Sling-Pulling and Macrovascular Transposition for Giant Basilar Artery Trigeminal Neuralgia

Overview

This report describes a novel surgical approach combining trigeminal nerve transposition via a sling-pulling technique with macrovascular transposition of a gigantic basilar artery to treat refractory trigeminal neuralgia. The combined transpetrosal approach enabled effective decompression, resulting in sustained pain relief at 20 months postoperatively.

Background

Trigeminal neuralgia caused by dolichoectatic vertebrobasilar arteries (DBA) is rare and challenging to treat, with conventional microvascular decompression showing high failure and recurrence rates. Macrovascular transposition techniques have shown promise but are limited by the complexity of giant DBAs and restricted posterior fossa space. Surgical strategies that achieve permanent vessel and nerve transposition may improve long-term outcomes in these patients.

Data Highlights

The patient was a 46-year-old male with a gigantic 11.69 mm DBA compressing the right trigeminal nerve root exit zone. Postoperative follow-up at 20 months showed complete pain relief. Facial palsy (House-Brackmann grade 3) occurred postoperatively but fully resolved by 4 months; mild facial hypoesthesia persisted. Imaging confirmed adequate decompression and increased cisternal space around the nerve and artery.

Key Findings

• The sling-pulling technique using a non-absorbable biological patch allowed permanent lateral transposition of the trigeminal nerve anchored to the temporal dura.
• Macrovascular transposition of the giant DBA was achieved by placing Teflon felt soaked in fibrin glue to tilt and anchor the artery anteriorly on the drilled petroclival bone.
• The combined transpetrosal approach provided optimal surgical exposure, enabling extensive bone drilling and safe arachnoid dissection.
• The dual transposition technique resulted in durable decompression of the trigeminal nerve root exit zone from the giant DBA.
• Postoperative complications were transient facial palsy and persistent mild hypoesthesia, with full resolution of palsy by 4 months.
• At 20-month follow-up, the patient remained pain-free, indicating sustained efficacy of the procedure.

Clinical Implications

For patients with trigeminal neuralgia caused by giant dolichoectatic basilar arteries, conventional decompression techniques may be insufficient due to limited posterior fossa space. The sling-pulling technique combined with macrovascular transposition via a combined transpetrosal approach offers a viable surgical option to achieve permanent nerve and vessel repositioning. This method may reduce recurrence risk and improve long-term pain control, though careful intraoperative technique is required to minimize complications.

Conclusion

The novel combined sling-pulling trigeminal nerve transposition and macrovascular transposition through a transpetrosal approach provides effective and durable decompression for giant basilar artery-induced trigeminal neuralgia. This approach may represent an important advancement in managing complex vascular compression cases refractory to conventional treatments.

References

1. P.N. et al. -- Sling-Pulling Technique for Trigeminal Nerve Transposition Combined with Macrovascular Transposition in Treating Giant Basilar Artery-Induced Trigeminal Neuralgia via a Transpetrosal Approach