decompression, and the symptoms were relieved immediately after surgery. At 11 to 15 months follow-up, there was no recurrence of pain. A variety of reasons can cause otalgia. The possibility of GPN is a clinical concern in patients with otalgia as the main complaint. The authors think the involvement of the glossopharyngeal nerve fibers in the tympanic plexus via Jacobson nerve may provide an important anatomic basis for GPN with predominant otalgia. Surface anesthesia test of the pharynx and preoperative magnetic resonance imaging is helpful for diagnosis. Microvascular decompression is effective in the treatment of GPN with predominant otalgia., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Microscopic microvascular decompression (MVD) has been considered a curative and reliable method for treating classical trigeminal neuralgia (TN) for decades. Endoscopy can provide bright illumination and a panoramic view, which enhances the visualization of the posterior fossa. In view of the above advantages of endoscopy, it gradually became an option for MVD for treating TN. This study was performed to evaluate the advantages of fully endoscopic MVD for treating TN and is presented with a description of our operative technique. From January 2020 to January 2022, 95 classical TN patients underwent fully endoscopic MVD performed by the same surgeon and assistant in our department. The assistant held the endoscope, and the surgeon operated. Brain stem auditory evoked potentials (BEMPs) were routinely monitored. For every patient, the neurovascular conflict was identified, and complete decompression was achieved. The Barrow Neurological Institute (BNI) pain intensity score was used to evaluate the degree of facial pain. The intraoperative findings, postoperative outcomes, and complications were analyzed. Immediately after the operation, 93 patients (97.9%) achieved complete pain relief (BNI score of I). Two patients (2.1%) still had some pain, but it could be adequately controlled with medicine (BNI score of III). During the 12-36 months of follow-up, recurrence was found in 3 patients (3.2%), including one patient (1.1%) with a BNI score of II and 2 patients (2.1%) with a BNI score of III. Complications were found in 5 patients (5.3%), including facial numbness in 3 patients (3.2%), vertigo in one patient (1.1%), and headache in one patient (1.1%). There were no cases of mortality, stroke, hearing impairment, facial paralysis, or other complications. Fully endoscopic MVD is a safe and effective method for treating TN. It provides bright illumination and a panoramic view for surgeons to better observe neurovascular conflicts in deep areas of the cerebellopontine angle (CPA)., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Trigeminal neuralgia, or tic douloureux, clinically presents as a unilateral paroxysmal, stabbing, intense pain of the face, lasting for seconds but occurring frequently. Alternative causes including multiple sclerosis or mass of the brainstem or cranial nerves must be ruled out. Medical treatment, most commonly with carbamazepine, remains an effective first-line treatment. Ultimately, if medical management becomes refractory or symptoms progressive, then procedural and surgical options including microvascular decompression, stereotactic radiosurgery, radiofrequency thermocoagulation, and others should be considered. Most notably, microvascular decompression, as in this case, can be considered with an 85%-95% initial success rate., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: To compare the efficacy and safety of full endoscopic or endoscope-assisted microvascular decompression (E-MVD) and microscopic microvascular decompression (M-MVD) for primary trigeminal neuralgia (TN)., Methods: We systematically searched the online database, including PubMed, Embase and Cochrane Library. The search terms used included, but were not limited to, "Trigeminal Neuralgia", "Microvascular Decompression Surgery" and "Endoscope". Postoperative facial pain relief and postoperative complications were considered for meta-analysis. All the outcomes were calculated as odds ratios (ORs) with 95% confidence intervals using R language., Results: A total of three studies involving 442 (E-MVD [218] versus M-MVD [224]) patients were included for analysis in our study. Postoperative facial pain relief (very much improved or much improved) was no difference between the two groups (OR, 0.95;95% CI, 0.57-1.58; I 2  = 0%; p = 0.83). In addition, the occurrence of some postoperative complications was not statistically different between the two groups, including CSFleak (OR, 1.35;95% CI, 0.16-11.13; I 2  = 0%; p = 0.94), facial paralysis (OR, 0.26;95% CI, 0.03-2.54; I 2  = 0%; p = 0.67), hearing loss (OR, 0.87;95% CI, 0.30-2.55; I 2  = 32%; p = 0.22), facial numbness (OR, 1.03;95% CI, 0.56-1.87; I 2  = 62%; p = 0.10)., Conclusions: Both endoscopic microvascular decompression and microscopic microvascular decompression for trigeminal neuralgia appear to provide patients with equivalent facial pain relief outcomes. Complication rates were also similar between the groups., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: A small posterior fossa (PF) has been hypothesized to explain the increased incidence of trigeminal neuralgia (TN) in females and could make microvascular decompression (MVD) more challenging. The aim of this study was to investigate the association between the PF volume and dimensions in relation to biological sex, type of neurovascular conflict (NVC), and outcome after MVD in classic TN., Methods: In this observational study, 84 patients with TN operated on with MVD with a preoperative head computed tomography(CT) scan were included. Eighty-two adults without TN who had undergone head CT for other reasons