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Classification of neurovascular compression in glossopharyngeal neuralgia: Three-dimensional visualization of the glossopharyngeal nerve.

Tanrikulu L, Hastreiter P, Dörfler A, Buchfelder M, Naraghi R - Surg Neurol Int (2015)

Bottom Line: The 3D visualizations were interactively compared with the intraoperative setup during microvascular decompression (MVD) in order to verify the results by the observed surgical-anatomical findings. 15 patients (female/male: 5/10) were examined.It proves to be advantageous in supporting to establish the diagnosis and microneurosurgical interventions by representing original, individual patient data in a 3D fashion.It provides an excellent global individual view over the entire neurovascular relationships of the brainstem and corresponding nerves in each case.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany; Department of Neurosurgery, Hannover Nordstadt Hospital, Hannover, Germany.

ABSTRACT

Background: We introduce a method of noninvasive topographical analysis of the neurovascular relationships of the glossopharyngeal nerve (CN IX) by three-dimensional (3D) visualization. Patients with glossopharyngeal neuralgia (GN) resulting from neurovascular compression (NVC) were studied.

Methods: 15 patients with GN were prospectively examined with 3D visualization using high-resolution magnetic resonance imaging with constructive interference in steady state (MR-CISS). The datasets were segmented and visualized with the real, individual neurovascular relationships by direct volume rendering. Segmentation and 3D visualization of the CN IX and corresponding blood vessels were performed. The 3D visualizations were interactively compared with the intraoperative setup during microvascular decompression (MVD) in order to verify the results by the observed surgical-anatomical findings.

Results: 15 patients (female/male: 5/10) were examined. All of them underwent MVD (100%). Microvascular details were documented. The posterior inferior cerebellar artery (PICA) was the most common causative vessel in 12 of 15 patients (80%), the vertebral artery (VA) alone in one case (6.7%), and the combination of compression by the VA and PICA in 3 patients (13.3%). We identified three distinct types of NVC within the root entry zone of CN IX.

Conclusion: 3D visualization by direct volume rendering of MR-CISS data offers the opportunity of noninvasive exploration and anatomical categorization of the CN IX. It proves to be advantageous in supporting to establish the diagnosis and microneurosurgical interventions by representing original, individual patient data in a 3D fashion. It provides an excellent global individual view over the entire neurovascular relationships of the brainstem and corresponding nerves in each case.

No MeSH data available.


Related in: MedlinePlus

Surgical aspect of microvascular decompression by the interpolation of teflon between the nerve and the causative vessel. The surgical microphotographs correspond to three-dimensional visualization in Figure 3. (a) Microneurosurgical view over the anatomical findings in a patient with left-sided glossopharyngeal neuralgia after left-sided suboccipital, retrosigmoid craniectomy, release of cerebrospinal fluid from cisterna magna and cerebellar retraction (CN VIII: Vestibulocochlear nerve, CN IX: Glossopharyngeal nerve, CN X: Vagus nerve, CN XI: Accessory nerve). Note the clear view over Bochdalek's flower basket at the nerval interspace between the glossopharyngeal and the vagus nerves. (b) Preparation of the causative vessel: The posterior inferior cerebellar artery originates medially from the vertebral artery and performs a loop over the glossopharyngeal-vagus nerve complex with its proximal segment. More distally the posterior inferior cerebellar artery performs neurovascular compression at the glossopharyngeal root entry zone at the ventrolateral medulla oblongata by performing a downward complex dome. (c) Microvascular decompression with teflon. Note the visualization of the more caudally localized and preserved laryngeal nerve
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Figure 6: Surgical aspect of microvascular decompression by the interpolation of teflon between the nerve and the causative vessel. The surgical microphotographs correspond to three-dimensional visualization in Figure 3. (a) Microneurosurgical view over the anatomical findings in a patient with left-sided glossopharyngeal neuralgia after left-sided suboccipital, retrosigmoid craniectomy, release of cerebrospinal fluid from cisterna magna and cerebellar retraction (CN VIII: Vestibulocochlear nerve, CN IX: Glossopharyngeal nerve, CN X: Vagus nerve, CN XI: Accessory nerve). Note the clear view over Bochdalek's flower basket at the nerval interspace between the glossopharyngeal and the vagus nerves. (b) Preparation of the causative vessel: The posterior inferior cerebellar artery originates medially from the vertebral artery and performs a loop over the glossopharyngeal-vagus nerve complex with its proximal segment. More distally the posterior inferior cerebellar artery performs neurovascular compression at the glossopharyngeal root entry zone at the ventrolateral medulla oblongata by performing a downward complex dome. (c) Microvascular decompression with teflon. Note the visualization of the more caudally localized and preserved laryngeal nerve

