Dolichoectatic Basilar artery and Trigeminal Neuralgia

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Let's talk about unusual cases of vascular compression causing refractory trigeminal neuralgia. More specifically, a giant dolichoectatic basilar artery, which may cause severe pain syndrome. I'm gonna use the case of this elderly gentleman, who underwent, a number of procedures previously, including two percutaneous procedures, and unfortunately his pain remained refractory. Axial T2 MRI demonstrates this very dolichoectatic basil artery, causing significant compression and vascular conflict. As you can see here, tenting up the trigeminal nerve superiorly. Due to a limited available options. I proceeded with microvascular decompression, knowing that mobilization of this highly calcified basil artery is almost impossible, and also very dangerous. Let's go ahead and share the interoperative findings in this case. A right-sided retromastoid craniotomy was completed. You can see the seven and eighth cranial nerve, at the tip of the arrow, very much mobilized superiorly. And, the fifth cranial nerve is actually mobilized to the level of the tentorium. So here is the tentorium, petrous bone, the very calcified dolichoectatic basilar artery and against seven and eighth cranial nerve. And I will try momentarily to mobilize, the artery inferiorly, which is very difficult to do. And now you can appreciate the trigeminal nerve at the tip of the arrow. Since really decompression and mobilization of the artery is impossible. I proceeded with a gentle massage of the vessel to cause it, rhizotomy and then placed thread of teflon as much as possible. This gentle rhizotomy was very effective, and he has been pain free for the past three years since this procedure. We, again warn against aggressive mobilization of this artery due to risk of embolization within the vessel. Thank you.

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