were included as controls. PF volume and dimensions (x-axis, y-axis, and z-axis) were evaluated on the CT scans. For the patients with TN, Barrow Neurological Institute (BNI) grade was evaluated 6 months after MVD., Results: There was no difference in PF volume or dimensions between the patients with TN and controls. Women showed a smaller volume and narrower (x-axis) PF than men, but these differences did not manifest when comparing patients with TN and controls within each sex. Patients with an NVC involving the superior cerebellar artery had a narrower (x-axis) and shorter (y-axis) PF than did patients with an NVC resulting from other arteries. PF volume or dimensions were not associated with BNI grade after MVD., Conclusions: PF anatomy was related to the NVC type but did not differ between patients with TN and controls and was not related to the surgical outcome after MVD., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Primary hemifacial spasm (pHFS) is a benign but disabling movement disorder caused by a neurovascular conflict involving the facial nerve. Surgical treatment by microvascular decompression (MVD) is the most effective therapeutic. Predictors of surgical failure and surgical complications are still lacking. The aim of this study is to identify such predictors through the retrospective analysis of a series of 200 consecutive patients. All patients who underwent MVD for pHFS from January 1991 to December 2017 were included. All patients had at least two years follow-up. In addition to the demographic data, the outcome and the complications were collected. The primary outcome analysis showed that 7.5% of patients had a recurrence. Multiple and AICA related neurovascular conflicts were statistically associated to a higher recurrence rate after MVD (respectively p < 0.001 and p = 0.02). Permanent facial palsy occurred in 2.5% of patients, hearing loss in 9.0% (2.0% of complete unilateral impairment) and dizziness in 2.5%. The risk of each of these peripheral neurological impairments was statistically increased by a long duration between the first pHFS symptom and the MVD (p < 0.001). In case of recurrence, a second MDV was offered. Long term follow-up showed that all patients had a complete resolution of the HFS. Post-operative complication rate was not significantly increased after a second MVD. Multiple and AICA related neurovascular conflicts are associated to a higher risk of surgical failure. When a pHFS recurrence occurs, a second surgical procedure is associated with excellent outcome without significant increase of post-operative complications and should therefore be recommended., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: Microvascular decompression (MVD) is already the preferred surgical treatment for medically refractory neurovascular compression syndromes (NVC) such as hemifacial spasm (HFS), trigeminal neuralgia (TN), and glossopharyngeal neuralgia (GPN). Endoscopy has significantly advanced surgery and provides enhanced visualization of MVD. The aim of this study is to analyze the efficacy and safety of fully endoscopic microvascular decompression (E-MVD) for the treatment of HFS, TN, and GPN, as well as to present our initial experience., Materials and Methods: This retrospective case series investigated fully E-MVD performed in 248 patients (123 patients with HFS, 115 patients with TN, and 10 patients with GPN ) from December 2008 to October 2021 at a single institution. The operation duration, clinical outcomes, responsible vessels, intra- and postoperative complications, and recurrences were recorded. Preoperative and immediate postoperative magnetic resonance imaging (MRI) and computerized tomography (CT) were performed for imageological evaluation. The Shorr grading and Barrow Neurological Institute (BNI) pain score were used to evaluate clinical outcomes. The efficacy, safety, and risk factors related to the recurrence of the operation were retrospectively analysed, and the surgical techniques of fully E-MVD were summarised., Results: A total of 248 patients (103 males) met the inclusion criteria and underwent fully E-MVD were retrospectively studied. The effective rate of 123 patients with HFS was 99.1%, of which 113 cases were completely relieved and 9 cases were significantly relieved. The effective rate of 115 patients with TN was 98.9%, of which 105 cases had completely pain relieved after surgery, 5 cases had significant pain relieved, 4 cases had partial pain relieved but still needed to be controlled by medication. The effective rate of 10 patients with GPN was 100%, 10 cases of GPN were completely relieved after surgery. As for complications, temporary facial numbness occurred in 4 cases, temporary hearing loss in 5 cases, dizziness with frequent nausea and vomiting in 8 cases, headache in 12 cases, and no cerebral hemorrhage, intracranial infection, and other complications occurred. Follow-up ranged from 3 to 42 months, with a mean of 18.6 ± 3.3 months. There were 4 cases of recurrence of HFS and 11 cases of recurrence of TN. The other effective patients had no recurrence or worsening of postoperative symptoms. The cerebellopontine angle (CPA) area ratio (healthy/affected side), the length of disease duration, and the type of responsible vessels are the risk factors related to the recurrence of HFS, TN, and GPN treated by fully E-MVD., Conclusions: In this retrospective study, our results suggest that the fully E-MVD for the treatment of NVC such as HFS, TN, and GPN, is a safe and effective surgical method. Fully E-MVD for the treatment of NVC has advantages and techniques not available with microscopic MVD, which may reduce the incidence of surgical complications while improving the curative effect and reducing the recurrence rate., (© 2023. The Author(s).)

