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Preoperative demonstration of the neurovascular compression characteristics with special emphasis on the degree of compression, using high-resolution magnetic resonance imaging: a prospective study, with comparison to surgical findings, in 100 consecutive patients who underwent microvascular decompression for trigeminal neuralgia

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Abstract

Purpose

Surgical outcome after microvascular decompression (MVD) for primary trigeminal neuralgia (TN) has been demonstrated as being related to the characteristics of the neurovascular compression (NVC), especially to the degree of compression exerted on the root. Therefore, preoperative determination of the NVC features could be of great value to the neurosurgeon, for evaluation of conflicting nature, exact localization, direction and degree of compression. This study deals with the predictive value of MRI in detecting and assessing features of vascular compression in 100 consecutive patients who underwent MVD for TN.

Methods

The study included 100 consecutive patients with primary TN who were submitted to a preoperative 3D MRI 1.5 T with T2 high-resolution, TOF-MRA, and T1-Gadolinium. Image analysis was performed by an independent observer blinded to the operative findings and compared with surgical data.

Findings

In 88 cases, image analysis showed NVC features that coincided with surgical findings. There were no false-positive results. Among 12 patients that did not show NVC at image analysis, nine did not have NVC at intraoperative observation, resulting in three false-negative cases. MRI sensitivity was 96.7% (88/91) and specificity 100% (9/9). Image analysis correctly identified compressible vessel in 80 of the 91 cases and degree of compression in 77 of the 91 cases. Kappa-coefficient predicting degree of root compression was 0.746, 0.767, and 0.86, respectively, for Grades I (simple contact), II (distortion), and III (marked indentation; p < 0.01).

Conclusion

3D T2 high-resolution in combination with 3D TOF-MRA and 3D T1-Gadolinium proved to be reliable in detecting NVC and in predicting the degree of the root compression.

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Acknowledgment

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University of Lyon, Lyon, France

    Paulo Roberto Lacerda Leal & Marc Sindou

  2. Department of Neuroradiology, University of Lyon, Lyon, France

    Marc Hermier & Jean Claude Froment

  3. Department of Neurosurgery of the Faculty of Medicine of Sobral, Federal University of Ceara, Sobral, Brazil

    Paulo Roberto Lacerda Leal & Gerardo Cristino-Filho

  4. Department of Clinical Medicine of the Faculty of Medicine of Fortaleza, Federal University of Ceara, Fortaleza, Brazil

    Miguel Angelo Souza

  5. Service de Neurochirurgie A, Hôpital Neurologique Pierre Wertheimer, 59, Boulevard Pinel, 69003, Lyon, France

    Paulo Roberto Lacerda Leal

Authors
  1. Paulo Roberto Lacerda Leal
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  2. Marc Hermier
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Corresponding author

Correspondence to Paulo Roberto Lacerda Leal.

Additional information

This paper provides interesting and important prospective data on radiological viteria for evaluation and selection of patients for microvascular decompression. An important feature is that patients were selected according to clinical criteria: they had typical trigeminal neuralgia. The likelihood of a neurovascular conflict is very high in this group, hence the high specificity and sensitivity. It is necessary to remember, that the MRI demonstration of a neurovascular conflict in other groups of patients, such as normal controls or atypical facial pain patients, will probably have lower specificity.

A good clinical diagnosis remains of primary importance. The figures even suggest that exploration may be justified with negative MRI findings. A false-negative rate of 3/12 suggests that up to 25% of patients in this subgroup may benefit from surgery. Of course, this subgroup needs to receive appropriate information of the expected success rate.

Tilt Mathiesen

Sweden

This paper is very informative and presents results on imaging in patients with TN in a clear way. The authors should be aware of the fact that the results come from a very experienced surgeon. Moreover, the imaging and its analysis are related to a very dedicated specialist group that uses more than one advanced MR technique in combination.

It is clear from the (cited) literature that others have so far not been able to reach the high sensitivity and selectivity figures that are presented here. Such “own” results have to be taken into account when recommendations are made to use this imaging for decision making by other institutions. So, these results cannot be generalized since with a little lower sensitivity, much more patients would be denied the “causative surgery” which is offered by a proper decompression.

Even with the authors’ results, one should be aware that from the 12 “negative” images, three would have been denied surgery when the decision had been made on these: that is 25% of the negatives, meaning a negative predictive value of 75%, as stated by the authors. Also, these data give strong evidence (being the result of a prospective study) about the frequency of real vascular compression as a cause for TN in patients with typical complaints: 91%!

That might be enough to warrant surgery in all cases.

Another conclusion of the authors is that when the images convincingly prove “only contact,” they state that alternatives are to be offered, the result of MVD then being only 60%.

Such a far-reaching conclusion is challenging but should be put forward as a topic for another prospective study, including the analysis of cost effectiveness of all the treatment options proposed in these cases.

Jan Jakob Mooij,

Groningen, The Netherlands

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Leal, P.R.L., Hermier, M., Froment, J.C. et al. Preoperative demonstration of the neurovascular compression characteristics with special emphasis on the degree of compression, using high-resolution magnetic resonance imaging: a prospective study, with comparison to surgical findings, in 100 consecutive patients who underwent microvascular decompression for trigeminal neuralgia. Acta Neurochir 152, 817–825 (2010). https://doi.org/10.1007/s00701-009-0588-7

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