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Microvascular Decompression for Trigeminal Neuralgia Using a Novel Fenestrated Clip and Tentorial Flap Technique
Accepted Manuscript Microvascular decompression for trigeminal neuralgia using a novel fenestrated clip and tentorial flap technique. Lain Hermes Gonzalez-Quarante, MD, Fernando Ruiz-Juretschke, PhD, Vijay Agarwal, MD, Roberto Garcia-Leal, MD PII:
S1878-8750(17)31210-X
DOI:
10.1016/j.wneu.2017.07.110
Reference:
WNEU 6172
To appear in:
World Neurosurgery
Received Date: 23 March 2017 Revised Date:
17 July 2017
Accepted Date: 18 July 2017
Please cite this article as: Gonzalez-Quarante LH, Ruiz-Juretschke F, Agarwal V, Garcia-Leal R, Microvascular decompression for trigeminal neuralgia using a novel fenestrated clip and tentorial flap technique., World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.07.110. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Microvascular decompression for trigeminal neuralgia using a novel fenestrated clip and
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tentorial flap technique.
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Lain Hermes Gonzalez-Quarante, MD1, 2; Fernando Ruiz-Juretschke, PhD2; Vijay Agarwal,
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MD3; Roberto Garcia-Leal, MD2
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Department of Neurosurgery, Hospital Universitario HM Sanchinarro. Madrid (Spain)
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Department of Neurosurgery, Hospital General Universitario Gregorio Marañón. Madrid
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(Spain)
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Previous presentation(s):
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Department of Neurosurgery, Mayo Clinic. Rochester (MN).
The content of this article has not been presented in any congress before the submission of this
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manuscript.
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Disclosures:
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The authors have no personal financial or institutional interest in any of the drugs, materials, or
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devices described in this article.
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Corresponding author contact information:
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Lain Hermes Gonzalez-Quarante, M.D Department of Neurosurgery Hospital Universitario HM Sanchinarro Calle Oña, 10. C.P 28050. Madrid (SPAIN) E-mail address: [email protected]
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KEYWORDS:
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Cranial nerves. Microvascular Decompression Surgery. Retrosigmoid approach. Surgical clip.
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Transposition. Trigeminal neuralgia.
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ABBREVIATIONS:
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MVD= Microvascular Decompression; SCA= Superior Cerebellar Artery; AICA= Anterior
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inferior cerebellar artery; MRI= Magnetic Resonance Imaging; REZ= Root Entry Zone; CSF=
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Cerebrospinal fluid; SPV= Superior Petrosal Vein; RVLM= Rostral Ventrolateral Medulla.
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ABSTRACT:
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BACKGROUND: Microvascular decompression (MVD) for neurovascular compression
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syndromes such as trigeminal neuralgia and hemifacial spasm has been traditionally described as
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an interposing technique using Teflon. Some alternative interposing materials have been
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proposed. Additionally, transposing techniques have been increasingly reported in recent years,
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as an alternative that may have a lower recurrence rate and fewer complications.
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OBJECTIVE: To describe our experience utilizing a technique consisting of transposition of the
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superior cerebellar artery using a fenestrated clip and a tentorial flap in patients with trigeminal
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neuralgia.
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METHODS: We describe a novel transposing technique using a fenestrated clip and a tentorial
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flap in patients with neurovascular compression. An illustrative case is provided of an 83-year-
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old female patient who complained of a 4-year history of left trigeminal neuralgia due to
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compression by the superior cerebellar artery who was treated with this technique. Furthermore,
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a thorough review of the literature is presented.
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RESULTS: The patient underwent the procedure with the proposed technique without
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complication. Both the surgery, and the postoperative course, were uneventful and the patient
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remains asymptomatic 1 year after the procedure.
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CONCLUSION: We propose a novel technique for the treatment of trigeminal neuralgia
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eliminating the need for padding the vessel with a foreign body. This technique can successfully
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be applied in selected cases of neurovascular compression syndromes.
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INTRODUCTION:
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Since its popularization by Peter Joseph Jannetta, microvascular decompression (MVD) surgery
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has become a well-known and accepted treatment for trigeminal neuralgia.1, 2 Despite the
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development of alternative, less aggressive surgical interventions such as percutaneous balloon
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microcompression, rhizotomies and stereotactic radiosurgery, MVD surgery has been proven to
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provide the highest rate of long-term patient satisfaction with the lowest rate of pain recurrence.3-
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the compressive etiology of idiopathic trigeminal neuralgia. Several variations and modifications
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of the original technique by Jannetta have been published. The aim of these techniques is to: 1)
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separate the culprit vessel from the vulnerable nerve and 2) to maintain this separation in order to
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avoid recurrence. As this pathology is often encountered, neurosurgeons should be acquainted
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with various interposing materials and techniques that can be complemented by sling, retraction
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or repositioning materials and techniques. A cornucopia of different materials have been
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proposed as “separators” in interposing procedures, from autologous tissue such as muscle7-9 and
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arachnoid membrane10 or tentorium11 to artificial or foreign materials ranging from Teflon to
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cotton pads12, Gelfoam13, surgical glue14, radiopaque sponge15, and Sundt clips16. Alternatively,
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various “slings” and repositioning procedures have also been reported; from a simple prolene or
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stitching technique to a sophisticated titanium bone fixation plate.17, 18 However, aside from
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stitched slings, the most commonly used materials are aneurysm clips and vascular surgery
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materials.16, 19-23 In the technique that we describe here, a fenestrated clip attached to a tentorial
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flap, in a stitch-less fashion with the culprit vessel passing through the clip fenestration.
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Additionally, we performed a thorough literature review of the alternative transposing techniques
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and interposed materials that have been previously reported.
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The most reasonable explanation for this higher success rate is that MVD surgery directly treats
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METHODS. ILLUSTRATIVE CASE AND SURGICAL PROCEDURE.
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CLINICAL PRESENTATION
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An 83-year-old female presented with a 4-year-history of lancinating and intense left hemifacial
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pain. The pain was intermittent and refractory to various regimens prescribed by neurologists
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such as pregabalin, baclofen, eslicarbazepine, amitriptyline and over-the-counter analgesics.
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Three-dimensional high-resolution MRI sequences (DRIVE, 1.5T Achieva, Philips Medical
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Systems, NL) revealed a vascular compression of the left trigeminal nerve by a vascular loop that
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appeared to be a branch of the superior cerebellar artery (SCA). The nerve was compressed at its
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superior aspect, near the root entry zone (REZ) (Figure 1).
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Given the clinical data consistent with trigeminal neuralgia Burchiel type I, the lack of response
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to medical treatment and the imaging findings, microvascular decompression of the left
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trigeminal nerve was proposed and scheduled. Informed consent was signed by the patient prior
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to undergoing surgery.
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SURGICAL INTERVENTION
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The patient was placed under general anesthesia in a park-bench position (See intraoperative
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video). We usually perform the microvascular decompression via a retrosigmoid approach, using
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a retroauricular curvilinear incision designed and adjusted depending on superficial landmarks,
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as described previously. 24 . A multilayer subcutaneous dissection is then carefully performed.
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Once the bone is exposed, and after identifying important bony landmarks such as the asterion
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and digastric groove, a 2 cm craniectomy is made just inferior to the transversve-sigmoid sinus
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junction. The dura is reflected towards the sinus junction.
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The cerebellopontine cistern is decompressed, and the the patient’s position is adjusted, to avoid
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retraction on the cerebellum. The cerebellar flocculus is identified along with the complex
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formed by cranial nerves VII, VIII, anterior inferior cerebellar artery (AICA) and the subarcuate
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artery. These are gently dissected and separated. The next step, which is of paramount
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importance, is to identify and recognize the superior petrosal vein (SPV) complex and its
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anatomy, which may be quite variable. In this illustrative case, our patient had 2 main trunks that 4
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converged towards the SPV complex: a pontocerebellar and a supracerebellar branch partially
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blocking the surgical corridor which were coagulated and sectioned. A transverse pontine vein
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drained directly to the clivus. (See intraoperative video).