Objective: Microvascular decompression (MVD) is an effective intervention in patients with trigeminal neuralgia (TN). How prior rhizotomy can impact long-term pain outcomes following MVD is not well understood. In this study, the authors sought to compare pain outcomes in patients who had undergone primary MVD versus those who had undergone secondary MVD after a single or multiple rhizotomies., Methods: The authors retrospectively reviewed the data on all patients who had undergone MVD at their institution from 2007 to 2020. Patients were included in the study if they had undergone primary MVD or if their surgical history was notable for past rhizotomy. Barrow Neurological Institute (BNI) pain scores were assigned at preoperative and final follow-up appointments. Perioperative complications were noted for each patient, and evidence of pain recurrence was recorded as well. A history of rhizotomy as well as other variables that might influence TN pain recurrence were evaluated using a Cox proportional hazards model. The impact of prior rhizotomy on TN pain recurrence following MVD was further assessed using Kaplan-Meier survival analysis., Results: Of 1044 patients reviewed, 947 met the study inclusion criteria. Of these, 796 patients had undergone primary MVD, 84 had a history of a single rhizotomy before MVD, and 67 had a history of ≥ 2 rhizotomies prior to MVD. Patients in the single rhizotomy and multiple rhizotomies cohorts exhibited a greater frequency of preoperative numbness (p < 0.001), higher preoperative BNI pain scores (p < 0.005), and higher rates of postoperative numbness (p = 0.04). However, final follow-up BNI pain scores were not significantly different between the primary MVD and prior rhizotomy groups (p = 0.34). Cox proportional hazards analysis revealed that younger age, multiple sclerosis, and female sex independently predicted an increased risk of pain recurrence following MVD. Neither a history of a single prior rhizotomy nor a history of multiple prior rhizotomies independently increased the risk of pain recurrence. Furthermore, Kaplan-Meier analysis of pain-free survival among the 3 groups revealed no relationship between a history of prior rhizotomy and pain recurrence following MVD (p = 0.57)., Conclusions: Percutaneous rhizotomy does not complicate outcomes following subsequent MVD for TN pain. However, patients undergoing rhizotomy before MVD may have an increased risk of postoperative facial numbness compared to that in patients undergoing primary MVD.

Purpose: Endoscopy is known to be a useful adjunct for microvascular decompression (MVD) surgery, assisting observation in blind spots such as Meckel's cave in cases of trigeminal neuralgia (TN) and the root exit zone (REZ) in hemifacial spasm (HFS). However, few reports have discussed the usefulness of endoscopy in relation to individual patient characteristics or preoperative magnetic resonance imaging (MRI)., Methods: We retrospectively reviewed the medical records of 109 patients (98 with HFS and 11 with TN, 85 women, median age 55 years) who had undergone endoscopically assisted MVD at our institution between 2017 and 2021. The usefulness of endoscopy in individual cases was scored by three neurosurgeons using a grading scale: 2, essential and indispensable; 1, useful and helpful; 0, not necessary. The mean value of the assigned scores was taken as an indicator of "usefulness," and endoscopy was considered to have been "useful" in cases with a score of > 1.0., Results: Endoscopic assistance was judged to have been useful in 69% of the patients. The proportion of patients evaluated as useful was significantly lower for TN (18.2%) than for HFS (74.5%). Patients with superior cerebellar artery compression had significantly lower scores than patients with other vessels. Endoscopy was considered useful in a significantly higher proportion of patients with anatomically complicated offending vessels (bifurcation or strong meandering) in the REZ detected by preoperative MRI (P < 0.005)., Conclusion: Endoscopy for MVD is useful for patients with HFS, especially when preoperative MRI shows bifurcation or strongly meandering vessels in the REZ., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: The incidence of postoperative nausea and vomiting (PONV) after microvascular decompression (MVD) surgery is high; however, its underlying mechanisms remain unknown. Serum 5-hydroxytryptamine (5-HT) levels are elevated in patients with PONV. However, the relationship between 5-HT and patients experiencing PONV after MVD surgery is still unknown. Therefore, we hypothesized that 5-HT levels are associated with PONV after MVD surgery., Methods: This prospective study included 85 patients with hemifacial spasm who received MVD surgery. Blood samples were collected preoperatively, postoperatively, and on postoperative day 1, and cerebrospinal fluid samples were collected intraoperatively. 5-HT levels were detected by enzyme-linked immunosorbent assay (ELISA). The incidence and severity of PONV were evaluated at 2, 6, and 24 h after MVD surgery., Results: In the multivariate regression analysis, PONV within 24 h after MVD surgery was associated with elevated cerebrospinal fluid 5-HT levels [odds ratio (OR) = 1.21, 95% confidence interval (CI): 1.01-1.45, p = 0.044], and reduction of intraocular pressure [OR = 11.54, 95% CI: 1.43-92.84, p = 0.022]. Receiver operating characteristic curve analysis revealed an area under the curve of 0.873 (95% CI: 0.77-0.98, p < 0.001)., Conclusion: Our study found that the cerebrospinal fluid 5-HT levels is an independent risk factor for PONV within 24 h after MVD surgery., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Object: Microvascular decompression (MVD) is the best curative treatment for trigeminal neuralgia and hemifacial spasm. We used the neuronavigation to reconstruct the 3D image of cranial nerve and blood vessel to identify the neurovascular compression, and to reconstruct the venous sinus and skull to optimize craniotomy., Patients and Methods: A total of 11 trigeminal neuralgia and 12 hemifacial spasm cases were selected. All patients had preoperative MRI which included 3D Time of Flight (3D-TOF), Magnetic Resonance Venography (MRV) and computer tomography (CT) for navigation. Imaging sequences were fused and reconstructed by navigation system before operation. The 3D-TOF