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Table of Contents    
LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 1  |  Page : 276-277

A case of trigeminal neuralgia caused by both duplicated superior cerebellar arteries


Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan

Date of Web Publication7-Mar-2019

Correspondence Address:
Dr. Kazuma Doi
3-2 Namiki, Tokorozawa, Saitama 359-8513
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.253640

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How to cite this article:
Doi K, Takeuchi S, Toyooka T, Otani N, Wada K, Mori K. A case of trigeminal neuralgia caused by both duplicated superior cerebellar arteries. Neurol India 2019;67:276-7

How to cite this URL:
Doi K, Takeuchi S, Toyooka T, Otani N, Wada K, Mori K. A case of trigeminal neuralgia caused by both duplicated superior cerebellar arteries. Neurol India [serial online] 2019 [cited 2019 Mar 20];67:276-7. Available from: http://www.neurologyindia.com/text.asp?2019/67/1/276/253640




Sir,

Several variations in the superior cerebellar artery (SCA) have been described, such as unilateral duplicated SCAs with an incidence of 11%––28% and bilateral duplicated SCAs with an incidence of 8%.[1] Therefore, duplicated SCA are sometimes seen. However, duplicated SCA as the offending vessel in trigeminal neuralgia is unusual. One case with one of the duplicated SCAs compressing the trigeminal nerve has been reported.[2] We report the first case of trigeminal neuralgia caused by both duplicated SCAs.

A 47-year-old man consulted a dentist with a complaint of pain around the right gums, but no problems were identified 1 year before presentation. However, the pain became so severe that he could not wash his face or hair, 4 months later. Carbamazepine was administered and his symptom was temporarily improved, but subsequently, gradually worsened. He was diagnosed with trigeminal neuralgia and referred to our hospital for surgical treatment.

On admission, neurological examination found no abnormalities except for trigeminal neuralgia, which was provoked during eating, occurring in the second and third division territories of the right trigeminal nerve. No obvious trigger points were identified. Hematological and electrolyte laboratory examinations showed no abnormal results. Magnetic resonance angiography demonstrated that the basilar artery was tortuous and the right duplicated SCAs were both deviated inferiorly [Figure 1]a. Constructive interference in the steady-state imaging demonstrated that these arteries contacted the right trigeminal nerve, which was compressed laterally [Figure 1]b.
Figure 1: Preoperative MR angiography (a) showing the right duplicated superior cerebellar arteries (black arrows). Constructive interference in the steady-state image (b) demonstrating the offending arteries (white arrows) in contact with the right trigeminal nerve

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Microvascular decompression was performed through a lateral suboccipital approach. The upper trunk of the duplicated SCAs compressed the cranioventral part of the root entry zone (REZ) [Figure 2]a. Transposition was not possible due to the presence of perforating arteries to the brainstem, so interposition with Teflon mesh was performed. The lower trunk of the duplicated SCAs passed through the trigeminal nerve and then compressed the caudoventral part of the REZ [Figure 2]b. The SCA transfixing the trigeminal nerve prevented transposition, so interposition with Teflon mesh was performed. The anatomical situation before interposition is illustrated in [Figure 3]. Postoperatively, the trigeminal neuralgia disappeared, so medical follow-up was continued with no recurrence.
Figure 2: Intraoperative images showing the upper trunk of the duplicated SCAs (a: blackarrow) compressing the cranioventral part of the REZ and the lower trunk of the duplicated SCAs (b: black arrowheads) passing through the trigeminal nerve, then compressing the caudoventral part of the REZ. Teflon mesh was interposed between the SCA and the trigeminal nerve at each site

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Figure 3: Anatomical situation before interposition

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The present case is the first reported case of trigeminal neuralgia caused by both duplicated SCAs. Meandering or bending of the vessels, caused by arteriosclerosis or aging, commonly leads to nerve compression resulting in trigeminal neuralgia.[3] In our case, the vertebral artery was strongly meandering and both duplicated SCAs were deviated inferiorly, so arteriosclerosis was the most likely underlying cause.