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Subsequently, we identified the left trigeminal nerve along with a bifurcated superior cerebellar
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artery. The inferior branch of the artery was intimately compressing the nerve in a pulsatile
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fashion (See Figure 2a and 2b). Several attempts were unsuccessfully made to transpose the
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artery cranially towards the tentorium separating it from the thinned and damaged nerve. We
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then proceeded with the proposed novel technique. A dural flap was elevated from the tentorium.
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A fenestrated clip was then used to encircle the superior branch of superior cerebellar artery in
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the fenestration and the blades were closed anchoring the clip to the dural flap. The final
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construct pulled the offending vessel away from the trigeminal nerve towards the tentorium
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(Figure 2c, Figure 3). The utilized angled clip had a 3.5-mm-diameter fenestration and a 5/7.8-
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mm length (Aesculap, Tuttlingen, Germany). Intraoperative 20 MHz micro-Doppler (Mizuho,
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Tokyo, Japan) was used to ensure patency of the vessels and their blood flow.
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RESULTS
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The surgical procedure was uneventful and the patient has remained pain-free thereafter, and she
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is being followed up in our outpatient clinic for the past 18 months. Her medical drug regimen
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was successfully weaned off during the postoperative period.
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DISCUSSION
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Microvascular decompression (MVD) using an interposition technique with a Teflon felt pad to
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separate the culprit vessel from the affected cranial nerve is the most effective and accepted
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definitive treatment reported for trigeminal neuralgia. Since the original description of this
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technique by Jannetta1,2 more than 40 years ago, it has been reported to have a good success rate
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and, therefore, it has gained a worldwide popularity among neurosurgeons. A thorough review
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by Tatli et al reported a good rate of immediate recovery, ranging from 76.4%-98.2%.3 Two
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large published series also showed good results after a long-term follow-up, with 70% of the
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patients having an excellent result 10 years after surgery and a probability of complete cure at 15
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years of 73,4%.25 Nevertheless, despite having good results, MVD is not devoid of
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complications, including hearing loss in up to 19% of the patients and a reported mortality of
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0.37%.3 Another drawback to take into account is the recurrence rate, which has been reported to
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vary from 3 to 30%, approximately. Given these recurrence and complication rates, alternative
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techniques and modifications for MVD have been proposed.
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We categorized alternative techniques and modifications of the original MVD procedure into 2
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major types, as previously proposed26: 1) procedures that consist of placing a synthetic material
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between the culprit vessel and the nerve, which fall into the category of “interposing techniques”
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and 2) techniques that consist of transposing the offending vessel with the purpose of avoiding
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the contact between the nerve and the vessel which are known as “transposing techniques”.
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Recent papers show a tendency towards an increase in the use of transposition techniques. One
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of the possible reasons for this tendency might be the high recurrence rate seen in the interposing
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techniques, which may be due to foreign body granuloma formation 27 and severe adhesions
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between the material used as “spacer” and the surrounding structures. Fibrin glue is also known
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to have potential risks such as the creation of new adhesions with the cranial nerves and the
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possibility of transmitting viral and prion diseases.28 Alternatively, transposing techniques may
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be deemed more technically challenging and demanding. Since they are less frequently utilized
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than the so-called interposing techniques, surgeons may have less experience, and be at an earlier
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point in the learning curve which may lead to a higher risk of complications. A wider corridor
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may be necessary since transposing may require inserting specific materials such as clips, glue or
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thread as well as conducting maneuvers such as suturing, additional dissection and vascular
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manipulation. These are the most common drawbacks in the literature mentioned for transposing
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techniques.18, 29-33
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We thoroughly reviewed articles describing alternative techniques with novel materials and
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found 30 papers describing modifications of interposing, transposing and even combined
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techniques. Regarding interposing techniques, the technical nuances are quite homogeneous and
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the main differentiating factor is the type of material that the authors utilize to separate the nerve
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from the offending structure. There are many variations, and authors have reported the use of
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autologous tissue (muscle or fascia) and different synthetics such as the popular Teflon, and
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alternatives such as Ivalon, Surgicel, Gelfoam34-36, Radiopaque Teletrast sponge with barium
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sulfide15, Silastic ring37, and Sundt clips16.
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Concerning the transposing techniques, they are often referred to as “sling” techniques, since a
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bow or sling is created with either autologous and/or artificial materials and used to pull the
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offending vessel away from the cranial nerve. More than 20 articles describe procedures of this
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type and are summarized in Table 1. The first reports describing such techniques were published
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in the last mid 80s by Japanese authors38-40 followed by Rawlinson in 198841. These techniques
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can be used for different vascular compression syndromes. Compared to “interposing”
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interventions, these procedures show a great heterogeneity when it comes to the technical
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nuances and maneuvers used. The materials utilized are also very varied, ranging from
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autologous arachnoid membrane, fascia or tentorium dura to a myriad of stitches, clips and even
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titanium bone fixation plates (Table 1). These procedures are considered more amenable for
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cases with dolichoectatic large or main vessels, since they are more resistant and can be less
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affected or kinked by the “sling”. Therefore, we found a predominance of transposition cases
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wherein the culprit vessel is an ectatic or tortuous vertebral or basilar artery or main arterial
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trunk. As mentioned in a majority of the previous reports and technical notes describing sling
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procedures, care must be taken in order not to kink or compress the vessel. Intraoperative devices
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such as Doppler probes may be used to ensure that blood flow is preserved. Lin et al previously
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described the use of Doppler probes and intraoperative angiography with indocyanin green to
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ensure that the blood flow in the manipulated vessels is preserved.23
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The use of dual techniques (transposition & interposition) has also been described. If complex
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anatomy or multiple compression points by tortuous big vessels and small branches are
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encountered, a combination of both sling and “spacer” is a very valuable therapeutic option. A
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few papers describe “dual techniques” wherein a combination of the two types of decompression
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procedures is used (Table 1). Despite a higher likelihood of success, these techniques may be
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more complex and challenging than a simple interposing or transposing decompression.
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The described technique differs from other “sling” MVD procedures reported in that the clip
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fenestration itself is used as the sling and the blades are closed clipping a tentorial flap. This
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avoids cumbersome, difficult and dangerous sling creation maneuvers. The proposed sling
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technique is not as straightforward as an interposing technique, and imparts additional challenges
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when working in a such a narrow space. Furthermore, creating the tentorial flap may give rise to
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slight bleeding. Six previous papers describe microvascular decompression procedures with
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aneurysm clips in patients with trigeminal neuralgia or hemifacial spasm19-21, 23, 37, 39, and even a
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case with malignant hypertension due to compression of the left rostral ventrolateral medulla
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(RVLM).20 However, these previous papers included complicated maneuvers such as suturing or
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stitching the clip to the surrounding dura or using the clip to hold a synthetic sling made from
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dural tape, equine collagen or gore-tex vascular grafts. Fenestrated clips have used in four
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previous studies19, 21, 37, 39, whereas a straight mini-aneurysm clip (Aesculap, Tuttlingen,
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Germany) along with a strip of equine collagen sheet was the utilized construct in the case with
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RVLM compression.20 Lin et al used various types of aneurysm clips to fix slings made from
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unabsorbable dural tape.23 Takamiya et al used the window of the clip as a sling for the affected
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nerve in lieu of the culprit vessel40. The concept of using the window of the fenestrated clip as
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the actual “sling” was solely described in a Japanese paper in 1986, by Niwa et al.38 Compared to
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that technique, the herein described procedure offers the novelty of using a tentorial flap as an
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anchoring site for the clip, instead of applying it directly to the dura. In Lin el al’s article, the
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authors do report the use of a fenestration of a clip as the sling in one of their 7 patients (case 3).
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However, they used an additional clip to fix it to the dura, obtaining a clip-sling-clip construct23.
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The main differences and nuances between the previously published transposing techniques and
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our proposed procedure are summarized in Table 1 (See Table 1 and Figure 3).
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The possibility of recurrence of symptoms due to compression by the clip is a drawback to be
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borne in mind when assessing transposing techniques like ours. Therefore, care must be taken to
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place the clip appropriately with a safe separation from surrounding structures that can give rise
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to postoperative complications should there be compressed or direct injury by the clip.
