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ObjectivesThis study aimed to investigate the feasibility of segmentation-independent volume rendering (SI-VR) in visualising the root entry zone (REZ), and to explore the influence on the management of vascular compression syndromes (VCSs).MethodsTwo hundred and twenty patients with VCSs were recruited in this prospective study from July 2015 to May 2019. SI-VR was reconstructed based on inverted 3D fast spin echo T2WI. They were assigned to the experimental group and control group randomly. Patients in the experimental group would accept extra evaluation based on SI-VR before microvascular decompression. Image quality and diagnostic accuracy between SI-VR and 3D fast spin echo T2WI in the experimental group were compared by Mann–Whitney U test and chi-square test, separately. Interobserver agreement was performed with intraclass correlation coefficient. Postsurgical outcomes and complications between two groups were compared by chi-square test.ResultsSI-VR had a better interobserver agreement (0.82 vs 0.68) and diagnostic accuracy (95.5% vs 83.6%, p = 0.004) than that of 3D fast spin echo T2WI. Especially, significantly improved diagnostic accuracy was reached in detecting the multi-vascular branches compression (100% vs 15.4%, p < 0.001). There were fewer complications (7.1% vs 26.8%, p = 0.004) and less operation time (20.7 min vs 14.5 min, p = 0.007) but no significant difference of pain relief (p = 0.19) in the experimental group than in the control group.ConclusionsThe SI-VR method is feasible for the precise demonstration of the anatomy structure along the REZ, with high reliability and reproducibility. Unbiased pre-surgical visualisation could reduce redundant explorations and post-surgical complications in patients who undergo microvascular decompression.Key Points• Visualisation of the root entry zone by the segmentation-independent volume rendering is in accordance with the landscape by the neuro-endoscopy.• Segmentation-independent volume rendering has an advantage over 3D fast spin echo T2WI in the visualisation of multi-vascular branches compression.• Presurgical 3D visualisation of the neurovascular compression at the root entry zone leads to less postsurgical complications from the decrease of redundant exploration.

Abstract BACKGROUND Microvascular decompression (MVD) is a potentially curative surgery for drug-resistant trigeminal neuralgia (TN). Predictors of pain freedom after MVD are not fully understood. OBJECTIVE To describe rates and predictors for pain freedom following MVD. METHODS Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, PubMed, Cochrane Library, and Scopus were queried for primary studies examining pain outcomes after MVD for TN published between 1988 and March 2018. Potential biases were assessed for included studies. Pain freedom (ie, Barrow Neurological Institute score of 1) at last follow-up was the primary outcome measure. Variables associated with pain freedom on preliminary analysis underwent formal meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for possible predictors. RESULTS Outcome data were analyzed for 3897 patients from 46 studies (7 prospective, 39 retrospective). Overall, 76.0% of patients achieved pain freedom after MVD with a mean follow-up of 1.7 ± 1.3 (standard deviation) yr. Predictors of pain freedom on meta-analysis using random effects models included (1) disease duration ≤5 yr (OR = 2.06, 95% CI = 1.08-3.95); (2) arterial compression over venous or other (OR = 3.35, 95% CI = 1.91-5.88); (3) superior cerebellar artery involvement (OR = 2.02, 95% CI = 1.02-4.03), and (4) type 1 Burchiel classification (OR = 2.49, 95% CI = 1.32-4.67). CONCLUSION Approximately three-quarters of patients with drug-resistant TN achieve pain freedom after MVD. Shorter disease duration, arterial compression, and type 1 Burchiel classification may predict more favorable outcome. These results may improve patient selection and provider expectations. Graphical Abstract Graphical Abstract

Background Microvascular decompression (MVD) represents the only definitive and non-ablative treatment for hemifacial spasm (HS). Teflon is the most used interposing material because considered inert; nevertheless, it is not free from complications. Method We discuss and illustrate our method to resolve the neurovascular conflict accounting for HS through a sling transposition technique using aneurysm clip and biopatch in carefully selected cases. Conclusion Several MVD procedures, including interposing and transposing techniques, have been proposed for HS, mainly selected according to surgeon’s preference. We consider the described technique a definitive treatment, safe, not associated to pain recurrence and without needing revision surgery.

Objective: This study aimed to investigate the clinical efficacy and early outcomes of endoscopic microvascular decompression (MVD) for primary trigeminal neuralgia (TN) and provide clinical experience for the application of full endoscopic techniques in MVD surgery. Methods: This study retrospectively collected medical records of patients who underwent microvascular decompression (MVD) surgery at our institution between January 2020 and January 2023. According to predefined inclusion and exclusion criteria, a total of 137 patients were ultimately included in the study. To evaluate the severity of facial pain in these patients, we utilized the Barrow Neurological Institute (BNI) pain intensity rating system. Additionally, this study analyzed and compared the clinical outcomes of MVD procedures performed endoscopically versus those performed under microscopy. Results: There were no statistically significant differences between endoscopic and microscopic microvascular decompression (MVD) in terms of postoperative hospital stay, recurrence rate, complication incidence, and surgical duration ( P  > 0.05). However, regarding the efficacy of treatment, the effectiveness rate after endoscopic MVD was superior to that of microscopic MVD, with a statistically significant difference observed between the two groups ( P  < 0.05). Conclusion: Endoscopic microvascular decompression (MVD) for primary trigeminal neuralgia is a safe and effective treatment, with the critical success factor being the accurate localization of the vessel compressing the nerve. Compared to traditional microscopic MVD, endoscopic MVD shows superior postoperative outcomes, offering wide-angle and multi-angle views along with close-up inspection capabilities. However, it requires attention to overcoming limitations such as a lack of stereoscopic vision and potential blind spots.

