MVD for Trigeminal Neuralgia: Challenging Arterial Loops

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Mobilizing the redundant long vascular loops along the medial aspect of the nerve can be quite challenging. This video describes some of the techniques for handling such offending vessels. This is a 62 year old female who presented with medical refractory left sided trigeminal neuralgia. MRI evaluation reveals the trigeminal nerve to be bawling out. There is evidence of a vascular loop just along the axilla of the nerve. You can see the deformity of the left tregeminal nerve more clearly here. This configuration usually signifies a redundant large vascular loop along the exit of the nerve pushing the nerve latterly. Mobilization of such offending vessels is quite challenging. Let's go ahead and view the interoperative events. Left sided at from asteroid craniotomy sigmoid sinus, transfer sinus. The dural is opened in a curvilinear fashion parallel to the dural sinuses. Here's the initial exposure. Rubber dam is used to go around the cerebellum, tentorium Petrus Dura, Dandy's vain or superior petrosal sinus. Arachnoid bands are opened and CSF is released. Micro scissors are used to open the superficial fake arachnoids bands. Here you can see the ascending loop and descending loop more posteriorly. The loop is quite long, extends for inferior toward the lower edge of the nerve. One has to exercise patience and gently tease off and mobilize the offending loop more superiorly. Dynamic refraction is used as superior petrosal vein was preserved. Here you can see the gentle mobilization of the artery. You can see both the nerve and the artery are manipulated. You can see the loop of their artery is now mobilized away from the axilla. It often returns to its normal position until it is moved to the posterior aspect of the nerve. Here you can see two of the arteries the branches of the superior cerebellar artery that make up the offending vessel. To mobilize the artery further the more medial arachnoid bands are dissected. Usually there is one branch that divides to two just close to the cisternal segment of the nerve. Further inspection reveals no obvious offending vessel. You can see some discoloration at the level of the axilla and the shoulder of the nerve by the offending vessel. The nerve should be circumferentially inspected for secondary offending vessels, more inferiorally. One sees the seven and eighth cranial nerve complex no offending vessel was found there. Small pieces of shredded Teflon implant are used to mobilize the offending vessel permanently away from the nerve along its entire segment. In other words, it's nerve root entry zone as well as its cisternal segment. It's very important that artery is not kinked because of the small space in the area and the long redundant length of the artery. Over use of Teflon should be minimized to decrease the risk of Teflon granuloma. This case smaller piece of Teflon was inserted to cover the entire cisternal segment as well as the entry zone of the nerve at the level of the brain stem. You see that I'm inspecting the artery making sure it's not kinked. So the flow within the artery is not compromised. Micro Doppler ultrasound is used to confirm adequate flow within the offending vessel. Multi magnified view of our operative corridor. All the cerebrovascular structures were protected and plumonary irrigation is used to make sure that the implant is not displaced with the flow of CSF. And here's the postoperative CT scan which demonstrates desirable result. The implant may show up on the postoperative CT. This patient made an extra recovery and the pain disappeared. Thank you.

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