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Furthermore, factors such as the final position of the clip once the patient is awake and in the
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standing position should be taken into account.
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Although some authors initially proposed these slinging techniques as procedures for relapsing
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cases or patients with a failed MVD procedure32, we believe that it may be used as a first option
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in those posterior fossae with ectatic vessels that can be easily transposed and separated from the
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symptomatic nerve, yielding a good result with less risk of recurrence and a lower incidence of
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complications related to interposing techniques.
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CONCLUSION
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We describe a modified transposing technique for microvascular decompression wherein a
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fenestrated clip is used to pull the SCA towards the tentorium, and present a case utilizing this
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technique in a patient with trigeminal neuralgia. To the best of our knowledge, no previous
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report of such a slinging construct have been reported. The proposed technique yielded excellent
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results at 18-month follow-up in the presented case, with no complications or side effects.
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However, longer follow-up and a larger series are needed in order to truly assess this technique,
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to accurately compare it to other transposition and interposing techniques for microvascular
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decompression.
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Jannetta PJ, Bissonette DJ: Management of the failed patient with trigeminal neuralgia. Clin Neurosurg 1985; 32:334-347.
35.
Linskey ME, Jho HD, Jannetta PJ: Microvascular decompression for trigeminal neuralgia caused by vertebrobasilar compression. J Neurosurg 1994; 81(1):1-9.
12
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36.
Sindou M, Amrani F, Mertens P: Does microsurgical vascular decompression for trigeminal
322
neuralgia work through a neo-compressive mechanism? Anatomical-surgical evidence for a
323
decompressive effect. Acta Neurochir Suppl (Wien) 1991; 52:127-129.
324
37.
Yoshimoto Y, Noguchi M, Tsutsumi Y: Encircling method of trigeminal nerve decompression for neuralgia caused by tortuous vertebrobasilar artery: technical note. Surg Neurol 1995;
326
43(2):151-153.
327
38.
RI PT
325
Niwa J, Fujishige M, Nakagawa T, Hashi K: Use of a fenestrated aneurysm clip for transposition of the tortuous vertebral artery [Article in Japanese]. No Shinkei Geka 1988; 16(5 Suppl):621-
329
624.
330
39.
SC
328
Suzuki S, Tsuchita H, Kurokawa Y, Kitami K, Sohma T, Takeda T: New method of MVD using a vascular tape for neurovascular compression involving the vertebrobasilar artery--report of two
332
cases. Neurol Med Chir (Tokyo) 1990; 30(13):1020-1023. 40.
334 335
caused by a tortuous vertebrobasilar system. Surg Neurol 1985; 24(5):559-562. 41.
336 337
42.
Hanakita J, Kondo A: Serious complications of microvascular decompression operations for trigeminal neuralgia and spasm. Neurosurgery 1988; 22(2):348-352
43.
340 341
Rawlinson JN, Coakham HB: The treatment of hemifacial spasm by sling retraction. Br J Neurosurg 1988; 2(2):173-178.
338 339
Takamiya Y, Toya S, Kawase T, Takenaka N, Shiga H: Trigeminal neuralgia and hemifacial spasm
TE D
333
M AN U
331
Stone JL, Lichtor T, Crowell RM: Microvascular sling decompression for trigeminal neuralgia secondary to ectatic vertebrobasilar compression. Case report. J Neurosurg 1993; 79(6):943-945.
44.
Fukushima T: Microvascular decompression for hemifacial spasm: results of 2890 cases. In Carter LP, Spetzler RF, Hamilton MG (eds): Neurovascular Surgery. New York: McGraw-Hill; 1995; 1133-
343
1147
345 346 347
45.
Shigeno T, Kumai J, Endo M, Oya S, Hotta S: Snare technique of vascular transposition for
AC C
344
EP
342
microvascular decompression-technical note. Neurol Med Chir (Tokyo) 2002; 42(4):184-190.
348 349 350 351 13
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352 353
AC C
EP
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354
14
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355
FIGURES:
356
Figure 1: MRI slides showing a vascular loop affecting the left trigeminal nerve. “DRIVE”
357
sequences. A, B) Coronal slides. C, D) Axial slides.
358
Figure 2: Intraoperative images. A) Compression of the trigeminal nerve by the caudal branch of
360
superior cerebellar artery (SCA). B) Thinned trigeminal nerve after moving away the culprit
361
vessel with a dissector. C) Final construct. Tentorial flap and fenestrated clip pulling the artery
362
away from the nerve. AICA: anterior inferior cerebellar artery; SCA: superior cerebellar artery;
363
SPV: superior petrous vein; V: cranial nerve V; VII-VIII: cranial nerves VII-VIII.
SC
RI PT
359
364
Figure 3: Illustrative drawing showing the proposed technique. V: fifth cranial nerve; VII-VIII:
366
seventh and eighth cranial nerve; 1: anterior inferior cerebellar artery; 2: superior cerebellar
367
artery; 3: tentorial flap
M AN U
365
368
OPERATIVE VIDEO:
370
The video shows the significant intraoperative findings.
371
00min:00sec-00min:15sec; Brief summary of clinical history, MRI findings and patient’s
372
position and planned incision considering the superficial anatomical landmarks.
373
00min:15sec-01min:30sec; Initial dissection and superior petrosal vein (SPV) complex
374
identification
375
01min:30sec- 03min:30sec; Attempts to separate the artery and transpose the artery using the
376
vein as a sling.
377
03min:30sec-04min:17sec: Coagulation of another venous branch and preparation of tentorial
378
flap
379
04min:17sec-End: Clipping and transposition of the artery. Revision of satisfactory blood flow
380
with Micro-Doppler probe end ensuring a good transposition with no kinking of the vessel.
EP
AC C
381
TE D
369
382 383 384
15
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Trigeminal nerve enclosed in the window of a fenestrated clip. Culprit vessel enclosed in the window of the fenestrated clip. Fix the clip to the dura mater. Thin silastic rubber sling surrounding the offending vessel. The sling is stitched to the dura with no. 4 Prolene. Transposition of the culprit vessel and fixation to dura mater with an adhesive agent (Alkyl-alphacyanoacrylate) Sling made with vascular tape. Incision of dura mater of the petrous pyramid and creation of a tunnel. Vascular tape is passed through the tunnel and used to transpose the vessel. Hemoclip is used to fix the tape. Synthetic vascular graft sling. Sling is made from unabsorbable gore-tex material. The sling is then sutured to the clival dura. Silicone sling transposing the culprit vessel + suture to the petrous dura. Teflon slings + fibrin glue and suture. The loops of Teflon that mobilized the offending vessel were affixed to the dura using fibrin glue and Surgicel. Tentorial sling + hemoclip. Dural sling made from the tentorium. The dura is used to wrap the culprit vessel. The dural flap is then fixed with hemoclips. Soft felt + suture. The sling is a Prolene suture. A Teflon pad is placed between the suture and the vessel in order to avoid vascular injury or kinking. Dural belt + Sugita Clip. The sling is made from dura and fixation is done using a Sugita clip applied to the sling.
T T
Ogawa et al. 22 1992 Stone et al. 42 1993 Fukushima 43 et al. 1995 Melvill et al. 11 1996 Bejjani et al. 17 1997 Kyoshima et 21 al. 2000
V and VII
N/A
Fenestrated clip
1
V
VA
Fenestrated clip
C
2
VII
N/A
T
1
V
BA
T
2
1: V 1: VII
1 BA. 1 VA
T
1
T
1
C
N/A
T
T
C
Material (s)
Complications
Follow-up
Mild CNV and CNVII palsy No
N/A
Good
N/A
N/A
Excellent
N/A
No
N/A
Excellent
N/A
Left PCA stroke
N/A
Excellent
N/A
Vascular tape and hemoclips.
