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Electrical neurocoagulation may be effective for intractable trigeminal neuralgia caused by vertebrobasilar dolichoectasia

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Authors and Affiliations

  1. Department of Neurosurgery, Asakadai Central General Hospital, Asaka, Saitama, Japan

    Akira Ishii, Yuichi Kubota, Saori Okamoto, Go Matsuoka & Seiji Yato

  2. Department of Neurosurgery, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan

    Akira Ishii, Yuichi Kubota, Saori Okamoto, Go Matsuoka & Yoshikazu Okada

  3. Department of Neurosurgery, Moriyama Memorial Hospital, Edogawa, Japan

    Tomokatsu Hori

Authors
  1. Akira Ishii
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  2. Yuichi Kubota
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  3. Saori Okamoto
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  4. Go Matsuoka
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  5. Seiji Yato
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  6. Tomokatsu Hori
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  7. Yoshikazu Okada
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Corresponding author

Correspondence to Akira Ishii.

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Comments

Isao Date, Okayama, Japan

Trigeminal neuralgia is often caused by a compression of trigeminal nerve with superior cerebellar artery. In most of the cases, transposition of the offending artery from the root entry zone can be done without major difficulty. However, we sometimes encounter a case in which sclerotic vertebrobasilar artery is the cause and in that situation it is not easy to perform transposition of the offending artery. In this case report, Ishii et al. performed electrical neurocoagulation of the trigeminal nerve for intractable trigeminal neuralgia caused by vertebrobasilar dolichoectasia. The trigeminal neuralgia disappeared without any permanent complication. As the intraoperative photo and schematic drawing show, coagulation was performed in the restricted region of the trigeminal nerve where compression was most severe. This technique is a good reference when we encounter a similar case of trigeminal neuralgia. Although the patient did not complain any hypesthesia after operation in the present case, we may have to be ready for the postoperative sensory disturbance in the affected area in a similar case. Also, long-term follow-up is required because at least the area around the coagulated site continues to be compressed by the artery.

Nasser M. F. El-Ghandour, Cairo, Egypt

In their current manuscript, Ishii et al. report an interesting case of a 77-year-old gentleman with left-sided trigeminal neuralgia of 9 months duration, attributed to vertebrobasilar dolichoectasia (VBD). A 600-mg daily dose of carbamazepine was given without any response, the pain was severe, progressive, and the patient was unable to eat, he developed anorexia and dehydration. Microsurgical exploration through a lateral suboccipital craniotomy revealed indentation of the ventrocaudal aspect of the trigeminal nerve by the outlet of the left superior cerebellar artery and the ectatic vertebrobasilar artery (VBA). Electrocoagulation of the compressed portion of the trigeminal nerve was done. The patient developed transient diplopia due to direct manipulation of the abducent nerve. Complete resolution of pain was encountered immediately postoperatively and all through the short-term follow-up (18 months). Case reports on the surgical treatment of trigeminal neuralgia and/or hemifacial spasm caused by VBD are welcome. This article is no exception. Unlike other previously reported cases, no effort was made to redirect the course of the ectatic VBA using vascular tapes, synthetic vascular grafts, flexible silicone slings, fenestrated aneurysm clips, or titanium bone fixation plates and screws. Intraoperatively, the ectatic VBA was calcified, firm and immobile; consequently, the authors did not try any mobilization or transposition. Electrical neurocoagulation of the compressed portion of the trigeminal nerve was performed with the bipolar forceps for few seconds intermittently. The authors mentioned that transposition of the VBD is mechanically difficult and hazardous. I totally agree, I never try to mobilize or redirect the ectatic VBA in these cases [1]. Such mobilization can be intimidating and frequently lengthier than a traditional approach. It is extremely difficult because of the tremendous tortuousity, hypertrophy, and sclerosis of the basilar artery [4], and it requires extensive neurovascular manipulation [3]. This extensive manipulation can induce vasospasm of small arteries with consequent brain stem ischemia [5], and can lead to brain stem infarction from damage of perforators or due to changes of blood flow and thrombus formation in the ectatic atherosclerotic VBA [2]. Mobilizing such a big artery can also result in new postoperative neurological deficits due to mechanical compression of other cranial nerves (fourth, sixth, or eighth nerves) by the VBA in its newly created anatomical course. Moreover, mobilization of the ectatic VBA does not improve the significant mechanical distortion of the trigeminal nerve in all the cases [3]. The authors’ experience is valuable; however, this method of treatment has a significant drawback, which is the absence of objective monitoring of the electrical neurocoagulation process including the bipolar intensity, frequency, and coagulation time. They used a 5-watt intensity, 350 Hz frequency, and 5 s intermittent coagulation time. It is not clear on what basis did they use and recommend such parameters. Another drawback of the current study is the short duration of follow-up (18 months). It is not uncommon to encounter pain recurrence among the long-term follow-up in these cases. Although no permanent complications were encountered in this patient, the procedure is risky with no guarantee of long-term pain relief. I still believe that microvascular decompression would be the procedure of choice in the treatment of trigeminal neuralgia caused by VBD. Simply, by separating the trigeminal nerve from the ectatic VBA using a Teflon-coated felt without attempting any macrovascular mobilization, long-lasting postoperative pain relief without any medication could be achieved. Our results in treating these patients suggest that relief of pulsatile compression is more significant than relief of mechanical distortion in ensuring an excellent clinical outcome [1].

References

1. El-Ghandour NM (2010) Microvascular decompression in the treatment of trigeminal neuralgia caused by vertebrobasilar ectasia. Neurosurgery 67: 330–337

2. Hanakita J, Kondo A (1988) Serious complications of microvascular decompression operations for trigeminal neuralgia and hemifacial spasm. Neurosurgery 22: 348–352

3. Linskey ME, Jho HD, Jannetta PJ (1994) Microvascular decompression for trigeminal neuralgia caused by vertebrobasilar compression. J Neurosurg 81: 1–9

4. Miyazaki S, Fukushima T, Tamagawa T, Morita A (1987) Trigeminal neuralgia due to compression of the trigeminal root by a basilar artery trunk: report of 45 cases. Neurol Med Chir (Tokyo) 27:742–748

5. Sindou M, Leston J, Decullier E, Chapuis F (2007) Microvascular decompression for primary trigeminal neuralgia: long-term effectiveness and prognostic factors in a series of 362 consecutive patients with clear-cut neurovascular conflicts who underwent pure decompression. J Neurosurg 107:1144–1153

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Ishii, A., Kubota, Y., Okamoto, S. et al. Electrical neurocoagulation may be effective for intractable trigeminal neuralgia caused by vertebrobasilar dolichoectasia. Neurosurg Rev 36, 657–660 (2013). https://doi.org/10.1007/s10143-013-0454-1

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