images were used to delineate cranial nerve and vessel. The CT and MRV images were used to mark transverse sinus and the sigmoid sinus for craniotomy. All patients underwent MVD and have the preoperative view compared with intraoperative findings., Results: Approaching to the cerebellopontine angle right after opening the dura and got no cerebellar retracion or petrosal vein rupture during craniotomy. Ten of 11 trigeminal neuralgia and all 12 hemifacial spasm patients got excellent preoperative 3D reconstruction fusion images, which were also confirmed by intraoperative findings. All 11 trigeminal neuralgia patients and 10 of 12 hemifacial spasm patients were symptom free without any neurological complications just after the surgery. Other 2 hemifacial spasm patients got delayed resolution in 2 months after surgery., Conclusions: Through the neuronavigation guided craniotomy and the 3D neurovascular reconstruction, surgeons can better identify the compression of nerve and blood vessel, and reduce complications., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Objective: To explore and analyze the clinical efficacy of a stepwise decompression technique in the treatment of trigeminal neuralgia (TN) caused by vertebrobasilar dolichoectasia (VBD)., Methods: A total of 918 patients with TN admitted to our hospital from June 2015 to May 2020 were divided into the VBD group (n = 61) and the conventional group (n = 857). The VBD group underwent stepwise decompression, while the conventional group received traditional microvascular decompression (MVD) surgery. Patients associated with the VBD were divided into direct compression (n = 14) and indirect compression group (n = 47) who had compression by other vessels in the presence of the VBD. Thereafter, the clinical data, intraoperative findings, efficacy, and complications were analyzed., Results: The curative ratio, efficacy, and recurrence rate for the VBD and conventional group were 83.6% and 89.6%, 93.4% and 95.3%, and 8.2% and 5.3%, respectively. The curative ratio, efficacy, and recurrence rate for the direct compression and indirect compression group were 85.7% and 83.0%, 92.9% and 93.6%, and 7.1% and 8.5%, separately. There were no significant differences in the curative ratio, efficacy, recurrence rate, and the incidence of complications between the two series (P > 0.05)., Conclusion: For TN caused by VBD, stepwise decompression not only reduces the direct compression of the trigeminal nerve by VBA but also allows identification and decompression of the actual vessels responsible for the compression. It has a good curative ratio, efficacy, and long-term pain relief rate, and it does not significantly increase the incidences of complications after surgery., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Hearing impairment is an important complication of microvascular decompression (MVD). In patients after MVD, we have occasionally noted slight to moderate hearing deterioration at low frequencies that is difficult to detect using pure tone average., Objective: To assess the incidence and features of low-frequency hearing impairment (LF-HI) after MVD and evaluate its associated factors., Methods: This single-center, retrospective observational study assessed the audiometric outcome of 270 patients who underwent MVD between January 2015 and December 2020. Preoperative and postoperative hearing levels were compared for each frequency. LF-HI was defined as a hearing deterioration of ≥15 dB at 125, 250, or 500 Hz. The incidence, symptoms, and associated factors of LF-HI were analyzed., Results: Statistical analysis of the patients overall demonstrated slight but significant decreases in the hearing level after MVD at lower frequencies on both the operative and contralateral sides. Eighty-one patients (30.0%) had LF-HI: 49 on the operative side, 24 on the contralateral side, and 8 on both sides, while pure tone average was worsened in 5 patients (1.8%). Subjective symptoms, including hearing deterioration, ear fullness, tinnitus, and dizziness, developed in 10.4% of the patients with LF-HI but improved subsequently within several weeks. "Older age" and "operative side" were associated with LF-HI., Conclusion: Decreases in lower-frequency hearing levels in both the ipsilateral and contralateral (nonoperative) ears were observed after trigeminal neuralgia and hemifacial spasm surgery. LF-HI does not cause permanent symptoms but may be a noteworthy phenomenon, possibly involved in the contralateral hearing loss encountered occasionally after other types of posterior cranial fossa surgery., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Purpose: To explore the predictive value of preoperative magnetic resonance imaging structural and diffusion indices of the spinal trigeminal tract (SpTV) on the results of microvascular decompression (MVD) in patients with trigeminal neuralgia (TN)., Methods: This retrospective study included patients diagnosed with TN and treated with MVD in the Jining First People's Hospital between January 2020 and January 2021. The patients were divided into good and poor results groups according to postoperative pain relief. Logistic regression analysis was performed to explore independent risk factors for poor results of MVD, and their predictive value was examined using receiver operating characteristic (ROC) curves., Results: A total of 97 TN cases were included, 24 cases with a poor result and 73 with a good result. They were comparable in demographic characteristics. Fractional anisotropy (FA) was lower (P < 0.001), and radial diffusivity (RD) was higher (P < 0.001) in the poor result group compared to the good result group. Patients in the good result group showed a higher proportion of grade 3 neurovascular contact (NVC) (39.7% vs. 16.7%, P = 0.001) and a lower RD (P < 0.001). The multivariate analysis showed that the RD of SpTV (OR = 0.000016, 95% CI: 0.000-0.004, P < 0.001) and NVC (OR = 8.07, 95% CI: 1.67-38.93, P = 0.009) were independently associated with poor results. The area under the curve (AUC) of RD and NVC were 0.848 and 0.710, and their combination achieved an AUC of 0.880., Conclusion: NVC and RD of SpTV are independent risk factors for poor results after MVD surgery, and combining the NVC and RD might achieve relatively high predictive value for poor results., (© 2023. The Author(s).)