No
21-30 months
Excellent
No
Silastic rubber, ivalon sponge and prolene suture Alkyl-alphacyanoacrylate
Result
Recurrence
V, VII & VIII
VA-BA
Gore-Tex vascular graft
No
N/A
Excellent
No
V
BA
Silicone sling
No
Excellent
No
VII
N/A
Teflon, fibrin glue and surgicel (ETHICON, INC., Somerville, NJ) Tentorial sling and hemoclip
N/A
4 to 5 years N/A
Excellent
N/A
No
1-8 months
Good
No
7
V
N/A
2
VII
VA
Teflon pad and prolene 7/0
No
5-11 months
Excellent
No
6
VII
2: VA. 3: VA + AICA. 1: VA + PICA 5: Teflon. 1: Granulo ma N/A.
Dura and Mizuho Lshaped clip (Muzho, Tokyo, Japan). 1 case vascular tape and Weck hemoclip. Bio-bond glue (Mitsubishi Pharma Corp., Osaka, Japan) and Teflon
Hearing loss 17%
0.2- 10 years
Excellent
17%
Hypoesthesia 50%
2.1 to 4.6 years
Excellent
No
Gore-tex tape. Suture
N/A
1-4 years
Excellent
No
EP
Suzuki et al. 38 1990
Vessel (s)
AC C
Hanakita et 41 al. 1988
Nerve (s)
RI PT
Takamiya et 39 al. 1985 Niwa et al. 37 1988 Rawlinson et 40 al. 1988
Number of cases 1
SC
Type
M AN U
Technique
TE D
Author/year
Matsushima 31 et al 2000
Sling retraction with a Teflon felt used as a sling. Fixation of the sling to the inferior surface of the tentorium with Bio-bond glue.
T
6
V
Shigeno et
Snare technique of vascular transposition. Gore-tex tape
T
20
13:VII.
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Kurokawa et 14 al. 2004
7: V T
2
V
VA
T
1
VII
VA
2: V. 6: VII.
TN: SCA 100% HFS: AICA 60% 3 SCA. 1 AICA.
Fenestrated aneurysm clip. Culprit vessel enclosed in the window of the clip. Suture of the clip to the tentorium.
T
8
Mitsos et al. 32 2008
Hanging technique. Sling made from autologous tissue (occipital muscle’s fascia). Fixation to the tentorium or petrous dura with monofilament suture. Arachnoid membrane + suture. Transposition of the culprit vessel and use of the arachnoid membrane of the cerebellopontine membrane to retain it away from the cranial nerve. Double-stick tape. Small piece of fibrin tissue-adhesive collagen fleece with fibrin glue added on the non-coated side. Vertebral artery is then pushed away and held with the tape fixed on the petrous dura.
T
4
T
30
Raabe et al. 20 2011
Masuoka et 30 al 2011
Lin et al 23 2012
T
1
V
SCA
VII
VA + AICA
1
M.O
VA
TN: SCA 82% HFS: VA 80% GPN: PICA VA and/or
EP
Ichikawa et 28 al. 2011
Strip-clip technique. A strip of equine collagen is used to wrap the culprit vessel. A clip is threaded through little holes made on the leaflets of the strip. A small hole is made on petrous dura and the blades are closed, clipping the petrous dura. Sling retraction. The sling is done by a simple suture.
T
T
36
28: V 5: VII 3: IX
String of unabsorbable dural tape fixed with a clip to the dura. Endoscope-assisted. “String and clip fixation”
T
7
3: V 4: VII
AC C
Skrap et al. 10 2010
V
TE D
Attabib et al. 19 2007
Titanium bone fixation plate. (10 cm). Small sheet of prosthetic Dacron. Methylmethacrylate. Biobond (Mitsubishi Pharma Corp., Osaka, Japan) and surgicel (ETHICON, INC., Somerville, NJ) Fenestrated aneurysm clip
No
9-18 months
Excellent
No
No
N/A
Excellent
No
No
13 months
Excellent 86%
14%
Fascia and monofilament suture.
No
6-24 months
Excellent
No
Arachnoid membrane of the cerebellopontine cistern TachoComb (CSL, Behring, Tokyo, Japan) with fibrin glue (BOLHEAL, Astellas Pharma Inc., Tokyo, Japan) Equine Collagen sheet (Vostra, Aachen, Germany) + Straight mini-aneurysm clip
No
24 months
Excellent
No
No
1 year
Excellent
No
No
N/A
Good
No
5-0 thread.
Transient ataxia due to venous infarction 11% CSF leakage 8% 1 transient hearing
8-30 months.
Excellent 86%
No.
9-92 weeks
Excellent x5
No
RI PT
Taki et al 18 2003
is used to wrap the culprit vessel. Suture of the tape to the petrous or tentorial dural. Titanium bone fixation plate. A stainless plate is bent and curved with pliers so as to transpose the culprit vessel and push it away from the cranial nerve. Fixation of the plate to the convexity of the occipital bone. Dacron between the metal plate and the culprit vessel. Surgical glue and Surgicel. Offending vessel is dissected and pushed away. Glue and Surgicel are used to fix the vessel to its new position.
SC
44
M AN U
al. 2002
Unabsorbable goretex dural tape.
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V
SCA
T
50
V
SCA 84% AICA 2% AICA + SCA 14%
Tentorial flap + Fenestrated clip. Culprit vessel is enclosed in the window of the fenestrated clip. A tentorial flap is dissected and prepared. The blades of the clip are closed, clipping the tentorial flap, while transposing the offending vessel (See video)
T
1
V
SCA
2-0 Silk thread
5-0 thread
M AN U
SC
12
Tentorial flap and Aesculap (Tuttlingen, Germany) fenestrated clip. L-shaped
impairment (hemotympanu m) 1 mild transient postoperative hyperesthesia No
Transient ataxia due to venous infarction 6% CSF leakage 8% No
Good x1 Fair x 1
24-38 months
Excellent
No
1.8-6.8 years.
Excellent 84%
4%
1 year
Excellent
No
Table 1: Review of the literature. Summary and significant findings of the studies describing transposing and/or combined techniques. Abbreviations: Type of technique: “T”=
TE D
Current Case
C
Transposing. “C” = Combined. N of cases= Number of cases. Cranial nerves are expressed with Roman numerals (i.e: V = Trigeminal Nerve). M.O = Medulla Oblongata. Vessels: BA=Basilar Artery. VA= Vertebral Artery. PICA= Postero-inferior cerebellarartery. AICA= antero-inferior cerebellarartery. SCA= Superior cerebellarartery. PCA= Posterior cerebral artery. Syndromes: TN= Trigeminal Neuralgia. HFS= Hemifacial Spasm. GPN= Glossopharyngeal Neuralgia. N/A = Not available. Results: BNI scale= Barrow
EP
Masuoka et 29 al. 2015
Sling retraction for failed or recurrent cases. A 2-0 silk thread is used to make a sling around the vessel. Suture to the tentorium dura. Sling retraction by a simple suture to petrous or clival dura.
Neurological Institute Pain Scale. MVD = Microvascular Decompression. CSF = Cerebrospinal Fluid.
AC C
Meybodi et 25 al. 2014
Fenestrated aneurysm clips
RI PT
BA
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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HIGHLIGHTS - A thorough description of an interposing technique with fenestrated clip for microvascular decompression is described. - The tentorial flap technique is less complex than previously published interposing techniques
AC C
EP
TE D
M AN U
SC
RI PT
- Meticulous review of the literature analyzing different interposing techniques is presented
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ABBREVIATIONS: MVD= Microvascular Decompression; SCA= Superior Cerebellar Artery; AICA= Anterior inferior cerebellar artery; MRI= Magnetic Resonance Imaging; REZ= Root Entry Zone; CSF=
AC C
EP
TE D
M AN U
SC
RI PT
Cerebrospinal fluid; SPV= Superior Petrosal Vein; RVLM= Rostral Ventrolateral Medulla.
S1878-8750(17)31210-X
DOI:
10.1016/j.wneu.2017.07.110
Reference:
WNEU 6172
To appear in:
World Neurosurgery
Received Date: 23 March 2017 Revised Date:
17 July 2017
Accepted Date: 18 July 2017
Please cite this article as: Gonzalez-Quarante LH, Ruiz-Juretschke F, Agarwal V, Garcia-Leal R, Microvascular decompression for trigeminal neuralgia using a novel fenestrated clip and tentorial flap technique., World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.07.110. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Microvascular decompression for trigeminal neuralgia using a novel fenestrated clip and
2
tentorial flap technique.
