WELCOME 1

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MICROVASCULAR DECOMPRESSION
IN TRIGEMINAL NEURALGIA :
SURGICAL OUTCOME
Dr. Sanjoy Kumar Saha

Indoor Medical Officer,

Clinical Neurosurgery, BLUE Unit
National Institute of Neurosciences &
Hospital.
OUR TEAM
 Dr. Md. Moklasur Rahman Mukul

Associate Professor & Unit chief

 Dr. Md. Rustom Ali

Assistant Professor
 Dr. Sanjoy Kumar Saha

IMO & FCPS Trainee in Neurosurgery

 Dr. Mesbah Uddin Ahmed

IMO & FCPS Trainee in Neurosurgery

 Dr. Ayatul Amin

IMO & Phasse –B Resident 5

INTRODUCTION

Trigeminal neuralgia (TN) is a chronic pain disorder,

characterized by paroxysms of severe, lancinating pain
in the distribution of the trigeminal nerve. Most
commonly, the second and third branches of the
trigeminal nerve are affected.

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The estimated annual incidence of TN is 27 per
100,000 person years, with peak incidence
between the ages of 50 and 60.2 The vast
majority of TN cases are due to microvascular
compression of the root entry zone of the
trigeminal nerve by vascular structures .

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Microvascular decompression (MVD) is considered
as the definitive treatment modality for vascular
compression on cranial nerves. The usual site of
vascular compression is at the root entry zone.

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 Endoscope-assisted microsurgery in the
cerebellopontine angle especially in MVD where
it resulted in the identification of the entire
course of the cranial nerve and avoidance of any
missing vascular structure.

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The endoscope is useful in minimizing the
cerebellar retraction compared with the
microscope. It enables wider areas of exploration
especially behind bony ridges. With the
endoscope, a true close up view and better
identification of the course of the vessel can be
achieved.
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OBJECTIVES

The aim of this paper is to report the

outcomes of patients treated with microvascular
decompression in a neurosurgical unit at
National Institute of Neurosciences & Hospital,
Dhaka, Bangladesh

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OBJECTIVES

Here, we also concentrated on our

procedure associated per-operative & post-
operative challenges with their managements.

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MATERIALS & METHOD

Patient population :

This study was retrospectively conducted on 33

patients in the department of clinical
neurosurgery in the period from November 2017
to August 2021.

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Among these patients, endoscope assisted MVD
done in 25 cases, where 8 cases were done under
microscope.

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PATIENT DEMOGRAPHY

Age (years) Min- Max 31-60

Average 45 ±2.43
Gender Female 18
Male 15
Pain Distribution V1 2
V2 7
V3 4
VI,V2 5
V1,V2,V3 2
V2,V3 13
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All the patients were evaluated their pain pre and
post-operatively by using Barrow Neurological
Institute pain score chart.

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Inclusion Criteria:
1. Patients unable to achieve adequate medical
control of trigeminal neuralgia with
medications ≥ 5 yrs, without significant
medical or surgical risk factors.

2. 2. The patients who do not fit the above

criteria, but have intractable pain and failed
other options except MVD.
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Exclusion Criteria:

Patients who have symptoms secondary to

neoplasms or multiple sclerosis and hemifacial
spasm were excluded.

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IMAGING

Pre-operative brain MRI was requested, focusing

on (FIESTA) “fast imaging employing steady
state acquisition” to demonstrate vascular
compression on fifth cranial nerves.

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MRI OF BRAIN WITH FIESTA PROTOCOL

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PROCEDURE:

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Through the microscope, it was difficult to
explore the trigeminal root entry zone without
addition of about 3–5 mm cerebellar retraction
and re-orientation of the microscope more
medially.

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POST-OPERATIVE CARE AND
FOLLOW-UP

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RESULT

During a 44-months of period, 33 patients underwent

MVD for TN. All patients were operated on by the
senior author. The patients included 18 females and 15
males, with a mean age of 45 years (range 31-60).

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The mean time from first neurosurgical clinic review
and operation was 12 months (range 60-763 days).20
of the patients had medical therapy alone prior to
microvascular decompression; 13 patients had
history of repeated visit to dentist and history of
teeth extraction of 8 patients.

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All of the patients had a vascular loop identified
on pre-operative MRI. There was an average
follow up of 8 months. A Barrow Neurological
Institute pain score was calculated for all patients.
Pre-operatively six (19%) patients had a score of
5, twenty-seven (81%) had a score of 4.

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Postoperatively, Nine patients(24%) had a score
of 4, five (16%) had a score of 3 and nineteen
patients (60%) had a score of 1. A post-operative
Barrow score of ≤3 was considered a satisfactory
outcome.

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Patient with neuralgia involving the opthalmic
division of trigeminal nerve had better outcome
than those without v1 involvement .

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OPERATIVE DATA OF PATIENTS
WITH TN
All patients

Timing till surgery Min -Max 1-6

Median 3
Compressing vessels SCA 27
AICA 2
Venous 3
Arachnoid band 1
Role of Endoscope Assisting microscope 08
Main role 25

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Complications Number(%)

Death 0

Facial palsy 2

Hearing Loss 0

CSF Leak 3

Minor Wound Infection 3

Haematoma 0

Contralateral pain 0
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LIMITATIONS

The limitations of this study are the small sample

size, the retrospective nature of the study and the
relatively short follow-up period.

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CONCLUSION:

Microvascular decompression is an effective

treatment for TN refractory to medical
management.

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Cerebellar retraction in less than a pure
microscopic intervention. Complications are
minimal, view is exceptionally panoramic and
focally in depth.

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Therefore, the endoscope can see what the
microscope cannot see; that's why, avoidance of
missing vascular compression and optimum
outcome can be assured.

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CASE 1

 37 years old male presented with left sided

severe facial pain not responding by
medications and thoroughly evaluated and
decided for Endoscopic assisted MVD

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 MRI OF BRAIN WITH MULTIPLE
AXIAL,CORONAL AND SAGGITAL VIEW

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 MRI OF BRAIN WITH MULTIPLE
AXIAL,CORONAL AND SAGGITAL VIEW

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POST OP CT
 The patient improved significantly in
immediate post operative period & discharged on 5 th
POD .
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THANK YOU

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