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Objective: Tumors may be responsible for up to 5% of trigeminal neuralgia cases. Predictors of long-term pain relief after surgical resection of various cerebellopontine angle tumor types are not well understood. Previous studies found that size and extent of resection predict long-term pain status, although resection of tumor involving the trigeminal ganglion may be associated with high morbidity. This study evaluated predictors of TN pain freedom after resection of a nonacoustic CPA tumor, with avoidance of any portion involving the TG., Methods: In a retrospective cohort study, we evaluated clinical outcomes and complications after surgical resection of nonacoustic CPA tumors with purposeful avoidance of the TG causing trigeminal neuralgia. The primary outcome was pain-freedom. We performed logistic regression analyses to examine the relationship between pain-freedom at last follow-up and age, side of symptoms, preoperative symptom duration, tumor diameter, tumor type, and concurrent neurovascular compression (NVC)., Results: Of 18 patients with nonacoustic CPA tumors causing TN treated with surgical resection, 83.3% were pain-free at last follow-up (mean 44.6 months). Age (P = 0.12), side (P = 0.41), preoperative symptom duration (P = 0.85), tumor diameter (P = 0.29), tumor type (P = 0.37), and NVC presence (P = 0.075) were not associated with long-term pain freedom., Conclusions: This study provides additional evidence that various tumor types causing TN may safely undergo surgical resection and decompression of the trigeminal nerve to treat TN. This study presents a cohort of patients that underwent resection of a nonacoustic CPA tumor, with purposeful avoidance of the TG to minimize complications, demonstrating high rates of long-term pain freedom., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The percutaneous balloon compression (PBC) is a safe and simple treatment for trigeminal neuralgia. It works by compressing the Gasserian ganglion to block pain signals from the trigeminal nerve. To ensure effectiveness, it is important to focus the compression on the lower part of the balloon., Objective: To validate the efficacy of a riveting technique, specifically pulling an inflated balloon, in order to apply enhanced compression on the ganglion., Methods: To compare this novel technique with the conventional approach, a retrospective investigation was conducted on consecutive PBCs performed in our department between 2019 and 2022. For postoperative outcome assessment, efficacy was defined as achieving a VAS score of 0 or an improvement exceeding 5 points. Postoperative numbness was graded as none, mild, or severe based on its impact on daily life and tolerance level., Results: Excluding cases with missed follow-up, a total of 179 participants were included in the study, and their follow-up period ranged up to 40 months. Postoperatively, symptomatic remission was achieved by 98.1% (52/53) of patients in the riveting technique group compared to 87.3% (110/126) in the conventional group (P<0.05). At the last follow-up period, with recurrence observed over time, the long-term efficacy of riveting and conventional groups were 94.3% and 74.6%, respectively (P<0.05). The majority of cases in both groups experienced ipsilateral facial numbness immediately following PBC, which appeared to diminish after 3 months in both groups without significant difference between them (P>0.05)., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The advantages and limitations of different craniotomy positions and approach trajectories to the gasserian ganglion (GG) and related structures using an anterior subtemporal approach have not been studied systematically. Knowledge of these features is of importance when planning keyhole anterior subtemporal (kAST) approaches to the GG to optimize access and minimize risks., Methods: Eight formalin-fixed heads were used bilaterally to assess temporal lobe retraction (TLR), trigeminal exposure, and relevant anatomical aspects of extra- and transdural classic anterior subtemporal (CLAST) approaches compared with slightly dorsally and ventrally allocated corridors., Results: TLR to the GG and foramen ovale was found to be lower via the CLAST approach (P < 0.001). Using the ventral variant, TLR to access the foramen rotundum was minimized (P < 0.001). The overall TLR was maximal using the dorsal variant (P < 0.001) owing to interposition of the arcuate eminence. An extradural CLAST approach required wide exposure of the greater petrosal nerve (GPN) and middle meningeal artery (MMA) sacrifice. Both maneuvers were spared using a transdural approach. Using CLAST, medial dissection >39 mm can enter the Parkinson triangle, jeopardizing the intracavernous internal carotid artery. The ventral variant enabled access to the anterior portion of the GG and foramen ovale without the need for MMA sacrifice or GPN dissection., Conclusions: The CLAST approach provides high versatility to approach the trigeminal plexus, minimizing TLR. However, an extradural approach jeopardizes the GPN and requires MMA sacrifice. The risk of cavernous sinus violation exists when progressing medially beyond 4 cm. The ventral variant has some advantages to access the ventral structures and avoid MMA and GPN manipulation. In contrast, the usefulness of the dorsal variant is rather limited owing to the greater TLR required., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The anatomy and spatial relationships of the dural sac comprising the Meckel cave (MC) and its ensheathed trigeminal ganglion (TG) are exceedingly intricate and complex. There are conflicting accounts in the literature regarding the dural configuration of the MC around the ganglion and the dual embryology of the MC and TG is still unclear., Methods: A combined systematic and narrative literature review was conducted to collate articles addressing MC and TG anatomy, in addition to their embryology, role in tumor spread, somatotopy, and association with trigeminal neuralgia., Results: Three key anatomic models by Paturet (1964), Lazorthes (1973), and Lang and Ferner (1983) have been put forward to show the arrangement of the MC around the TG. The TG is formed from both neural crest and placodal cells and drags the enveloping dura caudally to form the MC prolongation during development. Both a mediolateral and dorsoventral somatotopic arrangement of neurons exists in the TG, which corresponds to the 3 nerve divisions, of which V2 and V3 are prone to perineural tumor spread along their course., Conclusions: Sound knowledge concerning the dural arrangement of the MC and the trigeminal divisions will be invaluable in optimally treating cancers in this region, and understanding TG somatotopy will immensely improve treatment of trigeminal neuralgia in terms of specificity, efficacy, and positive patient outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To compare the advantages and disadvantages of V2 + V3 idiopathic trigeminal neuralgia using peripheral nerve radiofrequency (RF) thermocoagulation (PRF) via the foramen rotundum (FR) and foramen ovale (FO) with those of semilunar ganglion RF thermocoagulation (GRF) under local anesthesia, for exploring a new and available surgical method for patients with V2 + V3 idiopathic trigeminal neuralgia., Patients and Methods: 102 patients with V2 + V3 idiopathic trigeminal neuralgia were enrolled in this prospective randomized controlled clinical trial, and they were divided into the PRF and GRF group randomly (n = 51 in both groups). The outcome of pain relief was assessed using the Barrow Neurological Institute (BNI) pain score, and grouped as good (BNI Class I or II, no medication required) and bad (BNI Class III-V, medication required or failed). Recurrence was defined as a relapse to a previous lower level after attainment of any higher level of pain relief. The immediate effective rate, the 2-year postoperative effective rate, the 2-year postoperative recurrence rate, and the number of complications were observed and recorded., Results: Their basic conditions (age, gender ratio, side of pain, and disease duration) were similar. Furthermore, we found that the 2-year postoperative effective rate between them had no significant difference. By comparing the two groups, PRF group had the better immediate effective rate of the V2 branch and no severe complications such as corneal ulcer, however, GRF group had lower 2-year postoperative recurrence rate of the V3 branch and fewer facial swelling., Conclusion: The PRF surgery, like GRF, is another prospective treatment for V2 + V3 idiopathic trigeminal neuralgia by virtue of its excellent immediate effect, accurate positioning and high safety., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Persistent trigeminal artery (PTA) is the most common remnant of primitive circulation communicating the developing carotid and vertebrobasilar junction. Although discovered incidentally, an altered hemodynamic may lead to an increased association of aneurysms, vascular malformations, and stroke. Neurosurgeons should be aware of the presence and significance of PTA when interpreting imaging and planning interventions., Methods: We retrospectively reviewed all magnetic resonance angiography and cerebral digital subtraction angiography performed between 2012 and 2017 for the presence of PTA. The radiologic and anatomic details were noted and analyzed along with the clinical profiles. We categorized the radiologic findings with respect to the available classification systems. A review of the available literature was done comparing our results., Results: We found 33 cases of incidentally detected PTA. The average age of the patients was 45.42 years. The lateral surface of the proximal cavernous internal carotid artery was the most common origin (n = 23). Only 3 cases had a medial/transsellar course. Most cases were Saltzman/Weon type I (19/33). Intracranial aneurysms were associated with 6 patients (18.18%). Trigeminal neuralgia (TN) was a presenting feature in 5 patients. None had a direct neurovascular conflict at the root entry zone., Conclusions: Our study is one of the largest to describe the incidence of PTA. We emphasized the importance of PTA to the neurosurgeons; increased association of aneurysms, as a route for intervention in occlusive disease of the posterior fossa; risk of injury and bleeding during transsphenoidal surgery; and the association with TN. However, we found that only PTA variants are likely to be associated with TN because of their cisternal course causing NV conflict., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Renal cell carcinoma (RCC) accounts for ∼8% of all brain metastatic disease; however, spread to the cranial nerves and their ganglia is uncommon. To the best of our knowledge, we report the first case of RCC metastatic to