3
Lain Hermes Gonzalez-Quarante, MD1, 2; Fernando Ruiz-Juretschke, PhD2; Vijay Agarwal,
4
MD3; Roberto Garcia-Leal, MD2
5
1
Department of Neurosurgery, Hospital Universitario HM Sanchinarro. Madrid (Spain)
6
2
Department of Neurosurgery, Hospital General Universitario Gregorio Marañón. Madrid
7
(Spain)
8
3
9
Previous presentation(s):
SC
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1
M AN U
Department of Neurosurgery, Mayo Clinic. Rochester (MN).
The content of this article has not been presented in any congress before the submission of this
11
manuscript.
12
Disclosures:
13
The authors have no personal financial or institutional interest in any of the drugs, materials, or
14
devices described in this article.
15
Corresponding author contact information:
16 17 18 19 20 21 22
Lain Hermes Gonzalez-Quarante, M.D Department of Neurosurgery Hospital Universitario HM Sanchinarro Calle Oña, 10. C.P 28050. Madrid (SPAIN) E-mail address: [email protected]
23
KEYWORDS:
AC C
EP
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10
1
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Cranial nerves. Microvascular Decompression Surgery. Retrosigmoid approach. Surgical clip.
25
Transposition. Trigeminal neuralgia.
26
ABBREVIATIONS:
27
MVD= Microvascular Decompression; SCA= Superior Cerebellar Artery; AICA= Anterior
28
inferior cerebellar artery; MRI= Magnetic Resonance Imaging; REZ= Root Entry Zone; CSF=
29
Cerebrospinal fluid; SPV= Superior Petrosal Vein; RVLM= Rostral Ventrolateral Medulla.
30
ABSTRACT:
31
BACKGROUND: Microvascular decompression (MVD) for neurovascular compression
32
syndromes such as trigeminal neuralgia and hemifacial spasm has been traditionally described as
33
an interposing technique using Teflon. Some alternative interposing materials have been
34
proposed. Additionally, transposing techniques have been increasingly reported in recent years,
35
as an alternative that may have a lower recurrence rate and fewer complications.
36
OBJECTIVE: To describe our experience utilizing a technique consisting of transposition of the
37
superior cerebellar artery using a fenestrated clip and a tentorial flap in patients with trigeminal
38
neuralgia.
39
METHODS: We describe a novel transposing technique using a fenestrated clip and a tentorial
40
flap in patients with neurovascular compression. An illustrative case is provided of an 83-year-
41
old female patient who complained of a 4-year history of left trigeminal neuralgia due to
42
compression by the superior cerebellar artery who was treated with this technique. Furthermore,
43
a thorough review of the literature is presented.
44
RESULTS: The patient underwent the procedure with the proposed technique without
45
complication. Both the surgery, and the postoperative course, were uneventful and the patient
46
remains asymptomatic 1 year after the procedure.
AC C
EP
TE D
M AN U
SC
RI PT
24
2
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CONCLUSION: We propose a novel technique for the treatment of trigeminal neuralgia
48
eliminating the need for padding the vessel with a foreign body. This technique can successfully
49
be applied in selected cases of neurovascular compression syndromes.
50
INTRODUCTION:
51
Since its popularization by Peter Joseph Jannetta, microvascular decompression (MVD) surgery
52
has become a well-known and accepted treatment for trigeminal neuralgia.1, 2 Despite the
53
development of alternative, less aggressive surgical interventions such as percutaneous balloon
54
microcompression, rhizotomies and stereotactic radiosurgery, MVD surgery has been proven to
55
provide the highest rate of long-term patient satisfaction with the lowest rate of pain recurrence.3-
56
6
57
the compressive etiology of idiopathic trigeminal neuralgia. Several variations and modifications
58
of the original technique by Jannetta have been published. The aim of these techniques is to: 1)
59
separate the culprit vessel from the vulnerable nerve and 2) to maintain this separation in order to
60
avoid recurrence. As this pathology is often encountered, neurosurgeons should be acquainted
61
with various interposing materials and techniques that can be complemented by sling, retraction
62
or repositioning materials and techniques. A cornucopia of different materials have been
63
proposed as “separators” in interposing procedures, from autologous tissue such as muscle7-9 and
64
arachnoid membrane10 or tentorium11 to artificial or foreign materials ranging from Teflon to
65
cotton pads12, Gelfoam13, surgical glue14, radiopaque sponge15, and Sundt clips16. Alternatively,
66
various “slings” and repositioning procedures have also been reported; from a simple prolene or
67
stitching technique to a sophisticated titanium bone fixation plate.17, 18 However, aside from
68
stitched slings, the most commonly used materials are aneurysm clips and vascular surgery
69
materials.16, 19-23 In the technique that we describe here, a fenestrated clip attached to a tentorial
70
flap, in a stitch-less fashion with the culprit vessel passing through the clip fenestration.
71
Additionally, we performed a thorough literature review of the alternative transposing techniques
72
and interposed materials that have been previously reported.
SC
RI PT
47
AC C
EP
TE D
M AN U
The most reasonable explanation for this higher success rate is that MVD surgery directly treats
73 74
METHODS. ILLUSTRATIVE CASE AND SURGICAL PROCEDURE.
3
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CLINICAL PRESENTATION
76
An 83-year-old female presented with a 4-year-history of lancinating and intense left hemifacial
77
pain. The pain was intermittent and refractory to various regimens prescribed by neurologists
78
such as pregabalin, baclofen, eslicarbazepine, amitriptyline and over-the-counter analgesics.
79
Three-dimensional high-resolution MRI sequences (DRIVE, 1.5T Achieva, Philips Medical
80
Systems, NL) revealed a vascular compression of the left trigeminal nerve by a vascular loop that
81
appeared to be a branch of the superior cerebellar artery (SCA). The nerve was compressed at its
82
superior aspect, near the root entry zone (REZ) (Figure 1).
83
Given the clinical data consistent with trigeminal neuralgia Burchiel type I, the lack of response
84
to medical treatment and the imaging findings, microvascular decompression of the left
85
trigeminal nerve was proposed and scheduled. Informed consent was signed by the patient prior
86
to undergoing surgery.
87
M AN U
SC
RI PT
75
SURGICAL INTERVENTION
89
The patient was placed under general anesthesia in a park-bench position (See intraoperative
90
video). We usually perform the microvascular decompression via a retrosigmoid approach, using
91
a retroauricular curvilinear incision designed and adjusted depending on superficial landmarks,
92
as described previously. 24 . A multilayer subcutaneous dissection is then carefully performed.
93
Once the bone is exposed, and after identifying important bony landmarks such as the asterion
94
and digastric groove, a 2 cm craniectomy is made just inferior to the transversve-sigmoid sinus
95
junction. The dura is reflected towards the sinus junction.
96
The cerebellopontine cistern is decompressed, and the the patient’s position is adjusted, to avoid
97
retraction on the cerebellum. The cerebellar flocculus is identified along with the complex
98
formed by cranial nerves VII, VIII, anterior inferior cerebellar artery (AICA) and the subarcuate
99
artery. These are gently dissected and separated. The next step, which is of paramount
AC C
EP
TE D
88
100
importance, is to identify and recognize the superior petrosal vein (SPV) complex and its
101
anatomy, which may be quite variable. In this illustrative case, our patient had 2 main trunks that 4
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converged towards the SPV complex: a pontocerebellar and a supracerebellar branch partially
103
blocking the surgical corridor which were coagulated and sectioned. A transverse pontine vein
104
drained directly to the clivus. (See intraoperative video).
105
Subsequently, we identified the left trigeminal nerve along with a bifurcated superior cerebellar
106
artery. The inferior branch of the artery was intimately compressing the nerve in a pulsatile
107
fashion (See Figure 2a and 2b). Several attempts were unsuccessfully made to transpose the
108
artery cranially towards the tentorium separating it from the thinned and damaged nerve. We
109
then proceeded with the proposed novel technique. A dural flap was elevated from the tentorium.
