Microvascular Decompression for Vertebrobasilar Dolichoectasia-Related Primary Trigeminal Neuralgia: Surgical Strategies, Technical Nuances, and Clinical Outcomes

Microvascular Decompression for Vertebrobasilar Dolichoectasia-Related Primary Trigeminal Neuralgia: Surgical Strategies, Technical Nuances, and Clinical Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Microvascular Decompression for Vertebrobasilar Dolichoectasia-Related Primary Trigeminal Neuralgia: Surgical Strategies, Technical Nuances, and Clinical Outcomes Xueke Zhen, Xiaoli Xu, Xu Sao, Yanbing Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7400143/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jan, 2026 Read the published version in Neurosurgical Review → Version 1 posted 11 You are reading this latest preprint version Abstract Objectives: To investigate the surgical strategies, technical key points, and clinical efficacy of microvascular decompression (MVD) in treating primary trigeminal neuralgia (PTN) associated with vertebrobasilar dolichoectasia (VBD). Methods: A retrospective analysis was conducted on 34 consecutive VBD-related PTN patients treated by a single neurosurgeon at the China-Japan Friendship Hospital between January 2020 and April 2025. VBD compression patterns were classified into two types: ​Type I: Imaging showing significant brainstem deformation and obliterated arachnoid space by VBD (n=16, 47.1%). ​Type II: Imaging confirming VBD presence without or with minimal brainstem deformation and preserved arachnoid space (n=18, 52.9%). Type-specific MVD techniques were applied: a four-step approach for Type I and a three-step approach for Type II. Outcomes were evaluated using the Barrow Neurological Institute Pain Intensity Scale (BNI) during follow-up (range: 2–64 months). Results: Among 1,214 PTN patients treated during the study period, 34 (2.8%) had VBD-related PTN. ​Preoperative BNI grades: Grade V in 8 patients (23.5%); Grade IV in 26 patients (76.5%). 17.6% (6/34) had comorbid cranial neuropathies. ​Postoperative outcomes: BNI Grade I: 91.2% (31/34)，BNI Grade II: 8.9% (3/34)，Overall success rate (BNI ≤ II): 100%. Conclusion: VBD-related PTN is a rare clinical entity characterized by severe refractory pain. Based on VBD compression morphology (Type I vs. Type II), tailored MVD strategies provide a safe and effective surgical approach, achieving excellent pain relief. Vertebrobasilar Dolichoectasia Primary Trigeminal Neuralgia Microvascular decompression Surgical Strategies Clinical Outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Primary trigeminal neuralgia (PTN), defined by the International Association for the Study of Pain (IASP), manifests as unilateral, paroxysmal, electric-shock-like pain within the trigeminal distribution [1]. Attacks are triggered by innocuous stimuli (e.g., brushing teeth, chewing) and progressively increase in frequency/severity, impairing nutrition, sleep, and psychological well-being [2,3]. Over 90% of PTN involves neurovascular compression (NVC) causing focal demyelination and ectopic signaling [4,5]. Microvascular decompression (MVD) remains the only etiologically targeted treatment , achieving >95% long-term pain relief [6]. Vertebrobasilar dolichoectasia (VBD)—a rare vasculopathy characterized by elongation (>10 mm beyond midline), dilation (diameter >4.5 mm), and tortuosity of vertebral/basilar arteries—induces PTN via direct compression at the root entry zone (REZ), leading to demyelination or ischemia [7]. VBD-related PTN accounts for ≤3% of all PTN cases , substantially less frequent than superior cerebellar artery (SCA) or anterior inferior cerebellar artery (AICA) compression [8]. MVD for VBD-PTN poses heightened technical challenges due to: Massive, tortuous vessels occupying deep cerebellopontine angle (CPA) spaces [9] High REZ pressure with risk of adhesion or Teflon displacement Increased recurrence and brainstem injury risks [10]. Large-scale MVD series for VBD-PTN remain scarce. This study analyzed 34 VBD-related PTN patients undergoing MVD, proposing an etiological classification system and tailored surgical strategies. Long-term follow-up demonstrated satisfactory outcomes, as detailed below. ​​Materials and methods General information Among 34 patients, 24 were male and 10 female. Pain was left-sided in 19 and right-sided in 15. Mean age at onset