Background: Trigeminal neuralgia (TN), a severe type of facial pain, is mainly caused by a neurovascular conflict (NVC). The severity of the NVC seems associated with the outcome following microvascular decompression (MVD) surgery. This study aimed to investigate the outcome after MVD and whether it is affected by NVC severity and sex., Methods: TN patients (n = 109) were followed for 5 to 10 years after MVD. Barrow Neurology Index (BNI), Patients Global Impression of Change (PGIC), complications, and time to relapse were evaluated. The NVC severity was retrospectively reviewed from presurgical MRI. Demographic and clinical factors and NVC severity were analyzed for potential association with outcome after MVD., Results: The success rate (BNI ≤ 2) was 80% after 5 to 10 years follow-up for TN patients with severe NVC (grade 2-3) and 56% for TN patients with mild NVC (grade 0-1, P = 0.003). No sex difference was observed in outcome for patients with both mild (P = 0.924) and severe NVC (P = 0.883) respectively. Three patients (2.8%) during the hospital stay, and two patients (1.8%) at 6 weeks, experienced a complication requiring invasive treatment. At long-term 52/109 patients (47.7%) reported some type of persistent adverse event, of which the majority were mild and required no treatment., Conclusions: MVD offers an 80% probability of long-term pain relief in TN patients with severe NVC, with low frequency of serious complications. NVC severity significantly affects outcome after MVD, while no sex differences in outcome were found. In consistency with previous work, the results stress the importance of adequate neuroradiological assessment of the NVC for preoperative patient selection., (© 2023. The Author(s).)

Background: The trigeminocerebellar artery is a standard variant originating from the basilar artery and can be an infrequent cause of trigeminal neuralgia., Method: Total endoscopic microvascular decompression (eMVD) was performed using a 0-degree endoscope through a retro sigmoid keyhole. Multiple points of neurovascular conflict enhanced by indocyanine green angiography were identified, and the root entry zone was decompressed. The patient had an improvement in facial pain with no complications., Conclusion: Complete eMVD for a nerve-penetrating artery is a practical, minimally invasive, uncomplicated technique that improves visualization and patient comfort., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Objective: Microvascular decompression (MVD) is the only curative treatment modality for hemifacial spasm (HFS). Although generally considered to be safe, this surgical procedure is surrounded by many risks and possible complications. The authors present the spectrum of complications that they met in their case series, the possible causes, and the strategies recommended to minimize them., Methods: The authors reviewed a prospectively maintained database for MVDs performed from 2005 until 2021 and extracted relevant data including patient demographics, offending vessel(s), operative technique, outcome, and different complications. Descriptive statistics with uni- and multivariable analyses for the factors that may influence the seventh, eighth, and lower cranial nerves were performed., Results: Data from 420 patients were obtained. Three hundred seventeen of 344 patients (92.2%) with a minimum follow-up of 12 months had a favorable outcome. The mean follow-up (standard deviation) was 51.3 ± 38.7 months. Immediate complications reached 18.8% (79/420). Complications persisted in only 7.14% of patients (30/420) including persistent hearing deficits (5.95%) and residual facial palsy (0.95%). Temporary complications included CSF leakage (3.10%), lower cranial nerve deficits (3.57%), meningitis (0.71%), and brainstem ischemia (0.24%). One patient died because of herpes encephalitis. Statistical analyses showed that the immediate postoperative disappearance of spasms and male gender are correlated with postoperative facial palsy, whereas combined vessel compressions involving the vertebral artery (VA) and anterior inferior cerebellar artery can predict postoperative hearing deterioration. VA compressions could predict postoperative lower cranial nerve deficits., Conclusions: MVD is safe and effective for treating HFS with a low rate of permanent morbidity. Proper patient positioning, sharp arachnoid dissection, and endoscopic visualization under facial and auditory neurophysiological monitoring are the key points to minimize the rate of complications in MVD for HFS.

Pharmacotherapy is frequently selected over surgical interventions for late elderly patients with trigeminal neuralgia (TN). However, medication may affect these patients' activities of daily living (ADL). Hence, we investigated the effect of the surgical treatment of TN on ADL in older patients. This study included 11 late elderly patients >75 years old and 26 nonlate elderly patients who underwent microvascular decompression (MVD) for TN at our hospital from June 2017 to August 2021. We evaluated pre- and postsurgical ADL using the Barthel Index (BI) score, side effects of antineuralgic drugs, the BNI pain intensity score, and perioperative medication. The BI score of late elderly patients significantly improved postoperatively, particularly in transfer (pre: 10.5; post: 13.2), mobility (pre: 10; post: 12.7), and feeding (pre: 5.9 points; post: 10 points). Additionally, antineuralgic drugs caused preoperative disturbances of transfer and mobility. Trends of a longer disease duration and frequent occurrence of side effects were observed in all patients in the elderly group, compared to only 9 out of 26 patients in the younger group (100% vs. 35%, p = 0.0002). In addition, drowsiness was observed more frequently in the late elderly group (73% vs. 23%, p = 0.0084). However, the change in scores indicating improvement after surgery was significantly greater in the late elderly group, although both pre- and postoperative scores were higher in the nonlate elderly group (11.4 ± 1.9 vs. 6.9 ± 0.7, p = 0.027). Surgical treatment can improve older patients' ADL because it relieves pain and facilitates discontinuation of antineuralgic drugs. Consequently, MVD can be positively recommended for older patients with TN if general anesthesia is acceptable.