Background Various instruments are used in microvascular decompression (MVD) to mobilize offending vessels. Most instruments have straight tips for safety but provide limited ability to retract vessels toward the surgeon. To address this limitation, we developed a double-faced microprobe, designated as the “SWAN probe,” to enhance maneuverability in confined operative spaces. Methods The instrument has a 2.5-mm upward-bending tip (1.0-mm width) with multiple curved surfaces for controlled vessel manipulation. The inner face (angled at 45° with a narrow hollow) allows secure vessel capture and retraction, whereas the outer face (angled at 60° with a broader hollow) is optimized for advancing the vessel away from the nerve. Flat lateral surfaces enable gentle lateral displacement. The sandblasted surface reduces slippage and minimizes light reflection. The microprobe was used in 51 MVD procedures for trigeminal neuralgia (TN) and hemifacial spasm (HFS). Its utility and safety were assessed based on intraoperative performance across key maneuvers. Results Usability scores were consistently higher than the theoretical baseline representing procedures achievable with conventional straight-tip instruments. Benefits were most apparent during proximal retraction (“pull-out”) maneuvers of the superior cerebellar artery. The probe also aided Teflon sling handling and controlled arachnoid incision. No procedure-related complications attributable to the instrument were observed. Conclusions The double-faced microprobe allows both retraction and displacement of offending vessels, improving intraoperative maneuverability in selected situations. Within the limits of this study, the SWAN probe appears to be a safe and useful adjunct for MVD and may have broader applicability in microsurgery.

Abstract BACKGROUND Microvascular decompression (MVD) is the most effective procedure for hemifacial spasm (HFS). MVD results from nonspecialized or low-volume institutes are not always reliable. Most studies on MVD for HFS are retrospective and single centered; to the best of our knowledge, no prospective, multicenter studies exist. OBJECTIVE To evaluate short- and long-term outcomes and complications in patients who underwent MVD for HFS in specialized Japanese institutions, in this multicenter, prospective, cohort study. METHODS Included patients had undergone MVD for HFS in study centers between April 2012 and March 2015. Patients’ postoperative grade of involuntary movements and complications were recorded postoperatively at 7 d (short-term) and at 1 (mid-term) and 3 (long-term) yr. RESULTS A total of 486 patients (150 men, 336 women; mean age 53.9 yr with 181 patients over 60 yr) were enrolled during the study period. Neuromonitoring was used in 96.3% of the cases. The complete cure rate of symptom relief, mortality rate, and complication rate at short-term follow-up were 70.6%, 0%, and 15%, respectively. The long-term follow-up was completed by 463 patients (95.3%); the complete cure rate of symptom relief and complication rate were 87.1% and 3.0%, respectively. CONCLUSION Our study revealed that under expert guidance and intraoperative neuromonitoring, the long-term curative effect rate of MVD for HFS is high, while complications are uncommon and usually transient. Our results indicate that MVD is an effective and safe treatment for patients with HFS, including elderly patients. Graphical Abstract Graphical Abstract

Semantic segmentation involves an imminent part in the investigation of medical images, particularly in the domain of microvascular decompression, where publicly available datasets are scarce, and expert annotation is demanding. In response to this challenge, this study presents a meticulously curated dataset comprising 2003 RGB microvascular decompression images, each intricately paired with annotated masks. Extensive data preprocessing and augmentation strategies were employed to fortify the training dataset, enhancing the robustness of proposed deep learning model. Numerous up-to-date semantic segmentation approaches, including DeepLabv3+, U-Net, DilatedFastFCN with JPU, DANet, and a custom Vanilla architecture, were trained and evaluated using diverse performance metrics. Among these models, DeepLabv3 + emerged as a strong contender, notably excelling in F1 score. Innovatively, ensemble techniques, such as stacking and bagging, were introduced to further elevate segmentation performance. Bagging, notably with the Naïve Bayes approach, exhibited significant improvements, underscoring the potential of ensemble methods in medical image segmentation. The proposed EnsembleEdgeFusion technique exhibited superior loss reduction during training compared to DeepLabv3 + and achieved maximum Mean Intersection over Union (MIoU) scores of 77.73%, surpassing other models. Category-wise analysis affirmed its superiority in accurately delineating various categories within the test dataset.