The incidence of congenital anomaly transfixing the trigeminal nerve is about 0.8%.[4] Two surgical cases of trigeminal neuralgia involved the offending vessels penetrating into the trigeminal nerve. Microvascular decompression was successfully achieved with partial rhizotomy or partial nerve splitting.[3],[4] In our case, the lower trunk of the SCA passed through the trigeminal nerve and then compressed the caudoventral part of REZ. We judged that transposition was hard to perform. Therefore, Teflon mesh was interposed between the lower trunk of the SCA and the trigeminal nerve.

Microvascular decompression at the REZ is important in general in the surgical treatment of trigeminal neuralgia.[5] However, neurovascular compression is often found to be caused by multiple vessels during operation, ranging from 17% to 38% of cases.[6] Previously persistent trigeminal artery, basilar artery, anterior inferior cerebellar artery, and petrosal vein were identified as secondary offending vessels in addition to the SCA.[6],[7],[8] In one notable case of trigeminal neuralgia, microvascular decompression from the SCA was successfully accomplished, but recurrence of pain attack developed 1 year later due to insufficient decompression of the petrosal vein in the first operation.[8] Thus, failure to identify multiple vessels at surgery might be a cause of early treatment failure.[6] In the present case, we performed interposition with Teflon mesh at every site including the REZ, on the assumption that decompression only at the REZ would not be adequate. Therefore, in the case of trigeminal neuralgia associated with multiple vessels such as duplicated SCAs, preoperative identification of such vessels and recognition that this variation can cause trigeminal neuralgia are important for successful surgery without complications. All attachments between every vessel and the trigeminal nerve must be confirmed to ensure clinical cure. Special care is required for such anomalies associated with trigeminal neuralgia.

The present case of trigeminal neuralgia was caused by nerve compression by both duplicated SCAs. All attachments between every vessel and the trigeminal nerve must be confirmed for achieving a clinical cure of trigeminal neuralgia associated with multiple vessels such as duplicated SCAs. Special care is required for addressal of such anomalies associated with trigeminal neuralgia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mani RL, Newton TH, Glickman MG. The superior cerebellar artery: An anatomic-roentgenographic correlation. Radiology 1968;91:1102-8.  Back to cited text no. 1
    
2.
Uchino A, Sawada A, Takase Y, Kudo S. Variations of the superior cerebellar artery: MR angiographic demonstration. Radiat Med 2003;21:235-8.  Back to cited text no. 2
    
3.
Furuse M, Kuroda Y, Kobata H, Nagasawa S, Ohta T. [Trigeminal neuralgia with the offending artery transfixing the trigeminal nerve: A case report]. No Shinkei Geka 1999;27:1019-22. Japanese.  Back to cited text no. 3
    
4.
Tashiro H, Kondo A, Aoyama I, Nin K, Shimotake K, Nishioka T, et al. Trigeminal neuralgia caused by compression from arteries transfixing the nerve. Report of three cases. J Neurosurg 1991;75:783-6.  Back to cited text no. 4
    
5.
Barker FG II, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 1996;334:1077-83.  Back to cited text no. 5
    
6.
Yamada Y, Kondo A, Tanabe H. Trigeminal neuralgia associated with an anomalous artery originating from the persistent primitive trigeminal artery. Neurol Med Chir (Tokyo) 2006;46:194-7.  Back to cited text no. 6
    
7.
Choudhari KA. Quadruple vessel involvement at root entry zone in trigeminal neuralgia. Clin Neurol Neurosurg 2007;109:203-5.  Back to cited text no. 7
    
8.
Kitahara I, Fukuda A, Tanaka R, Morito T, Yokochi T. [Transient- or continuous-recurrence of trigeminal neuralgia after microvascular decompression]. The Journal of the Japanese Society for the Study of Chronic Pain 2015;34:1-4. Japanese.  Back to cited text no. 8
    


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