Oculomotor nerve palsies are typically associated with posterior communicating artery (PcommA) aneurysms. We report a rare case of an oculomotor nerve palsy caused by a PcommA infundibular dilatation. Although there are cases of infundibular dilatations causing cranial nerve palsies, only reports of three involving the PcommA exists. We review these reported cases in the literature and discuss their treatments as well as other non-aneurysmal compressive etiologies that may cause oculomotor nerve palsies. We present the case of a 53-year-old female with transient oculomotor nerve palsy that was initially diagnosed with a PcommA aneurysm. She underwent a craniotomy with plans of microsurgical clipping; however, the dilatation was identified correctly as an infundibulum intraoperatively. The operation was completed as a microvascular decompression and her oculomotor nerve palsy has not returned at the 1-year follow-up. We provide a detailed microsurgical report and video detailing the operative technique and relevant anatomy for this operation. Although rare and not as life-threatening as aneurysms, infundibular dilatations as a cause of oculomotor nerve palsy should remain as a differential diagnosis. Given the difference in natural history and treatment of these two entities, it is important to diagnose and treat them appropriately. Multimodal imaging such as thin-sliced computed tomography angiogram (CTA) and 3-dimensional (3D) rotational angiography can aid in diagnosis.

Microvascular decompression (MVD) has a satisfactory safety, and it is the only surgical treatment for neurovascular compression diseases, such as hemifacial spasm, trigeminal neuralgia, and glossopharyngeal neuralgia, from the perspective of etiology. Bilateral dilated and fixed pupils have long been regarded as a sign of life threatening, which is common in patients with cerebral herniation due to cranial hypertension. However, transient dilated pupils after MVD have not been previously reported. Here, we presented 2 patients with bilateral transient dilated and fixed pupils after MVD and discussed the possible etiologies through the literature review. Physical examination of both patients showed bilateral pupils were normal and without a medical history of pupil dilation. They underwent MVD under general anesthesia and used propofol and sevoflurane. In both cases, the vertebral artery was displaced, and Teflon pads were inserted between the vertebral artery and the brain stem. Postoperation, we found transient bilateral mydriasis without light reflection in both patients. The emergency head computed tomography revealed no obvious signs of hemorrhage and cerebral herniation. About 1 hour later, this phenomenon disappeared. Therefore, the authors think if MVD is successfully carried out, bilateral transient mydriasis may not necessarily indicate brain stem hemorrhage, cerebral herniation, and other emergency conditions, which can be recovered within a short time. The causes could be related to stimulation of the sympathetic pathway in the brain stem during MVD and side effects of anesthetics., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Objective: In most cases of trigeminal neuralgia (TN), the trigeminal nerve is compressed by the arterial vasculature. We sought to address the gap in understanding of pain outcomes in patients with sole arterial versus sole venous compression., Methods: We retrospectively reviewed all patients undergoing microvascular decompression at our institution, identifying patients with either sole arterial or venous compression. We dichotomized patients into arterial or venous groups and obtained demographics and postoperative complications for each case. Barrow Neurological Index (BNI) pain scores were collected preoperatively, postoperatively, and at final follow-up, as well as recurrence of pain. Differences were calculated via χ 2 tests t tests, and Mann-Whitney U Tests. Ordinal regression was used to account for variables known to influence TN pain. Kaplan-Meier analysis was used to determine recurrence-free survival., Results: Of 1044 patients, 642 (61.5%) had either sole arterial or venous compression. Of these cases, 472 showed arterial compression and 170 showed sole venous compression. Patients in the venous compression group were significantly younger (P < 0.001). Patients with sole venous compression showed worse preoperative (P = 0.04) and final follow-up (P < 0.001) pain scores. Patients with sole venous compression had significantly higher rate of pain recurrence (P = 0.02) and BNI score at pain recurrence (P = 0.04). On ordinal regression, venous compression was found to independently predict worse BNI pain scores (odds ratio, 1.66; P = 0.003). Kaplan-Meier analysis showed a significant relationship between sole venous compression and increased risk of pain recurrence (P = 0.03)., Conclusions: Patients with TN with sole venous compression show worse pain outcomes after microvascular decompression compared with those with only arterial compression., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Whether the total number of compressive vessels in trigeminal neuralgia (TN) affects outcomes after microvascular decompression (MVD) is unknown., Objective: To investigate whether the number of compressive vessels is associated with outcomes after MVD., Methods: We retrospectively reviewed all patients with TN who underwent MVDs at our institution from 2007 to 2020. The number and identity of compressive vessels on the trigeminal nerve were recorded. Preoperative and postoperative pain and