PMC4533392_01
Three-dimensional reconstructed magnetic resonance (MR) angiography showing the tortuous and elongated left vertebral artery.
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Three dimensionally reconstructed (3D) MR angiography showed tortuous and elongated left vertebral artery (VA) (Fig. 1).
Axial three dimensionally reconstructed magnetic resonance (3D-MR) cisternography with contrast enhancement shows that the left trigeminal nerve was compressed from underneath by the tortuous and elongated left vertebral artery.
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The coronal section of 3D-T2-driven equilibrium radio frequency reset pulse (DRIVE), axial, and coronal 3D-MR cisternography with contrast enhancement showed that the left trigeminal nerve was compressed from underneath by the tortuous and elongated left VA (Figs. 2, 3A, B).
The pre- (A) and postoperative (C) coronal section of 3D-T2-driven equilibrium radio frequency reset pulse (DRIVE) and pre- (B) and postoperative (D) coronal section of 3D-MR cisternography with contrast enhancement show the successful transposition of the left vertebral artery away from the left trigeminal nerve. Upper arrow: left trigeminal nerve, lower arrow: left vertebral artery, arrow head: Teflon  sheet (Fluoro-Plastics, Inc., Philadelphia, Pennsylvania, USA).
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The coronal section of 3D-T2-driven equilibrium radio frequency reset pulse (DRIVE), axial, and coronal 3D-MR cisternography with contrast enhancement showed that the left trigeminal nerve was compressed from underneath by the tortuous and elongated left VA (Figs. 2, 3A, B). MR images at 3 months after the operation showed that the left VA was separated from the trigeminal nerve (Fig. 3C, D).
Intraoperative images. A: The trigeminal nerve was directly compressed by the left tortuous vertebral artery (VA). B: The VA was able to be easily moved with a suction because the wall of the left VA was rather soft and not arteriosclerotic. C, D: Prior to the transposition of the VA, a small piece of Teflon sheet were inserted between VA and pons proximal to the vessel-nerve conflict site, so that the entire left VA is moved away from the trigeminal nerve to diverse the pressure from VA to the prosthesis and to prevent the rebound of the tortuous VA. The VA was transposed to the caudal side with Teflon sling covering cranial side of the artery. E: In this procedure, we used a wide Teflon sling, which enable to diverse the pressure to the arterial wall during the transposition. The Teflon sling was fixed to the petrous bone and pons with fibrin glue. F: The trigeminal nerve is free from the Teflon sling and vertebral artery. asterisk: left vertebral artery.
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The trigeminal nerve was directly compressed by the left tortuous VA (Fig. 4A). Based on the intraoperative findings, wall of the left VA was rather soft and not arteriosclerotic, thus, VA was able to be moved easily with a suction or microdissection (Fig. 4B). Teflon sheet was inserted between VA and pons proximal to the vessel-nerve conflict site, so that the entire left VA was moved away from the trigeminal nerve; it is an useful technique to diverse the pressure from VA to the prosthesis and to prevent the rebound of the tortuous VA (Fig. 4C, D). Then the VA was transposed to the caudal side with a wider Teflon sling covering cranial side of the artery. Teflon sling, which enabled to diverse the pressure to the arterial wall during the transposition preventing arterial dissection (Fig. 4E). Then the Teflon sling was fixed to the petrous bone and pons with fibrin glue (Fig. 4F).