was 59.8 ± 8.1 years (range: 33–76). Symptom duration: Median 2.5 years (IQR: 1–5). All patients were assessed using the Barrow Neurological Institute (BNI) Pain Intensity Score preoperatively. Preoperative cranial CT and MRI confirmed vertebrobasilar dolichoectasia. Inclusion Criteria (1) Facial pain consistent with classic PTN features: trigeminal distribution, sharp/electric shock-like quality, identifiable trigger points, initial carbamazepine response waning over time. (2) Good general health with no surgical contraindications. Surgical procedure All procedures utilized the lateral decubitus position with the affected side up and mastoid prominence highest. A 4cm straight incision was made within the hairline. Following routine disinfection, draping, and layered dissection, a craniotomy was performed, extending anteriorly to the sigmoid sinus and superiorly to the transverse sinus. The dura was incised curvilinearly and retracted. Gentle cerebellar retraction along the horizontal fissure released cerebrospinal fluid. Access to the cerebellopontine angle (CPA) was gained via the tentorium-trigeminal corridor. Trigeminal nerve arachnoid membranes were dissected to expose the nerve. Based on preoperative imaging and intraoperative findings, compression patterns were classified using the CPA four-space system: Space I: Tentorium-trigeminal Space II: Trigeminal-facial/acoustic nerve complex Space III: Facial/acoustic-lower cranial nerves Space IV: Below lower cranial nerves Type I: Space II compressed by elongated, tortuous VBD (predominantly vertebral artery). Imaging showed significant brainstem deformation with obliterated arachnoid space (Fig 1A, B). Type II: Space II compressed by elongated, dilated VBD (predominantly basilar artery). Imaging showed no/minimal brainstem deformation with preserved arachnoid space (Fig 2A, B). Meticulous hemostasis was achieved. The dura was closed, the bone defect repaired with a titanium plate, then muscle/skin sutured. Outcome Assessment and Follow-up Postoperative pain was assessed using the BNI Pain Intensity Score [5]. A score ≤ II defined excellent/good outcome; > II defined poor outcome. In-person scoring occurred within 7 days postoperatively; subsequent follow-up utilized outpatient visits and telephone calls to track BNI scores and complications. Outcome Clinical Statistics (Table 1) Pain Distribution: V2+V3: 16 cases (47.1%); V2: 11 (32.4%); V3: 5 (14.6%); V1+V2: 2 (5.9%). Isolated PTN: 28 cases (82.4%); PTN with other cranial neuropathies: 6 cases (17.6%). Prior Failed Interventions: Balloon compression/radiofrequency: 13 cases (38.2%); Recurrent MVD: 3 cases (8.8%). Preoperative BNI Scores: Grade V: 8 cases (23.5%); Grade IV: 26 cases (76.5%). Table 1. Clinical Characteristics of 34 Patients with PTN Related to VBD Item Category Value Age (years) Mean ± SD 59.8±8.1 Gender Male 24（70.6%） Female 10（29.4%） Disease Duration (years) Median（Q1，Q3） 2.5（1，5） Affected Side Left 19（55.9%） Right 15（44.1%） Pain Distribution V2 11（32.4%） V3 5（14.6%） V2+V3 16（47.1%） V1+V2 2（5.9%） With Comorbid NVC TN+FS 4（11.8%） TN+GPN 2（5.9%） BNI Pain Intensity Score V级 8（23.5%） IV级 26（76.5%） Classification of VBD Compression Type I: 16 cases (VA+SCA: 8; VA+AICA+SCA: 5; VA+AICA: 3). Type II: 18 cases (VBD+SCA: 13; VBD+AICA+SCA: 2; VBD+AICA: 2; Pure VBD: 1). Results Median follow-up: 7.5 months (IQR: 4-25.75). Pain Relief: Complete resolution (BNI I): 31 cases (91.2%); Significant improvement (BNI II): 3 cases (8.8%). Overall excellent/good rate: 100% (Fig 3).Time to Relief: Immediate: 30 cases (88.3%); 1–3 months: 2 cases (5.9%); 1 month: 1 case (2.9%); 6 months: 1 case (2.9%) (Fig 4). Complications: Facial hypoesthesia (7 cases, 20.6%); Hearing impairment (3, 8.8%); Tinnitus (2, 5.9%); Diplopia (3, 8.8%); Contralateral hemisensory disturbance (1, 2.9%). Following neurotrophic/hyperbaric oxygen therapy: 2 hearing impairments resolved completely; 1 hemisensory disturbance resolved completely; 2 hearing impairments and 5 facial hypoesthesia showed partial improvement. Discussion Clinical characteristics of VBD-related PTN VBD-related PTN is exceptionally rare. As reported by Rodrigo, VBD accounts for ≤3% of causative vessels in all PTN cases [11]. Chelmis F further indicated through literature review that the population-based incidence of VBD-related PTN is <0.05%, classifying it as a rare