Mentions: The MR-CISS images clearly depicted the CN IXs and corresponding vessels within the hyperintense CSF volume. We could distinguish nerves from vessels on the basis of signal intensity, anatomical characteristics, and the anatomical course in the MR-CISS. The interactive 3D visualization demonstrated the spatial relationships between the CN IX and the corresponding vessels in all patients (100%); [Figures 3 and 4]. The PICA was the most common causative vessel in 12 out of 15 patients (80%), the VA alone in one case (6.7%) and the combination of a compression by the VA and the PICA in two cases (13.3%). Each offending vessel at the REZ of CN IX, which was visualized preoperatively, could also be detected intraoperatively (Figures 3 and 6a–c; the operative field in Figures 6a–c correspond to the 3D visualization in Figure 3). The surgeon was able to observe the entire microvascular and neural structures within the CSF space of the individual patient by 3D visualization corresponding to the microsurgical operative domain. Pulsation artifacts were not observed at the lateral medulla oblongata and the interesting CN IXs. We were able to find several characteristic situations which led us to describe distinct types of NVC [Figure 5]. The PICA, as coming from the VA has first to travel cranially and later downward after performing a loop over the IX-X-nerve-complex as proximal vessel portion and then performing NVC at the REZ of the CN IX within the retro-olivary sulcus and coursing more laterally [Figure 5, Type I]. The VA alone performs NVC at the glossopharyngeal REZ by the shoulder of the vessel [Figure 5, Type II]. A “sandwich-like” compression was observed in cases where the VA and the PICA perform a combination of compression [Figure 5, Type III].


Classification of neurovascular compression in glossopharyngeal neuralgia: Three-dimensional visualization of the glossopharyngeal nerve.

Tanrikulu L, Hastreiter P, Dörfler A, Buchfelder M, Naraghi R - Surg Neurol Int (2015)

Surgical aspect of microvascular decompression by the interpolation of teflon between the nerve and the causative vessel. The surgical microphotographs correspond to three-dimensional visualization in Figure 3. (a) Microneurosurgical view over the anatomical findings in a patient with left-sided glossopharyngeal neuralgia after left-sided suboccipital, retrosigmoid craniectomy, release of cerebrospinal fluid from cisterna magna and cerebellar retraction (CN VIII: Vestibulocochlear nerve, CN IX: Glossopharyngeal nerve, CN X: Vagus nerve, CN XI: Accessory nerve). Note the clear view over Bochdalek's flower basket at the nerval interspace between the glossopharyngeal and the vagus nerves. (b) Preparation of the causative vessel: The posterior inferior cerebellar artery originates medially from the vertebral artery and performs a loop over the glossopharyngeal-vagus nerve complex with its proximal segment. More distally the posterior inferior cerebellar artery performs neurovascular compression at the glossopharyngeal root entry zone at the ventrolateral medulla oblongata by performing a downward complex dome. (c) Microvascular decompression with teflon. Note the visualization of the more caudally localized and preserved laryngeal nerve
© Copyright Policy - open-access
Related In: Results  -  Collection