numbness Barrow Neurological Institute scores were compared. Factors associated with pain recurrence were assessed using survival analyses and multivariate regressions., Results: We identified 496 patients with a single vessel and 381 patients with multiple vessels compressing the trigeminal nerve. Compared with patients with a single compressive vessel, patients with multiple sources of compression exhibited increased Barrow Neurological Institute pain scores preoperatively ( P = .01). In addition, pain recurrence was more frequent ( P < .001) and occurred after a significantly shorter pain-free duration ( P < .001) for the multiple compression group. Using multivariate ordinal regression, a greater number of arteries ( P = .03) and veins ( P = .03) were both significantly associated with higher pain scores at final follow-up. Furthermore, the number of arteries ( P = .01) and of veins ( P = .01) was significantly associated with a higher risk for pain recurrence., Conclusion: TN patients with a single compressive vessel exhibited better pain outcomes after an MVD. Patients with multiple compressive vessels exhibited higher pain scores preoperatively and incurred a higher risk for pain recurrence, which occurred after a shorter pain-free interval compared with the single compression cohort., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Objective: This study aimed to compare the clinical outcomes of a modified microvascular decompression (MVD) with a traditional MVD in hemifacial spasm., Methods: A tota1 of 120 patients with hemifacial spasm who received a modified MVD (modified MVD group) and 115 patients who received a traditional MVD (traditional MVD group) from January 2013 to March 2021 were retrospectively reviewed. The surgery efficiency rate, surgery time and postoperative complications in both groups were recorded and analyzed., Results: There was no significant difference between the 2 groups regarding surgery: efficiency rate (modified MVD group VS traditional MVD group: 92.50% vs 92.17%, respectively; P = .925). The intracranial surgery time and postoperative complications rate in the modified MVD group were significantly lower than in the traditional MVD group (31.00 ± 1.78 min vs 48.00 ± 1.74 min, respectively; P < .05; 8.33% vs 20.87%; P = .006, respectively). There was no statistical difference between open skull time and close skull time between the 2 groups (modified MVD group vs traditional MVD group: 38.50 ± 1.76 min vs 40.00 ± 1.78 min, respectively; P = .055; 38.50 ± 1.76 min vs 36.00 ± 1.78 min, respectively; P = .086)., Conclusion: The modified MVD for hemifacial spasm can achieve satisfactory clinical outcomes and reduce intracranial surgery time and postoperative complications.

Trigeminal neuralgia (TN) is a syndrome consisting of episodic neuropathic facial pain. Although the precise symptoms vary across individuals, TN is typically described as lancinating electrical shocks triggered by sensory stimuli (light touch, talking, eating, and brushing teeth) that improve with antiepileptic medication (especially carbamazepine), remit spontaneously for weeks to months (pain-free intervals), and do not involve any changes in baseline sensation. The etiology of TN has not been definitively established, but many cases are associated with compression of the trigeminal nerve by a blood vessel at the trigeminal root entry zone adjacent to the brainstem. Patients who do not respond to medical management and who are not candidates for microvascular decompression often benefit from focal therapeutic injury to the trigeminal nerve at some point along its course. Many lesions have been described, including peripheral neurectomies that target distal branches of the trigeminal nerve, rhizotomies of the Gasserian ganglion of the nerve within Meckel's cave, radiosurgery of the trigeminal nerve at its root entry zone, partial sensory rhizotomy at the root entry zone, tractotomy of the spinal nucleus of the trigeminal nerve, and DREZotomy of the trigeminal nucleus caudalis, Though the latter two interventions are seldom done for TN and more commonly performed for trigeminal neuropathic pain. This article reviews the relevant anatomy and lesioning procedures for the treatment of trigeminal neuralgia., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This article reports a case of spontaneous spinal subdural hematoma (SSDH) after brain surgery in a patient with immune thrombocytopenic purpura (ITP), reviews the relevant literature, and discusses the etiology, pathogenesis, and clinical features of SSDH in patients with ITP. A male patient in his early 50 s with an 8-year history of ITP and suffering from coexistent hemifacial spasm and trigeminal neuralgia underwent microvascular decompression in our department. His preoperative corrected platelet count was within the normal range. On postoperative day 2, the patient complained of acute low back pain and sciatica. Lumbar magnetic resonance imaging demonstrated an SSDH extending from L3 to L4 with a significantly decreased platelet count (30.0 × 10 9 /L). The pain was gradually relieved after 2 weeks of conservative treatment, and no neurological deficit occurred during the 1-year follow-up. Brain surgery may increase the risk of postoperative SSDH in patients with ITP. Clinicians planning brain surgery must conduct a rigorous assessment through detailed physical examination, laboratory tests, and medical history records and maintain perioperative platelet counts within the normal range to prevent various risks associated with spinal cord compression.