disease [12]. These patients typically present with medically refractory pain, which can be alleviated by MVD surgery to relieve neurovascular compression. Zheng analyzed clinical data from 918 PTN patients over 5 years [13], identifying 61 VBD-related cases (6.6%). In our cohort of 1,214 PTN patients, 34 cases (2.8%) were attributed to VBD, consistent with existing literature. Owing to the rarity of this condition, large-sample studies on VBD-related PTN remain limited, with most reports being isolated case studies. Zheng described the largest cohort to date (61 patients), yet without classifying VBD compression patterns. Given the elongation, dilatation, and tortuosity of vertebrobasilar arteries—which may even cause brainstem compression or displacement—a uniform "stepwise" MVD technique is insufficient to address diverse compression types and severity levels. Chai analyzed imaging data from 44 VBD-related PTN patients over 7 years, revealing significantly reduced cerebellopontine cistern volume on the affected side compared to the contralateral side, thereby increasing the probability of neurovascular contact and compression[14]. However, their study lacked analysis of MVD surgical implications, limiting its clinical utility for surgical guidance. Our cohort of 34 patients demonstrated three key clinical characteristics of VBD-related PTN: (1) Severe pain intensity: All patients had preoperative BNI grade IV or higher pain (grade V: n=8; grade IV: n=26). This may stem from higher wall contact pressure exerted by dilated and tortuous VBD vessels on the REZ compared to SCA or AICA compression, resulting in more severe trigeminal nerve injury [15,16]. (2) High comorbidity with multiple cranial neuropathies: Takei identified 10 cases of concurrent PTN and hemifacial spasm in 8 case reports (2013–2023), all attributed to VBD [15]. In our cohort, 17.6% (6/34) exhibited multi-cranial nerve involvement. (3) Poor efficacy of non-MVD therapies: Chelmis F [12] and Takei M [15] reported suboptimal pain control with high-dose carbamazepine in VBD-related PTN patients. Additionally, 38.2% (13/34) of our cohort underwent percutaneous balloon compression (PBC) or radiofrequency rhizotomy (RF) with unsatisfactory outcomes, indicating more complex pathophysiology in VBD-related PTN Characteristics and Types of Vascular Compression in VBD-related PTN In patients with VBD-related PTN is frequently accompanied by simultaneous compression from the SCA, AICA, or petrosal veins. As reported by Feng [17], 76.7% (23/30) of cases exhibited concurrent compression by additional causative vessels: VBD+SCA (n=6), VBD+SCA+AICA (n=5), and VBD+AICA (n=12). Zheng [13] observed that 77% (47/61) of VBD patients had multi-vessel compression, including venous compression in 4.9% (3/61). In our cohort of 34 patients, isolated VBD compression occurred in only 1 case (2.9%), while combined VBD+SCA compression was present in 82.4% (28/34) and VBD+AICA in 32.4% (11/34). Therefore, although VBD reduces the ipsilateral cerebellopontine angle space—particularly obscuring the Space I—it is imperative to initially mobilize the VBD toward the skull base and lower cranial nerves via the Space II. This maneuver allows the trigeminal nerve, displaced toward the tentorium, to reposition and expand the Space I. Subsequent exploration and decompression of the SCA are critical to avoid missing compressive vessels and ensure long-term efficacy. Preoperative multimodal imaging is critical for delineating spatial relationships among VBD, brainstem, and trigeminal nerve, thereby guiding intraoperative maneuvers. Based on imaging and surgical findings, we first propose a classification of VBD-related PTN compression patterns and corresponding tailored decompression strategies: Type I Compression (High Vascular Tension with Brainstem Deformation) Characterized by elevated vascular tension and significant brainstem distortion, direct mobilization of VBD is extremely challenging. A four-step strategy is required: (1) Dissection of the Space III arachnoid; Elevation of the proximal vertebral artery (VA) with Teflon felt insertion; Reduces distal VA tension in the Space II and increases space between VA and brainstem/trigeminal root . (2) Felt insertion in the distal VA of Space II; Mobilization of VA toward the skull base. (3) Expansion of the Space I; Arachnoid