Meckel's cave, which was diagnosed secondary to new trigeminal sensory loss., Methods: A 45-year-old man had presented with acute-onset right V3 numbness. Magnetic resonance imaging demonstrated contrast enhancement of the ipsilateral V3, extending from its root at the Gasserian ganglion to the foramen ovale., Results: He elected for observation, and his symptoms resolved over several weeks. At the scheduled, routine 3-month follow-up examination, he reported symptomatic relapse with new concomitant hyperesthetic/neuropathic pain. Magnetic resonance imaging demonstrated interval enlargement of the enhancing lesion in an atypical pattern, potentially consistent with trigeminal schwannoma versus meningioma, and operative resection was recommended., Conclusion: We have reported a case of RCC presenting with numbness via metastatic spread to Meckel's cave. Although uncommon, metastasis is an important diagnostic consideration for enhancing cranial nerve lesions. Our case has demonstrated that, although a history of malignancy, multiple lesions, or systemic/constitutional symptoms are typical, rare cases can demonstrate isolated central nervous system findings. Thus, short-term radiographic surveillance is indicated if the diagnosis of an intracranial or cranial nerve mass lesion is equivocal., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Trigeminal ganglion stimulation can be effective for trigeminal neuralgia. For patients who respond well to neurostimulation delivered percutaneously through the foramen ovale but require extensive revision and removal of instrumentation, a subtemporal approach for stimulation of the trigeminal ganglion is an alternative option as a salvage procedure., Case Description: We report on a 47-year-old woman who responded well to neurostimulation for trigeminal neuropathic pain over a 1-year period from 2008 to 2009. Her preoperative pain on the numerical rating scale (NRS) was between 7 and 8 out of 10, which decreased to 2 out of 10 postoperatively. However, she developed lead migration because of a motor vehicle accident. After revision surgeries to correct this, she continued to experience pain relief until 2011. At follow-up, signs of infection prompted removal of instrumentation and subsequent return of her pain. She continued to experience persistent and severe pain (NRS score 7 of 10), which was intractable to pharmacologic treatment over 5 years. She returned in 2016 to discuss neurosurgical options, and the original approach was ruled out because of her history of lead migration, erosion, and scarring. A subtemporal approach was pursued as a salvage option, which provided several advantages for this patient., Conclusions: The subtemporal approach for salvage placement of the trigeminal ganglion stimulating electrode was effective in this patient and minimized risks given her history of erosion and multiple operations. This suggests that the subtemporal approach is a viable salvage operation for trigeminal ganglion stimulation for trigeminal neuropathic pain., (Copyright © 2018. Published by Elsevier Inc.)

Background: Microvascular decompression (MVD) is an established surgical therapy for patients with idiopathic trigeminal neuralgia (TN). The role of MVD in patients with definite or suspected multiple sclerosis (MS) remains controversial., Methods: During the period 2000-2012, 10 patients with medically refractory TN and ipsilateral brainstem T2 hyperintensity underwent MVD. In 5 patients, additional clinical features suspicious for MS were present, including prior optic neuritis (n = 2), multiple disseminated lesions (n = 3), and elevated immunoglobulin G index (n = 2). One patient had failed prior percutaneous surgery; 1 patient had Burchiel type 2 TN. Follow-up (median, 14 months) was censored at the time of additional surgery (n = 6) or last clinic visit (n = 4)., Results: Neurovascular compression was confirmed at surgery from the superior cerebellar artery (SCA) plus adjacent vein (n = 4), vein alone (n = 3), SCA alone (n = 2), and SCA plus anterior inferior cerebellar artery (n = 1). Initially after MVD, 8 patients (80%) were pain-free and subsequently tapered off medications for their facial pain. Pain recurred in 6 patients at a median of 4 months (range, 1-23 months). Actuarial rates of being pain-free off medications were 50% at 3 months and 15% at 2 years. In 6 patients, additional treatments were performed, including glycerol rhizotomy (n = 4), radiosurgery (n = 2), balloon compression (n = 2), and repeat MVD (n = 1). At last contact, 5 of the 6 patients who were retreated were pain-free., Conclusions: Facial pain outcomes after MVD in patients with suspected MS-related TN are poor compared with outcomes for patients with idiopathic TN. This study provides further support that many patients with MS-related TN have pain that is centrally mediated, reducing the effectiveness of procedures performed on the trigeminal root, ganglion, or divisions., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The computerized freezing milling technique is derived from the virtual human project. It has been widely used in three-dimensional (3D) reconstruction of the human body and organs. With this technique, the study was undertaken to explore the 3D features and adjacent anatomic relationships of the sellar region for skull base surgery., Methods: Continuous thin sections on the coronary plane were performed with the computerized freezing