This study aims to explore the causes of primary young onset trigeminal neuralgia (TN) and the clinical outcomes of these patients. From May 2015 to December 2020, 19 primary TN patients with onset age under 30 years underwent microvascular decompression (MVD) in Nanjing Drum Tower Hospital. In this study, the clinical characteristics, surgical outcomes, and postoperative complications of these patients were analyzed retrospectively. Of the 19 patients, 5 were males and 14 were females, and the pain was located on the right side in 10 cases (52.6%). Vascular compression was observed in 17 patients, including 14 cases of superior cerebellar artery (SCA) alone, 2 cases of superior petrosal vein (SPV) alone, and 1 case of SCA and SPV combined. Two patients had no neurovascular conflict, and nerve combing was performed. After surgery, 18 patients got immediate pain relief; 1 patient improved but still had occasional pain. With a mean follow-up of 42.7 ± 22.3 months, one patient was found to have a relapse 45 months after MVD. Surgical complications including mild facial numbness in two patients and hearing impairment in one patient. Neurovascular compression is the main cause of young onset primary TN, and the most commonly encountered vascular was SCA. MVD is a safe and effective treatment for these patients., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Despite being rarely reported, ischemic insults resulting from compromising small brainstem perforators following microvascular decompression (MVD) remain a potential devastating complication. To avoid this complication, we have been using indocyanine green (ICG) angiography intraoperatively to check the flow within the small brainstem perforators. We aim to evaluate the safety and usefulness of ICG videoangiography in MVD., Methods: We extracted retrospective data of patients who received ICG videoangiography from our prospectively maintained database for microvascular decompression. We noted relevant data including demographics, offending vessels, operative technique, outcome, and complications., Results: Out of the 438 patients, 15 patients with a mean age (SD) of 53 ± 10.5 years underwent intraoperative ICG angiography. Male:female was 1:1.14. The mean disease duration prior to surgery was 7.7 ± 5.3 years. The mean follow-up (SD) was 50.7 ± 42.0 months. In 14 patients, the offending vessel was an artery, and in one patient, a vein. Intraoperative readjustment of the Teflon pledget or sling was required in 20% (3/15) of the cases. No patient had any sort of brainstem ischemia. Eighty percent of the patients (12/15) experienced complete resolution of the spasms. 86.7% (13/15) of the patients reported a satisfactory outcome with marked improvement of the spasms. Three patients experienced slight hearing affection after surgery, which improved in two patients later. There was no facial or lower cranial nerve affection., Conclusion: Intraoperative ICG is a safe tool for evaluating the flow within the brain stem perforators and avoiding brainstem ischemia in MVD for hemifacial spasm., (© 2022. The Author(s).)

Glossopharyngeal neuralgia (GPN) is a neurological condition characterized by paroxysmal, stabbing-like pain along the distribution of the glossopharyngeal nerve that lasts from a couple of seconds to minutes. Pharmacological treatment with anticonvulsants is the first line of treatment; however, about 25% of patients remain symptomatic and require surgical intervention, which is usually done via microvascular decompression (MVD) with or without rhizotomy. More recently, the use of stereotactic radiosurgery (SRS) has been utilized as an alternative treatment method to relieve patient symptoms by causing nerve ablation. We conducted a systematic review to analyze whether MVD without rhizotomy is an equally effective treatment for GPN as MVD with the use of concurrent rhizotomy. Moreover, we sought to explore if SRS, a minimally invasive alternative surgical option, achieves comparable outcomes. We included retrospective studies and case reports in our search. We consulted PubMed and Medline, including articles from the year 2000 onwards. A total of 36 articles were included for review. Of all included patients with glossopharyngeal neuralgia, the most common offending artery compressing the glossopharyngeal nerve was the posterior inferior cerebellar artery (PICA). MVD alone was successful achieving pain relief immediately postoperatively in about 85% of patients, and also long term in 65-90% of patients. The most common complication found on MVD surgery was found to be transient hoarseness and transient dysphagia. Rhizotomy alone shows an instant pain relief in 85-100% of the patients, but rate of long-term pain relief was lower compared to MVD. The most common adverse effects observed after a rhizotomy were dysphagia and dysesthesia along the distribution of the glossopharyngeal nerve. SRS had promising results in pain reduction when using 75 Gy radiation or higher; however, long-term rates of pain relief were lower. MVD, rhizotomy, and SRS are effective methods to treat GPN as they help achieve instant pain relief and the decrease use of medication. Patients with MVD alone presented with less adverse effects than the group that underwent MVD plus rhizotomy. Although SRS may be a viable alternative treatment for GPN, further studies must be done to evaluate long-term treatment efficacy., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

To date, microvascular decompression (MVD) and botulinum therapy (BT) confirm own efficacy in the treatment of hemifacial spasm (HFS). Quality of life (QOL) suffers first of all in these patients. Therefore, the dynamics of QOL indicators determines postoperative outcomes. Various researchers have proposed specialized scales for assessing QoL in HPS patients (HFS-7, HFS-8, HFS-30)., Objective: To analyze QOL in patients with HPS before and after MVD and BT including HFS-7 score and regression of HFS., Material and Methods: We analyzed data of patients ( n =80) divided into two groups: group I - MVD of the facial nerve ( n =66), group II - BT ( n =14). Mean age of patients was 52.4 (range 28-76) and 58.1 years (range 23-73), respectively. QOL was assessed using a questionnaire enrolling clinical and anamnestic data, as well as HFS-7 scale. Clinical severity of HFS and effect on daily activity were assessed using the Tan scale. We analyzed the results of MVD and BT considering clinical improvement (regression of spasm) and HFS-7 score. A four-level gradation of clinical regression of spasm was used., Results: Patients with mild course of disease and higher QOL prefer BT. In our sample, 3 (21%) patients from the 2 nd group preferred surgery a year after BT, and 13 (20%) patients from the 1 st group had previously undergone BT in other hospitals. Changes in HFS-7 score before and after treatment were significant in both groups ( p <0.005, t -test). Spearman's coefficient (R= -0.66) shows the correlation between clinical effect and HFS-7 score., Conclusion: MVD and BT significantly improve QOL in patients suffering from HFS. Patients with less severe hemispasm prefer BT, but conversion to surgery is possible as disease progresses. Both treatment methods should be available for HFS patients. Treatment outcomes should be assessed using specialized scales designed for HFS.