110
A fenestrated clip was then used to encircle the superior branch of superior cerebellar artery in
111
the fenestration and the blades were closed anchoring the clip to the dural flap. The final
112
construct pulled the offending vessel away from the trigeminal nerve towards the tentorium
113
(Figure 2c, Figure 3). The utilized angled clip had a 3.5-mm-diameter fenestration and a 5/7.8-
114
mm length (Aesculap, Tuttlingen, Germany). Intraoperative 20 MHz micro-Doppler (Mizuho,
115
Tokyo, Japan) was used to ensure patency of the vessels and their blood flow.
116
RESULTS
117
The surgical procedure was uneventful and the patient has remained pain-free thereafter, and she
118
is being followed up in our outpatient clinic for the past 18 months. Her medical drug regimen
119
was successfully weaned off during the postoperative period.
120
DISCUSSION
121
Microvascular decompression (MVD) using an interposition technique with a Teflon felt pad to
122
separate the culprit vessel from the affected cranial nerve is the most effective and accepted
123
definitive treatment reported for trigeminal neuralgia. Since the original description of this
124
technique by Jannetta1,2 more than 40 years ago, it has been reported to have a good success rate
125
and, therefore, it has gained a worldwide popularity among neurosurgeons. A thorough review
126
by Tatli et al reported a good rate of immediate recovery, ranging from 76.4%-98.2%.3 Two
127
large published series also showed good results after a long-term follow-up, with 70% of the
128
patients having an excellent result 10 years after surgery and a probability of complete cure at 15
129
years of 73,4%.25 Nevertheless, despite having good results, MVD is not devoid of
AC C
EP
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M AN U
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102
5
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complications, including hearing loss in up to 19% of the patients and a reported mortality of
131
0.37%.3 Another drawback to take into account is the recurrence rate, which has been reported to
132
vary from 3 to 30%, approximately. Given these recurrence and complication rates, alternative
133
techniques and modifications for MVD have been proposed.
134
We categorized alternative techniques and modifications of the original MVD procedure into 2
135
major types, as previously proposed26: 1) procedures that consist of placing a synthetic material
136
between the culprit vessel and the nerve, which fall into the category of “interposing techniques”
137
and 2) techniques that consist of transposing the offending vessel with the purpose of avoiding
138
the contact between the nerve and the vessel which are known as “transposing techniques”.
139
Recent papers show a tendency towards an increase in the use of transposition techniques. One
140
of the possible reasons for this tendency might be the high recurrence rate seen in the interposing
141
techniques, which may be due to foreign body granuloma formation 27 and severe adhesions
142
between the material used as “spacer” and the surrounding structures. Fibrin glue is also known
143
to have potential risks such as the creation of new adhesions with the cranial nerves and the
144
possibility of transmitting viral and prion diseases.28 Alternatively, transposing techniques may
145
be deemed more technically challenging and demanding. Since they are less frequently utilized
146
than the so-called interposing techniques, surgeons may have less experience, and be at an earlier
147
point in the learning curve which may lead to a higher risk of complications. A wider corridor
148
may be necessary since transposing may require inserting specific materials such as clips, glue or
149
thread as well as conducting maneuvers such as suturing, additional dissection and vascular
150
manipulation. These are the most common drawbacks in the literature mentioned for transposing
151
techniques.18, 29-33
152
We thoroughly reviewed articles describing alternative techniques with novel materials and
153
found 30 papers describing modifications of interposing, transposing and even combined
154
techniques. Regarding interposing techniques, the technical nuances are quite homogeneous and
155
the main differentiating factor is the type of material that the authors utilize to separate the nerve
156
from the offending structure. There are many variations, and authors have reported the use of
157
autologous tissue (muscle or fascia) and different synthetics such as the popular Teflon, and
158
alternatives such as Ivalon, Surgicel, Gelfoam34-36, Radiopaque Teletrast sponge with barium
159
sulfide15, Silastic ring37, and Sundt clips16.
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Concerning the transposing techniques, they are often referred to as “sling” techniques, since a
161
bow or sling is created with either autologous and/or artificial materials and used to pull the
162
offending vessel away from the cranial nerve. More than 20 articles describe procedures of this
163
type and are summarized in Table 1. The first reports describing such techniques were published
164
in the last mid 80s by Japanese authors38-40 followed by Rawlinson in 198841. These techniques
165
can be used for different vascular compression syndromes. Compared to “interposing”
166
interventions, these procedures show a great heterogeneity when it comes to the technical
167
nuances and maneuvers used. The materials utilized are also very varied, ranging from
168
autologous arachnoid membrane, fascia or tentorium dura to a myriad of stitches, clips and even
169
titanium bone fixation plates (Table 1). These procedures are considered more amenable for
170
cases with dolichoectatic large or main vessels, since they are more resistant and can be less
171
affected or kinked by the “sling”. Therefore, we found a predominance of transposition cases
172
wherein the culprit vessel is an ectatic or tortuous vertebral or basilar artery or main arterial
173
trunk. As mentioned in a majority of the previous reports and technical notes describing sling
174
procedures, care must be taken in order not to kink or compress the vessel. Intraoperative devices
175
such as Doppler probes may be used to ensure that blood flow is preserved. Lin et al previously
176
described the use of Doppler probes and intraoperative angiography with indocyanin green to
177
ensure that the blood flow in the manipulated vessels is preserved.23
178
The use of dual techniques (transposition & interposition) has also been described. If complex
179
anatomy or multiple compression points by tortuous big vessels and small branches are
180
encountered, a combination of both sling and “spacer” is a very valuable therapeutic option. A
181
few papers describe “dual techniques” wherein a combination of the two types of decompression
182
procedures is used (Table 1). Despite a higher likelihood of success, these techniques may be
183
more complex and challenging than a simple interposing or transposing decompression.
184
The described technique differs from other “sling” MVD procedures reported in that the clip
185
fenestration itself is used as the sling and the blades are closed clipping a tentorial flap. This
186
avoids cumbersome, difficult and dangerous sling creation maneuvers. The proposed sling
187
technique is not as straightforward as an interposing technique, and imparts additional challenges
188
when working in a such a narrow space. Furthermore, creating the tentorial flap may give rise to
189
slight bleeding. Six previous papers describe microvascular decompression procedures with
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aneurysm clips in patients with trigeminal neuralgia or hemifacial spasm19-21, 23, 37, 39, and even a
191
case with malignant hypertension due to compression of the left rostral ventrolateral medulla
192
(RVLM).20 However, these previous papers included complicated maneuvers such as suturing or
193
stitching the clip to the surrounding dura or using the clip to hold a synthetic sling made from
194
dural tape, equine collagen or gore-tex vascular grafts. Fenestrated clips have used in four
195
previous studies19, 21, 37, 39, whereas a straight mini-aneurysm clip (Aesculap, Tuttlingen,
196
Germany) along with a strip of equine collagen sheet was the utilized construct in the case with
197
RVLM compression.20 Lin et al used various types of aneurysm clips to fix slings made from
198
unabsorbable dural tape.23 Takamiya et al used the window of the clip as a sling for the affected
199
nerve in lieu of the culprit vessel40. The concept of using the window of the fenestrated clip as
200
the actual “sling” was solely described in a Japanese paper in 1986, by Niwa et al.38 Compared to
201
that technique, the herein described procedure offers the novelty of using a tentorial flap as an
202
anchoring site for the clip, instead of applying it directly to the dura. In Lin el al’s article, the
203
authors do report the use of a fenestration of a clip as the sling in one of their 7 patients (case 3).
204
However, they used an additional clip to fix it to the dura, obtaining a clip-sling-clip construct23.
205
The main differences and nuances between the previously published transposing techniques and
206
our proposed procedure are summarized in Table 1 (See Table 1 and Figure 3).
207
The possibility of recurrence of symptoms due to compression by the clip is a drawback to be
208
borne in mind when assessing transposing techniques like ours. Therefore, care must be taken to
209
place the clip appropriately with a safe separation from surrounding structures that can give rise
210
to postoperative complications should there be compressed or direct injury by the clip.
211
Furthermore, factors such as the final position of the clip once the patient is awake and in the
212
standing position should be taken into account.