dissection; Isolation and decompression of the SCA with felt placement. (4) Final isolation of VA-trigeminal root contact with thin-layered felt (Fig. 5A-D). Type II Compression (Moderate Brainstem Compression with Arachnoid Space Preservation) Mobilization of the VBD within the Space II is relatively straightforward due to the presence of a preserved arachnoid plane between the vessel and brainstem, coupled with minimal local brainstem compression. Consequently, only the final three steps of the decompression protocol established for Type I lesions are required (Fig. 6A-C). It must be emphasized that the initial step for Type I is not routinely performed, as it introduces additional mechanical stimulation to the facial (CN VII) and vestibulocochlear (CN VIII) nerves, thereby increasing the risk of hearing impairment and facial paralysis. Furthermore, during felt implantation, three critical principles should be observed: (1) Adhere to the "pier-and-girder principle" by implanting felt at multiple points to distribute focal pressure exerted by the vessel on the brainstem. (2) Ensure both the offending vessel and felt remain distant from the trigeminal nerve trunk and its root entry zone (REZ) to prevent adhesion. (3) Limit the volume of implanted felt to avoid local overcompression, which may exacerbate brainstem compression or compromise surgical efficacy. MVD for VBD-PTN is technically demanding MVD for VBD-PTN poses significant technical challenges. Singh demonstrated that the compressive force exerted by tortuous and elongated VBD vessels on neural structures substantially exceeds that of the SCA, necessitating a greater volume of felt and an extended decompression range to achieve effective vascular displacement. This approach, however, escalates the risks of cranial nerve injury and brainstem infarction [18,19]. Furthermore, the CPA cistern on the affected side is often anatomically constrained, demanding advanced microsurgical skills [14]. Precise quantification of implanted felt is critical: insufficient placement fails to alleviate compression, while excessive volume may induce brainstem compression, manifesting as facial paralysis, diplopia, contralateral limb motor deficits, or sensory disturbances. Long-term follow-up data from our cohort revealed the following postoperative complications: facial hypoesthesia (20.6%), hearing impairment (8.8%), diplopia (8.8%), tinnitus (5.9%), and hemisensory loss (2.9%). Tailored MVD for VBD-PTN with high overall efficacy In our cohort, 91.2% (31/34) of patients achieved BNI grade I pain relief, and 8.8% (3/34) reached BNI grade II, resulting in an overall excellent outcome rate of 100%. Moreover, immediate postoperative pain resolution occurred in the majority of patients (88.3%, 30/34), with residual symptoms typically subsiding within six months. Davide's meta-analysis of 2,102 PTN patients undergoing MVD reported BNI grade I outcomes in 82.9% and grades II–III in 14.5% [20], indicating a lower overall efficacy compared to our cohort. We propose that tailored MVD strategies based on VBD compression patterns ensure thorough decompression and contribute to superior surgical outcomes. Conclusions In summary, VBD-related PTN is clinically rare and typically manifests with severe pain that responds poorly to pharmacological therapy. Based on intraoperative findings during MVD, two distinct compression patterns can be identified. Tailoring surgical strategies to these specific etiological subtypes is critical for achieving safe and effective outcomes. Furthermore, enhancing comprehension of MVD principles and refining operative techniques are pivotal measures to minimize complications and optimize therapeutic efficacy Declarations Funding This study was supported by the Beijing-Tianjin-Hebei cooperation project, H2024206573. The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing interests The authors declare no competing interests. Author’ contributions XKZ: date acquisition and analysis and drafting and writing of the manuscript; XLX: date analysis and important revisions to the manuscript; XS: date collection; YBY: work concept or design and important revisions to the manuscript. The authors read and approved the final manuscript. Ethical approval This study (2023-KY-102) was granted by the Institutional Review Board in compliance with the Declaration of