August 17, 2016
Let's talk about management of undesirable, intraoperative events, during MVD for trigeminal neuralgia, including managing cerebellar swelling. This is a 52 year old female with left-sided, trigeminal neuralgia. MI evaluation revealed some displacement of the nerve on the left side, more laterally, most likely due to an arterial offending vessel. Left-sided craniotomy, retromastoid craniotomy completed, sigmoid sinus transfer sinus. The brain appeared somewhat tense from the beginning, although a lumbar puncture was completed during the initial part of the operation. Ultimately, the cerebellopontine angle was interred and CSF was released and the cerebellum appeared more relaxed. There was a vein on the inferior edge of the nerve. I did not feel the vein was the offending vessel. Therefore I diverted my attention to the more superior and the shoulder of the nerve where the real offending vessel just underneath the motor root was noted. Here, you can see the vascular loop. The thick like bands were opened. Here's the loop. As I was continuing microsurgery without the use of retractors, the brain became more and more swollen. The superior petrosal vein was not sacrificed and remained patent. You can see the tense condition of the cerebellum. This point I stopped any further dissection, relieved pressure on the cerebellum, ask the anesthesiologist for a dose of mannitol and also asked the anesthesiologist to inspect the endotracheal tube for patency. Adequate ventilation was confirmed, since the brain did not appear too tense, I felt that I can proceed with the use of a retractor to displace their cerebellum gently and efficiently continue with microsurgery. The offending vascular loop was mobilized away from the axilla of the trigeminal nerve. Shattered pieces of Teflon were used to mobilize the artery away from the nerve and its root entry zone. Here's another view of operative corridor. At the end of the operation, the cerebellum appeared relaxed. Postoperative CT scan revealed the location of the implant. No evidence of cerebellar injury was noted, and this patient made an excellent recovery and her pain disappeared after surgery. Again, during unexpected brain or cerebellar swelling, it's important to exclude any root causes of brain swelling, including inadequate ventilation, as well as using drugs would be helpful in terms of relieving brain tension such as mannitol. Thank you.
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