Trigeminal Neuralgia due to Vertebrobasilar Artery Compression

OBJECTIVE: Classical trigeminal neuralgia (cTN) is rarely caused by ectatic vertebrobasilar artery compression of the trigeminal nerve. These patients present a surgical challenge and often are not considered for microvascular decompression (MVD) due to assumed risk. METHODS: A review of patients who were surgically treated by the senior author between 1997 and 2016 with an admitting diagnosis of cTN was performed. Details of the surgery were documented, including the technique for maintaining vascular decompression, complications, and the length of stay. Clinical follow-up was obtained from patient charts as well as telephone questionnaires. RESULTS: During the 20-year review, 552 patients underwent MVD for cTN, and 13 (2.4%) had dolichoectatic vertebrobasilar compressions (10 male, 3 female). The average hospital length of stay was 2.8 days (range 2-7) with no major complications. At final follow-up (> 2 years), 7 had no pain with nomedications (78%), 2 had persistent pain (22%)-1 of whom underwent a successful glycerol rhizotomy at 8 months-2 were lost to follow-up, and 2 had surgery within 2 years. CONCLUSIONS: Patients with cTN due to a dolichoectatic vertebrobasilar artery compression present a unique surgical challenge. Mobilizing the vessel can be difficult because it may be firm from atherosclerosis, maintaining its separation from the nerve is similarly difficult, and manipulating the vessel can be dangerous because of its brainstem perforators. Our case series provides some evidence to support the safety and efficacy of MVD for patients with vertebrobasilar ectasia for those that major surgery is not contraindicated.