Helsinki. Consent to participate Informed consent was obtained from all individual participants included in the study. Clinical trial number Not applicable Clinical trial number Not applicable References Rados I (2022) Treatment options for trigeminal neuralgia. Acta Clin Croat 61(Suppl 2):96–102. https://doi.org/10.20471/acc.2022.61.s2.12 Chow A, Haider I, Athanaselos A, Patel M (2024) In-hospital management of acute trigeminal neuralgia pain crises. Clin Med Res 22(4):215–221. https://doi.org/10.3121/cmr.2024.1945 Liang Y, Zhao Q, Hu Z, Bo K, Meyyappan S, Neubert J, et al (2023) Imaging the neural substrate of trigeminal neuralgia pain using deep learning. Front Hum Neurosci 17:1144159. https://doi.org/10.3389/fnhum.2023.1144159 Mousavi SH, Lindsey JW, Westlund KN, Alles SRA (2024) Trigeminal neuralgia as a primary demyelinating disease: potential multimodal evidence and remaining controversies. J Pain 25(2):302–311. https://doi.org/10.1016/j.jpain.2023.08.012 Yang L, Cheng H (2022) Surgical technique management of microvascular decompression for trigeminal neuralgia. Ideggyogy Sz 75(11-12):369-375. https://doi.org/10.18071/isz.75.0369 Herber S, Zimmerman RS, Chen A, Yang M, Martinez F (2024) Teflon granuloma with active inflammation: a cause of recurrent trigeminal neuralgia after microvascular decompression. Clin Nucl Med 49(12):1105–1108. https://doi.org/10.1097/RLU.0000000000005444 Wang Y, Yu J (2022) Prospects and dilemmas of endovascular treatment for vertebrobasilar dolichoectasia. Front Neurol 13:895527. https://doi.org/10.3389/fneur.2022.895527 Visocchi M, Zeoli F, Signorelli F (2024) Microvascular decompression for trigeminal neuralgia secondary to vertebrobasilar dolichoectasia. J Clin Med 13(21):6342. https://doi.org/10.3390/jcm13216342 Amagasaki K, Takusagawa Y, Tatebayashi K, Nakaguchi H (2022) Macrovascular decompression with transposition method using Teflon sling for trigeminal neuralgia. World Neurosurg 167:1395–1401. https://doi.org/10.1016/j.wneu.2022.09.049 Sun J, Wang J, Jia J, Cao Z, Li Z, Zhang C, et al (2024) Fully endoscopic microvascular decompression for trigeminal neuralgia caused by vertebrobasilar artery. Oper Neurosurg 26(4):433–441. https://doi.org/10.1227/ons.0000000000000998 Uribe-Pacheco R, Sangrador-Deitos MV, Guinto-Nishimura GY, Villalonga JF, Baldoncini M, et al (2025) Transposition of megadolichoectatic basilar artery in trigeminal neuralgia. World Neurosurg 193:225. https://doi.org/10.1016/j.wneu.2024.11.015 Chelmis F, Pakataaridis P, Sorotou I, Tzineris A, Ranguelov C (2024). Microvascular Decompression: An Effective Approach for Trigeminal Neuralgia Caused by a Dolichoectatic Basilar Artery after Multiple Treatment Failures. J Neurol Surg Rep 85(3):156-160. https://doi.org/10.1055/a-2342-4086 Zheng W, Wang L, Wang H, Zhou H, Du Q (2023) Trigeminal neuralgia caused by vertebrobasilar dolichoectasia: efficacy of stepwise decompression technique. Acta Neurochir 165(10):3019–3026. https://doi.org/10.1007/s00701-023-05691-7 Chai S, Cheng R, Yang J, Shen L, Fu K, Zhou J, et al (2023) Cerebellopontine angle cistern volumetric differences in trigeminal neuralgia. Neurosurg Rev 46(1):243. https://doi.org/10.1007/s10143-023-02141-x Takei M, Takizawa K, Okada A, Otani N, Noma N (2023) Trigeminal neuralgia with concomitant continuous pain due to vertebrobasilar dolichoectasia. Cureus 15(12):49953. https://doi.org/10.7759/cureus.49953 Bethamcharla R, Abou-Al-Shaar H, Maarbjerg S, Chang Y, Gacka CN, Sekula RF (2023) Percutaneous glycerol rhizolysis for trigeminal neuralgia. Eur J Neurol 30(10):3307–3313. https://doi.org/10.1111/ene.15977 Feng Y, Jia Y, Lu PG, Zhao ZY, Zhang YQ, Men XZ (2022) Microvascular decompression by interposition method for vertebrobasilar dolichoectasia. Neurosurg Rev 45(4):2709–2715. https://doi.org/10.1007/s10143-022-01776-6 Singh H, da Silva HB, Zeinalizadeh M, Elarjani T, Straus D, Sekhar L (2018) Basilar artery ectasia causing trigeminal neuralgia. Oper Neurosurg 14(2):194–199. https://doi.org/10.1093/ons/opx087 Ferreira M, Walcott BP, Nahed BV, Sekhar LN (2011) Vertebral artery pexy for microvascular decompression. J Neurosurg 114(6):1800–1804. https://doi.org/10.3171/2010.12.JNS10891 Di Carlo DT, Benedetto N, Perrini P (2022) Clinical outcome after microvascular decompression for trigeminal neuralgia: a systematic review and meta-analysis. Neurosurg