213
Although some authors initially proposed these slinging techniques as procedures for relapsing
214
cases or patients with a failed MVD procedure32, we believe that it may be used as a first option
215
in those posterior fossae with ectatic vessels that can be easily transposed and separated from the
216
symptomatic nerve, yielding a good result with less risk of recurrence and a lower incidence of
217
complications related to interposing techniques.
218
CONCLUSION
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We describe a modified transposing technique for microvascular decompression wherein a
220
fenestrated clip is used to pull the SCA towards the tentorium, and present a case utilizing this
221
technique in a patient with trigeminal neuralgia. To the best of our knowledge, no previous
222
report of such a slinging construct have been reported. The proposed technique yielded excellent
223
results at 18-month follow-up in the presented case, with no complications or side effects.
224
However, longer follow-up and a larger series are needed in order to truly assess this technique,
225
to accurately compare it to other transposition and interposing techniques for microvascular
226
decompression.
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229
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Kyoshima K, Watanabe A, Toba Y, Nitta J, Muraoka S, Kobayashi S: Anchoring method for hemifacial spasm associated with vertebral artery: technical note. Neurosurgery 1999;
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Ruiz-Juretschke F, Vargas AJ, Gonzalez-Quarante LH, Gil de Sagredo OL, Montalvo A, Fernandez-
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Sindou M, Leston J, Howeidy T, Decullier E, Chapuis F: Micro-vascular decompression for primary Trigeminal Neuralgia (typical or atypical). Long-term effectiveness on pain; prospective study 11
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Meybodi AT, Habibi Z, Miri M, Tabatabaie SA: Microvascular decompression for trigeminal neuralgia using the 'Stitched Sling Retraction' technique in recurrent cases after previous
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Ohta M, Komatsu F, Abe H, Sakamoto S, Tsugu H, Oshiro S, Fukushima T: Complication caused by
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48(1):30-32. 29.
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technique. Neurosurg Rev 2015; 38(2):361-365; discussion 365. 31.
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retraction technique for microvascular decompression: procedures and techniques based on an
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Matsushima T, Yamaguchi T, Inoue TK, Matsukado K, Fukui M: Recurrent trigeminal neuralgia after microvascular decompression using an interposing technique. Teflon felt adhesion and the
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neuralgia work through a neo-compressive mechanism? Anatomical-surgical evidence for a
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Yoshimoto Y, Noguchi M, Tsutsumi Y: Encircling method of trigeminal nerve decompression for neuralgia caused by tortuous vertebrobasilar artery: technical note. Surg Neurol 1995;
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Niwa J, Fujishige M, Nakagawa T, Hashi K: Use of a fenestrated aneurysm clip for transposition of the tortuous vertebral artery [Article in Japanese]. No Shinkei Geka 1988; 16(5 Suppl):621-
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Suzuki S, Tsuchita H, Kurokawa Y, Kitami K, Sohma T, Takeda T: New method of MVD using a vascular tape for neurovascular compression involving the vertebrobasilar artery--report of two
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cases. Neurol Med Chir (Tokyo) 1990; 30(13):1020-1023. 40.
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caused by a tortuous vertebrobasilar system. Surg Neurol 1985; 24(5):559-562. 41.
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Hanakita J, Kondo A: Serious complications of microvascular decompression operations for trigeminal neuralgia and spasm. Neurosurgery 1988; 22(2):348-352
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Rawlinson JN, Coakham HB: The treatment of hemifacial spasm by sling retraction. Br J Neurosurg 1988; 2(2):173-178.
338 339
Takamiya Y, Toya S, Kawase T, Takenaka N, Shiga H: Trigeminal neuralgia and hemifacial spasm
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Stone JL, Lichtor T, Crowell RM: Microvascular sling decompression for trigeminal neuralgia secondary to ectatic vertebrobasilar compression. Case report. J Neurosurg 1993; 79(6):943-945.
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Fukushima T: Microvascular decompression for hemifacial spasm: results of 2890 cases. In Carter LP, Spetzler RF, Hamilton MG (eds): Neurovascular Surgery. New York: McGraw-Hill; 1995; 1133-
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1147
345 346 347
45.
Shigeno T, Kumai J, Endo M, Oya S, Hotta S: Snare technique of vascular transposition for
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microvascular decompression-technical note. Neurol Med Chir (Tokyo) 2002; 42(4):184-190.
348 349 350 351 13
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355
FIGURES:
356
Figure 1: MRI slides showing a vascular loop affecting the left trigeminal nerve. “DRIVE”
357
sequences. A, B) Coronal slides. C, D) Axial slides.
358
Figure 2: Intraoperative images. A) Compression of the trigeminal nerve by the caudal branch of
360
superior cerebellar artery (SCA). B) Thinned trigeminal nerve after moving away the culprit
361
vessel with a dissector. C) Final construct. Tentorial flap and fenestrated clip pulling the artery
362
away from the nerve. AICA: anterior inferior cerebellar artery; SCA: superior cerebellar artery;
363
SPV: superior petrous vein; V: cranial nerve V; VII-VIII: cranial nerves VII-VIII.
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364
Figure 3: Illustrative drawing showing the proposed technique. V: fifth cranial nerve; VII-VIII:
366
seventh and eighth cranial nerve; 1: anterior inferior cerebellar artery; 2: superior cerebellar
367
artery; 3: tentorial flap
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OPERATIVE VIDEO:
370
The video shows the significant intraoperative findings.
371
00min:00sec-00min:15sec; Brief summary of clinical history, MRI findings and patient’s
372
position and planned incision considering the superficial anatomical landmarks.
373
00min:15sec-01min:30sec; Initial dissection and superior petrosal vein (SPV) complex
374
identification
375
01min:30sec- 03min:30sec; Attempts to separate the artery and transpose the artery using the
376
vein as a sling.
377
03min:30sec-04min:17sec: Coagulation of another venous branch and preparation of tentorial
378
flap
379
04min:17sec-End: Clipping and transposition of the artery. Revision of satisfactory blood flow
380
with Micro-Doppler probe end ensuring a good transposition with no kinking of the vessel.
EP
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382 383 384
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Trigeminal nerve enclosed in the window of a fenestrated clip. Culprit vessel enclosed in the window of the fenestrated clip. Fix the clip to the dura mater. Thin silastic rubber sling surrounding the offending vessel. The sling is stitched to the dura with no. 4 Prolene. Transposition of the culprit vessel and fixation to dura mater with an adhesive agent (Alkyl-alphacyanoacrylate) Sling made with vascular tape. Incision of dura mater of the petrous pyramid and creation of a tunnel. Vascular tape is passed through the tunnel and used to transpose the vessel. Hemoclip is used to fix the tape. Synthetic vascular graft sling. Sling is made from unabsorbable gore-tex material. The sling is then sutured to the clival dura. Silicone sling transposing the culprit vessel + suture to the petrous dura. Teflon slings + fibrin glue and suture. The loops of Teflon that mobilized the offending vessel were affixed to the dura using fibrin glue and Surgicel. Tentorial sling + hemoclip. Dural sling made from the tentorium. The dura is used to wrap the culprit vessel. The dural flap is then fixed with hemoclips. Soft felt + suture. The sling is a Prolene suture. A Teflon pad is placed between the suture and the vessel in order to avoid vascular injury or kinking. Dural belt + Sugita Clip. The sling is made from dura and fixation is done using a Sugita clip applied to the sling.
T T
Ogawa et al. 22 1992 Stone et al. 42 1993 Fukushima 43 et al. 1995 Melvill et al. 11 1996 Bejjani et al. 17 1997 Kyoshima et 21 al. 2000
V and VII
N/A
Fenestrated clip
1
V
VA
Fenestrated clip
C
2
VII
N/A
T
1
V
BA
T
2
1: V 1: VII
1 BA. 1 VA
T
1
T
1
C
N/A
T
T
C
Material (s)
Complications
Follow-up
Mild CNV and CNVII palsy No
N/A
Good
N/A
N/A
Excellent
N/A
No
N/A
Excellent
N/A
Left PCA stroke
N/A
Excellent
N/A
Vascular tape and hemoclips.
