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Preoperative MRI/MRA for microvascular decompression in trigeminal neuralgia: consecutive series of 67 patients

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Abstract

Background

Microvascular decompression is an accepted treatment for primary trigeminal neuralgia. In recent years, efforts have been made to investigate the role of preoperative MRI/MRA in selecting patients with neurovascular compression.

Methods

Ninety-two consecutive patients underwent a standard retrosigmoid craniotomy for microvascular decompression between 2005 and 2009, of whom 67 had a preoperative MRI and MRA according to the protocol of our department. Operative findings were accurately recorded and compared to MRI/MRA results. Follow-up was in the form of telephone interview.

Results

Preoperative MRI sensitivity was 96%, while specificity was 75% (1 false positive among 4 patients with negative intra-operative findings). The predictive value of a positive MRI/MRA was 98%, while the predictive value of a negative MRI/MRA was 50%. Fifty-four patients were available for outcome assessment at a mean follow-up of 3.8 years (range 1–5). Seventy-two percent of patients were pain-free, 9.5% had mild residual pain, while 18.5% had a poor outcome (moderate to severe residual pain). The correlation between preoperative MRI/MRA and outcome was not statistically significant (P = 0.570).

Conclusions

Preoperative MRI has both good sensitivity and positive predictive value. Specificity and negative predicitve value were limited in this series. No correlation was found between preoperative imaging and outcome. Both radiological and clinical criteria are important for patient selection.

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Conflicts of interest

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Authors and Affiliations

  1. Department of Neurosurgery, Royal Victoria Infirmary, Queen Victoria road, Newcastle Upon Tyne, UK

    Francesco Vergani, Prokopios Panaretos, Alvin Penalosa, Claire Nicholson & Alistair Jenkins

  2. Neuroradiology, Regional Neurosciences Centre, Royal Victoria Infirmary, Newcastle Upon Tyne, UK

    Philip English

Authors
  1. Francesco Vergani
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  2. Prokopios Panaretos
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  3. Alvin Penalosa
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  4. Philip English
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  5. Claire Nicholson
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  6. Alistair Jenkins
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Corresponding author

Correspondence to Francesco Vergani.

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Comment

The authors confirm the usefulness to complement standard MRI with 3D-T2 high-resolution and 3D-TOF-Angio sequences to predict vascular compression at origin of the primary trigeminal neuralgia, and therefore indicate Micro-Vascular Decompression (MVD).

We would like to advise to add a third high-resolution sequence to the two previously advocated, namely a 3D-T1 sequence with gadolinium, in order to detect venous compression. As a matter of fact 3D-TOF Angio only shows high velocity vessels, i.e., arteties. Indeed there are cases with a compressive vein as the sole responsible conflict (5.5% in our series) or in addition to arterial compression (22.1% in our series) (M. Sindou, T. Howeidy and G. Acevedo - Anatomical observations during microvascular decompression for idiopathic trigeminal neuralgia. Prospective study in a series of 579 patients. Acta Neurochir 2002, 144 : 1-13). A number of failures of MVD are likely to be due to surgical decompression that misses vein(s).

The most frequent compressive vein is the transverse, inferior, pontine vein, which is generally located at the exit of the trigeminal root from porus of Meckel Cave. This vein may be the sole compressive vessel, where the root is crossing over the upper petrous ridge especially in sagging brains. Transverse inferior pontine vein may also be compressive in association with an arterial conflict, especially when an elongated superior cerebellar artery lies on the superior surface of the root, exerting there pulsations and a pushing-down effect. In both eventualities, the trigeminal root at the site of compression has a marked engrooving with a greyish focal zone of demyelination. Such venous conflict can be found, and the root dissected free from an adhesive thickened arachnoid, only if craniotomy and surgical trajectory have been designed in such a way to allow reaching easily the exit part of the root from Meckel Cave. Predicting venous decompression is of practical importance.

Marc Sindou

Lyon, France

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Vergani, F., Panaretos, P., Penalosa, A. et al. Preoperative MRI/MRA for microvascular decompression in trigeminal neuralgia: consecutive series of 67 patients. Acta Neurochir 153, 2377–2382 (2011). https://doi.org/10.1007/s00701-011-1135-x

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  • DOI: https://doi.org/10.1007/s00701-011-1135-x

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