August 17, 2016
Here's another video discussing technical nuances for handling tortuous offending arterial loops causing Trigeminal neuralgia. This is a 63-year-old female with right-sided, medically-refractory trigeminal neuralgia. MRI evaluation reveals evidence of a vascular loop along the axilla of the nerve. The nerve is somewhat displaced more laterally. Where the loop is really embedded so much into the axilla the mobilization of the artery can be quite challenging. And let's go ahead and review the intraoperative events in this case. Right-sided Retromastoid craniotomy was completed. Here is the superior petrosal sinus tentorium dura over the petrous bone trigeminal nerve. You can see the artery is very much again embedded in the axilla of the nerve. Gentle mobilization of both the nerve and the artery are required. You can see counter-traction on the nerve while the dissector mobilizes the artery out of the axilla of the nerve itself. The artery is again gently mobilized through repetitive movements. This is a very redundant loop, which makes its mobilization quite difficult. There are a number of arachnoid adhesions that tether the artery down. You can see the superior cerebellar artery bifurcates, just one branch more proximal that divides just about here. Here's the parent branch, the two daughter branches. Now that the artery has been mobilized before we implant the Teflon, I went ahead and used a parent soak gelfoam to relieve the spasm in the arteries. The arteries generously mobilized away from the nerve. Any other secondary offending vessels are excluded both above and below the nerve. Small pieces of shredded Teflon are used to mobilize the artery away from the nerve. One has to remember that the use of the small pieces of Teflon would alow a nice modeling of the implant in order to separate the nerve from the artery. Again, these implants are gently mobilized along the distal aspect of the nerve. The nerve has to be relatively in a normal physiological posture. Therefore, the implants are fashioned and the nerve is gently mobilized superiorly so that the nerve is not deflected in fairly, after finalizing the morphology of the implant. I'm happy with the position of these two pieces of implant along the cisternal segment of the nerve. I'm going to use another piece of shredded Teflon to mobilize the offending vessel away from the root entry zone of the nerve. You can see the nerve is in relatively good physiological posture. Overuse of the implant should be avoided. The artery should not be kinked as it may lead to compromise flow within its lumen. And here's a final view of the nerve as well as the implant and the opening. And this patient's pain was relieved after surgery. Thank you.
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