No
21-30 months
Excellent
No
Silastic rubber, ivalon sponge and prolene suture Alkyl-alphacyanoacrylate
Result
Recurrence
V, VII & VIII
VA-BA
Gore-Tex vascular graft
No
N/A
Excellent
No
V
BA
Silicone sling
No
Excellent
No
VII
N/A
Teflon, fibrin glue and surgicel (ETHICON, INC., Somerville, NJ) Tentorial sling and hemoclip
N/A
4 to 5 years N/A
Excellent
N/A
No
1-8 months
Good
No
7
V
N/A
2
VII
VA
Teflon pad and prolene 7/0
No
5-11 months
Excellent
No
6
VII
2: VA. 3: VA + AICA. 1: VA + PICA 5: Teflon. 1: Granulo ma N/A.
Dura and Mizuho Lshaped clip (Muzho, Tokyo, Japan). 1 case vascular tape and Weck hemoclip. Bio-bond glue (Mitsubishi Pharma Corp., Osaka, Japan) and Teflon
Hearing loss 17%
0.2- 10 years
Excellent
17%
Hypoesthesia 50%
2.1 to 4.6 years
Excellent
No
Gore-tex tape. Suture
N/A
1-4 years
Excellent
No
EP
Suzuki et al. 38 1990
Vessel (s)
AC C
Hanakita et 41 al. 1988
Nerve (s)
RI PT
Takamiya et 39 al. 1985 Niwa et al. 37 1988 Rawlinson et 40 al. 1988
Number of cases 1
SC
Type
M AN U
Technique
TE D
Author/year
Matsushima 31 et al 2000
Sling retraction with a Teflon felt used as a sling. Fixation of the sling to the inferior surface of the tentorium with Bio-bond glue.
T
6
V
Shigeno et
Snare technique of vascular transposition. Gore-tex tape
T
20
13:VII.
ACCEPTED MANUSCRIPT
Kurokawa et 14 al. 2004
7: V T
2
V
VA
T
1
VII
VA
2: V. 6: VII.
TN: SCA 100% HFS: AICA 60% 3 SCA. 1 AICA.
Fenestrated aneurysm clip. Culprit vessel enclosed in the window of the clip. Suture of the clip to the tentorium.
T
8
Mitsos et al. 32 2008
Hanging technique. Sling made from autologous tissue (occipital muscle’s fascia). Fixation to the tentorium or petrous dura with monofilament suture. Arachnoid membrane + suture. Transposition of the culprit vessel and use of the arachnoid membrane of the cerebellopontine membrane to retain it away from the cranial nerve. Double-stick tape. Small piece of fibrin tissue-adhesive collagen fleece with fibrin glue added on the non-coated side. Vertebral artery is then pushed away and held with the tape fixed on the petrous dura.
T
4
T
30
Raabe et al. 20 2011
Masuoka et 30 al 2011
Lin et al 23 2012
T
1
V
SCA
VII
VA + AICA
1
M.O
VA
TN: SCA 82% HFS: VA 80% GPN: PICA VA and/or
EP
Ichikawa et 28 al. 2011
Strip-clip technique. A strip of equine collagen is used to wrap the culprit vessel. A clip is threaded through little holes made on the leaflets of the strip. A small hole is made on petrous dura and the blades are closed, clipping the petrous dura. Sling retraction. The sling is done by a simple suture.
T
T
36
28: V 5: VII 3: IX
String of unabsorbable dural tape fixed with a clip to the dura. Endoscope-assisted. “String and clip fixation”
T
7
3: V 4: VII
AC C
Skrap et al. 10 2010
V
TE D
Attabib et al. 19 2007
Titanium bone fixation plate. (10 cm). Small sheet of prosthetic Dacron. Methylmethacrylate. Biobond (Mitsubishi Pharma Corp., Osaka, Japan) and surgicel (ETHICON, INC., Somerville, NJ) Fenestrated aneurysm clip
No
9-18 months
Excellent
No
No
N/A
Excellent
No
No
13 months
Excellent 86%
14%
Fascia and monofilament suture.
No
6-24 months
Excellent
No
Arachnoid membrane of the cerebellopontine cistern TachoComb (CSL, Behring, Tokyo, Japan) with fibrin glue (BOLHEAL, Astellas Pharma Inc., Tokyo, Japan) Equine Collagen sheet (Vostra, Aachen, Germany) + Straight mini-aneurysm clip
No
24 months
Excellent
No
No
1 year
Excellent
No
No
N/A
Good
No
5-0 thread.
Transient ataxia due to venous infarction 11% CSF leakage 8% 1 transient hearing
8-30 months.
Excellent 86%
No.
9-92 weeks
Excellent x5
No
RI PT
Taki et al 18 2003
is used to wrap the culprit vessel. Suture of the tape to the petrous or tentorial dural. Titanium bone fixation plate. A stainless plate is bent and curved with pliers so as to transpose the culprit vessel and push it away from the cranial nerve. Fixation of the plate to the convexity of the occipital bone. Dacron between the metal plate and the culprit vessel. Surgical glue and Surgicel. Offending vessel is dissected and pushed away. Glue and Surgicel are used to fix the vessel to its new position.
SC
44
M AN U
al. 2002
Unabsorbable goretex dural tape.
ACCEPTED MANUSCRIPT
V
SCA
T
50
V
SCA 84% AICA 2% AICA + SCA 14%
Tentorial flap + Fenestrated clip. Culprit vessel is enclosed in the window of the fenestrated clip. A tentorial flap is dissected and prepared. The blades of the clip are closed, clipping the tentorial flap, while transposing the offending vessel (See video)
T
1
V
SCA
2-0 Silk thread
5-0 thread
M AN U
SC
12
Tentorial flap and Aesculap (Tuttlingen, Germany) fenestrated clip. L-shaped
impairment (hemotympanu m) 1 mild transient postoperative hyperesthesia No
Transient ataxia due to venous infarction 6% CSF leakage 8% No
Good x1 Fair x 1
24-38 months
Excellent
No
1.8-6.8 years.
Excellent 84%
4%
1 year
Excellent
No
Table 1: Review of the literature. Summary and significant findings of the studies describing transposing and/or combined techniques. Abbreviations: Type of technique: “T”=
TE D
Current Case
C
Transposing. “C” = Combined. N of cases= Number of cases. Cranial nerves are expressed with Roman numerals (i.e: V = Trigeminal Nerve). M.O = Medulla Oblongata. Vessels: BA=Basilar Artery. VA= Vertebral Artery. PICA= Postero-inferior cerebellarartery. AICA= antero-inferior cerebellarartery. SCA= Superior cerebellarartery. PCA= Posterior cerebral artery. Syndromes: TN= Trigeminal Neuralgia. HFS= Hemifacial Spasm. GPN= Glossopharyngeal Neuralgia. N/A = Not available. Results: BNI scale= Barrow
EP
Masuoka et 29 al. 2015
Sling retraction for failed or recurrent cases. A 2-0 silk thread is used to make a sling around the vessel. Suture to the tentorium dura. Sling retraction by a simple suture to petrous or clival dura.
Neurological Institute Pain Scale. MVD = Microvascular Decompression. CSF = Cerebrospinal Fluid.
AC C
Meybodi et 25 al. 2014
Fenestrated aneurysm clips
RI PT
BA
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
HIGHLIGHTS - A thorough description of an interposing technique with fenestrated clip for microvascular decompression is described. - The tentorial flap technique is less complex than previously published interposing techniques
AC C
EP
TE D
M AN U
SC
RI PT
- Meticulous review of the literature analyzing different interposing techniques is presented
ACCEPTED MANUSCRIPT
ABBREVIATIONS: MVD= Microvascular Decompression; SCA= Superior Cerebellar Artery; AICA= Anterior inferior cerebellar artery; MRI= Magnetic Resonance Imaging; REZ= Root Entry Zone; CSF=
AC C
EP
TE D
M AN U
SC
RI PT
Cerebrospinal fluid; SPV= Superior Petrosal Vein; RVLM= Rostral Ventrolateral Medulla.