Intraneural Vein during MVD: Management Strategies

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Most typically an artery or a vein comes in contact with the trigeminal nerve to cause trigeminal neuralgia. However, there are extremely rare situation where a vein or an artery can actually transect the body of the nerve, and create anterior and posterior fascicles of the nerve in relationship to the vessel. In this situation, the vessel is called an intraneural vein or an artery, and management of these vessels can be quite challenging as their mobilization is not straightforward and quite risky. Let's review the case of this 57 year old patient,, who presented with typical left sided V3 trigeminal neuralgia, and the MRI in this situation did not reveal any remarkable findings around the nerve. As you can see in this situation, there is an intraneural vein, transecting the nerve to anterior and posterior facties. And this vein is located along the anterior aspect of the brain stem. In this situation, I attempted gently to mobilize this vessel, but as you can see any significant manipulation of this vessel would be associated with significant handling and a potentially injury to the nerve and could cause post operative, disabling numbness and paresthesias. in this situation, I recommend performing a gentle rhizotomy and leaving the vessel on the brain stem as is, as you can see, a gentle rhizotomy using forceps was performed here and the vessel was left alone. These vessels can be very vital for the brainstem as they are located on the anterior aspect of the pons. Thank you.

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