Purpose Building on the pioneering observations of Dandy and Gardner and on Jannetta’s establishment of microvascular decompression (MVD) through microsurgical demonstration of vascular compression, MVD has continuously evolved into a safe and durable treatment for neurovascular compression syndromes. Despite advances in radiosurgery and pharmacotherapy, MVD remains widely used as a first-line surgical option for appropriately selected patients with trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia. Methods This selective narrative historical review traces MVD’s modern evolution after its establishment by Jannetta, organized into four pillars: surgical anatomy, optimization of approaches, decompression strategies, and operative support. Results Detailed microsurgical anatomy, including the “Rule of Three” framework for the cerebellopontine angle, has helped guide tailored, minimally invasive approaches (e.g., the lateral supracerebellar-infratentorial route for trigeminal neuralgia and infrafloccular exposure for hemifacial spasm). Decompression strategies have extended from prosthetic interposition toward noncompressive transposition and biologically harmonious fixation. Advances in visualization (endoscopic and exoscopic systems), simulation, and neuronavigation have extended the original visualization ethos and enhanced surgical education. Intraoperative monitoring, including brainstem auditory evoked potentials and lateral spread responses, has improved both complication avoidance and intraoperative confidence. Conclusion Together, these anatomical “maps” and physiological “compasses” help define contemporary MVD practice aimed at safe and durable outcomes across diverse patient anatomies.

BACKGROUND:In trigeminal neuralgia type 1 (TN1), neurovascular compression (NVC) is often assumed to be the pain initiating mechanism. NVC can be surgically addressed by microvascular decompression (MVD). However, some patients with TN1 present without NVC (WONVC). OBJECTIVE:To characterize and analyze the clinical spectrum of a TN1 patient population WONVC. METHODS:A retrospective chart review of patients presenting with TN1 between 2007 and 2017 was performed. Patients who were potential candidates for MVD surgery underwent high-resolution imaging with 3-dimensional (3D) reconstruction to address the presence, or absence, of NVC. Demographic data about the populations with NVC (WNVC) and WONVC were collected. RESULTS:Of 242 patients with TN1, 32% did not have NVC. Patients WONVC were on average 10.6 yr younger than those WNVC. TN1 onset in patients WONVC was more frequent below 48.7 yr, and the opposite was found in patients WNVC. Compared to patients WNVC, those WONVC were predominantly female (odds ratio 4.8), on average were 4 yr younger at symptom onset (34.7 yr) and 7.8 yr younger at first clinic visit, and had a 3.7 yr shorter symptom duration. CONCLUSION:Patients presenting with TN1 WONVC were predominantly females in their mid-30s with short symptom duration. In the absence of NVC, this subgroup of TN1 patients has limited surgical options, and potentially a longer condition duration that must be managed medically or surgically. This population WONVC might provide insights into the true pathophysiology of TN1.

Background Trigeminal neuralgia secondary to vertebrobasilar dolichoectasia (VBD-TN) poses a significant challenge in the surgical management of trigeminal neuralgia. This study aimed to evaluate and compare the therapeutic efficacy of microvascular decompression (MVD) and percutaneous balloon compression (PBC) in patients with VBD-TN. Methods We conducted a retrospective cohort analysis of consecutive VBD-TN patients treated at a tertiary hospital in China between September 2013 and August 2022. Participants were stratified by the intervention (MVD vs PBC), with systematic evaluation of postoperative pain control efficacy and complication rates. Results This study enrolled 107 patients with VBD-TN, with a mean age of 64.8 ± 10.0 years and a mean follow-up duration of 3.9 ± 1.9 years. The cohort comprised 64 patients undergoing MVD and 43 receiving PBC. Both groups achieved excellent initial pain control (The Barrow Neurological Institute scoring system (BNI) pain score I or II). The recurrence (BNI Ⅲ, Ⅳ, Ⅴ) rates were 12.5% (8/64) in the MVD group versus 20.9% (9/43) in the PBC group ( p  = 0.242) at the last follow-up, showing no statistically significant difference. Early postoperative assessment revealed significantly higher incidences of trigeminal dysfunction including facial numbness, dry eye symptoms, and masticatory muscle weakness in the PBC group compared to the MVD group ( p  < 0.05 for all). Conversely, the MVD group demonstrated more diverse complications, with craniotomy-related adverse events including intracranial infection (4.7%), cerebrospinal fluid leakage (3.1%), and incision infection (3.1%), while cranial nerve complications comprised diplopia (3.1%), facial palsy (1.6%), hearing loss (7.8%), and tinnitus (9.4%). At the final follow-up, the PBC group exhibited significantly higher BNI numbness scores than the MVD group ( p  = 0.001). The PBC group showed advantages in healthcare utilization metrics, with significantly shorter postoperative hospital stays and lower hospitalization costs compared to the MVD group ( p  < 0.001). Conclusions Both MVD and PBC are safe and effective therapeutic options for VBD-TN. MVD is associated with higher hospitalization costs, prolonged hospital stays, and a greater incidence of cranial nerve complications, though most of these complications are treatable. The main disadvantage of PBC lies in the long-term facial numbness.