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Figure 6: Surgical aspect of microvascular decompression by the interpolation of teflon between the nerve and the causative vessel. The surgical microphotographs correspond to three-dimensional visualization in Figure 3. (a) Microneurosurgical view over the anatomical findings in a patient with left-sided glossopharyngeal neuralgia after left-sided suboccipital, retrosigmoid craniectomy, release of cerebrospinal fluid from cisterna magna and cerebellar retraction (CN VIII: Vestibulocochlear nerve, CN IX: Glossopharyngeal nerve, CN X: Vagus nerve, CN XI: Accessory nerve). Note the clear view over Bochdalek's flower basket at the nerval interspace between the glossopharyngeal and the vagus nerves. (b) Preparation of the causative vessel: The posterior inferior cerebellar artery originates medially from the vertebral artery and performs a loop over the glossopharyngeal-vagus nerve complex with its proximal segment. More distally the posterior inferior cerebellar artery performs neurovascular compression at the glossopharyngeal root entry zone at the ventrolateral medulla oblongata by performing a downward complex dome. (c) Microvascular decompression with teflon. Note the visualization of the more caudally localized and preserved laryngeal nerve
Mentions: The MR-CISS images clearly depicted the CN IXs and corresponding vessels within the hyperintense CSF volume. We could distinguish nerves from vessels on the basis of signal intensity, anatomical characteristics, and the anatomical course in the MR-CISS. The interactive 3D visualization demonstrated the spatial relationships between the CN IX and the corresponding vessels in all patients (100%); [Figures 3 and 4]. The PICA was the most common causative vessel in 12 out of 15 patients (80%), the VA alone in one case (6.7%) and the combination of a compression by the VA and the PICA in two cases (13.3%). Each offending vessel at the REZ of CN IX, which was visualized preoperatively, could also be detected intraoperatively (Figures 3 and 6a–c; the operative field in Figures 6a–c correspond to the 3D visualization in Figure 3). The surgeon was able to observe the entire microvascular and neural structures within the CSF space of the individual patient by 3D visualization corresponding to the microsurgical operative domain. Pulsation artifacts were not observed at the lateral medulla oblongata and the interesting CN IXs. We were able to find several characteristic situations which led us to describe distinct types of NVC [Figure 5]. The PICA, as coming from the VA has first to travel cranially and later downward after performing a loop over the IX-X-nerve-complex as proximal vessel portion and then performing NVC at the REZ of the CN IX within the retro-olivary sulcus and coursing more laterally [Figure 5, Type I]. The VA alone performs NVC at the glossopharyngeal REZ by the shoulder of the vessel [Figure 5, Type II]. A “sandwich-like” compression was observed in cases where the VA and the PICA perform a combination of compression [Figure 5, Type III].

Bottom Line: The 3D visualizations were interactively compared with the intraoperative setup during microvascular decompression (MVD) in order to verify the results by the observed surgical-anatomical findings. 15 patients (female/male: 5/10) were examined.It proves to be advantageous in supporting to establish the diagnosis and microneurosurgical interventions by representing original, individual patient data in a 3D fashion.It provides an excellent global individual view over the entire neurovascular relationships of the brainstem and corresponding nerves in each case.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany; Department of Neurosurgery, Hannover Nordstadt Hospital, Hannover, Germany.

ABSTRACT

Background: We introduce a method of noninvasive topographical analysis of the neurovascular relationships of the glossopharyngeal nerve (CN IX) by three-dimensional (3D) visualization. Patients with glossopharyngeal neuralgia (GN) resulting from neurovascular compression (NVC) were studied.

Methods: 15 patients with GN were prospectively examined with 3D visualization using high-resolution magnetic resonance imaging with constructive interference in steady state (MR-CISS). The datasets were segmented and visualized with the real, individual neurovascular relationships by direct volume rendering. Segmentation and 3D visualization of the CN IX and corresponding blood vessels were performed. The 3D visualizations were interactively compared with the intraoperative setup during microvascular decompression (MVD) in order to verify the results by the observed surgical-anatomical findings.

Results: 15 patients (female/male: 5/10) were examined. All of them underwent MVD (100%). Microvascular details were documented. The posterior inferior cerebellar artery (PICA) was the most common causative vessel in 12 of 15 patients (80%), the vertebral artery (VA) alone in one case (6.7%), and the combination of compression by the VA and PICA in 3 patients (13.3%). We identified three distinct types of NVC within the root entry zone of CN IX.

Conclusion: 3D visualization by direct volume rendering of MR-CISS data offers the opportunity of noninvasive exploration and anatomical categorization of the CN IX. It proves to be advantageous in supporting to establish the diagnosis and microneurosurgical interventions by representing original, individual patient data in a 3D fashion. It provides an excellent global individual view over the entire neurovascular relationships of the brainstem and corresponding nerves in each case.

No MeSH data available.


Related in: MedlinePlus