milling technique using a human head specimen. The related structures were described in six sections. After segmenting, labeling, and extracting in serial sections, the 3D reconstruction of the sellar region was finished with Amira 4.1 software., Results: A total of 390 thin coronary sections were obtained. In six sections, the anatomic relationships of the pituitary gland, carotid artery, sphenoid sinus, and nerves are displayed. Three-dimensional images of the sellar region are video films that continuously and dynamically display anatomic structures in 3D space at different velocities. It can show that the cavernous segment of the internal carotid artery is located anterolateral to the sphenoid sinus and lateral to the pituitary gland. The optic nerve protrudes into the superolateral portion of the sphenoid sinus., Conclusions: The combination of coronary sectional anatomy and 3D reconstruction can display the anatomic characteristics of the sellar region. The 3D models are video films that continuously and dynamically display anatomic structures in 3D space at different velocities., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Idiopathic trigeminal neuralgia (ITN) is often treated with balloon compression, considered in the literature to be a safer and more efficient procedure than other surgeries, with a high success rate., Methods: This study evaluated 105 patients with idiopathic trigeminal neuralgia who underwent balloon compression of the trigeminal ganglion, with a follow-up of 210 days, and clinical questionnaires and a systematic physical evaluation used as instruments., Results: There was a significant decrease in the shock-like complaint (P < .001), although 66.3% still experienced pain after 7 days of surgery from other causes; 50.5% presented limitation during jaw activities. Other complaints were hearing, taste and/or smelling loss, and visual difficulties. One patient had a TMJ ankylosis and needed surgical TMJ treatment., Conclusions: Although neurosurgery in the treatment of severe ITN pain is known to provide relief and its importance is recognized, there may also be severe complications that could compromise habitual tasks to various degrees. Therefore, the patient needs to be alerted about all complaints that he or she might present after the procedure. The professional has a duty to correctly inform and alert every patient under his or her care.

This investigation evaluates the results of percutaneous trigeminal ganglion compression (PTGC) and compares them those for microvascular decompression (MVD) in treating trigeminal neuralgia. The authors report 127 cases of trigeminal neuralgia treated by PTGC and comparing the results with those of 114 patients whom underwent MVD from 1985 to 2000. The following parameters were compared: technical success, pain relief and recurrence, complications, perioperative morbidity, and perioperative mortality. PTGC and MVD initially had similar initial success rates. However, MVD had a higher rate of pain recurrence at the first 2 years follow-up, as well as higher rates of major complications and perioperative morbidity. Meanwhile, PTGC had higher rates of facial numbness, dysesthesia and minor complications.

A profusion of surgical approaches to gain access to the anterior and middle cranial fossa and skull base have been described. An attempt has been made to simplify the position by suggesting a classification of surgical approaches and to describe a standard approach (of at most 4 defined osteotomies, or at least 2) to give a craniofacial approach to the anterior and middle cranial fossae, the infratemporal fossa, the orbit and the superior nasal cavity. The full extent of the osteotomies have been likened to an ancient Corinthian face mask, or to the stylized face-mask worn by the comic book hero, Batman.

The lancinating facial pain of trigeminal neuralgia usually responds to medical treatment. However, in some patients, trigeminal neuralgia is refractory to drug therapy. In addition, some patients are unable to tolerate the side effects of medication. In these cases, several safe and effective surgical procedures are available for the treatment of this common facial pain syndrome.

A case of carotid-cavernous fistula following percutaneous trigeminal ganglion approach is presented. The case was treated by a combination of trapping and embolisation of the carotid artery. Percutaneous approach to the trigeminal ganglion via the foramen ovale was described by Taptas (1911) and Hartel (1914). Since then this procedure has been used in large series, for the injection of alcohol (Harris, 1940), electrocoagulation (Kirschner, 1942) or the injection hot water (Jeager, 1957) to the trigeminal ganglion for the treatment of trigeminal neuralgia. In 1965 White and Sweet used the percutaneous trigeminal ganglion approach for the radio-frequency (R.F.) thermocoagulation of the trigeminal ganglion. This procedure is a simple and safe method. It has been used in large series in the treatment of trigeminal neuralgia. In our department we have performed 252 R.F. thermocoagulation of the gasserion ganglion in 228 patients since 1975. In 252 interventions using the percutaneous trigeminal ganglion approach, via the foramen ovale, we observed only one carotid-cavernous fistula following the procedure. This is the second report in the literature of a carotid-cavernous fistula following the percutaneous trigeminal ganglion approach.