Rev 46(1):8. https://doi.org/10.1007/s10143-022-01922-0 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Jan, 2026 Read the published version in Neurosurgical Review → Version 1 posted Editorial decision: Revision requested 08 Nov, 2025 Reviews received at journal 31 Oct, 2025 Reviews received at journal 29 Oct, 2025 Reviewers agreed at journal 27 Oct, 2025 Reviewers agreed at journal 25 Oct, 2025 Reviewers agreed at journal 25 Oct, 2025 Reviewers agreed at journal 22 Oct, 2025 Reviewers invited by journal 22 Oct, 2025 Editor assigned by journal 22 Oct, 2025 Submission checks completed at journal 21 Aug, 2025 First submitted to journal 18 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7400143","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":538442505,"identity":"2645d00d-874e-4fa9-ba3c-6f6855544e3c","order_by":0,"name":"Xueke Zhen","email":"","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xueke","middleName":"","lastName":"Zhen","suffix":""},{"id":538442506,"identity":"279163a5-f9ed-4831-8a69-c944a498abc8","order_by":1,"name":"Xiaoli Xu","email":"","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaoli","middleName":"","lastName":"Xu","suffix":""},{"id":538442507,"identity":"45dc18c5-e315-4531-8811-9bee479176fd","order_by":2,"name":"Xu Sao","email":"","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Sao","suffix":""},{"id":538442508,"identity":"e1a4f30b-2a54-4473-bcde-9fda0f2fca29","order_by":3,"name":"Yanbing Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYDACCQZmhgdsNjxs7A0MB4jXksCWJsPHc4A0LYdt5CQSiHSX/OweY4OEssM8bJLPHx4uqGGQ5xcjYBnjnGPJCQnn0nnYpHMMDs84xmA4czYB65glkg8fSGyzBmlhANrFkGBwm4AWNonEZqAWZqDDjj84zPOPCC08QFsSEtucedgkGAwO87YRoUVCIi3ZIOFcGg8bD9AvvH0ShP0iPyPHWOJDmY29fPvxx595vtnI80sT0IJhK2nKR8EoGAWjYBRgBwAjnjugKGivwwAAAABJRU5ErkJggg==","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yanbing","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2025-08-18 13:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7400143/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7400143/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-025-04057-0","type":"published","date":"2026-01-19T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":95010679,"identity":"71df6cba-8e0d-42eb-904e-2d9836f4e054","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":812765,"visible":true,"origin":"","legend":"","description":"","filename":"MicrovascularDecompressionforVertebrobasilarDolichoectasiaRelatedPrimaryTrigeminalNeuralgiaSurgicalStrategiesTechnicalNuancesandClinicalOutcomes1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/29bec1932db4c3b4973b592b.docx"},{"id":95010672,"identity":"22a6c6a1-51f8-4c6b-b8ac-168dd2ef80af","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5596,"visible":true,"origin":"","legend":"","description":"","filename":"c86fb8708bb14b3ca8ab11b88abef489.json","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/667fc3c3a1e294c8f7690db2.json"},{"id":95010676,"identity":"56bea673-0bb0-4dac-b63b-469fd8ab13ee","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73285,"visible":true,"origin":"","legend":"","description":"","filename":"c86fb8708bb14b3ca8ab11b88abef4891enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/8f044a9214e7abd362a38fe7.xml"},{"id":95221082,"identity":"0705ee1d-cd18-4a88-bb7b-98871cca9e48","added_by":"auto","created_at":"2025-11-05 16:18:12","extension":"eps","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":394,"visible":true,"origin":"","legend":"","description":"","filename":"drawingimage1.eps","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/55eeb141edbb285da3ee20bd.eps"},{"id":95221294,"identity":"4f2a2063-e41d-469a-9555-9a65cca7b38a","added_by":"auto","created_at":"2025-11-05 16:18:45","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":823071,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/d1233bde9477a3d97989ae67.jpeg"},{"id":95010693,"identity":"366d182c-30f2-4eb0-a9a0-eacaebcaa208","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":460666,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/c4b3cfc4ec3e60a7f861650c.jpeg"},{"id":95221329,"identity":"8a5dfb8c-1808-4798-9c51-f9a3f730816f","added_by":"auto","created_at":"2025-11-05 16:18:50","extension":"jpeg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":186029,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/2fe8d696f003e6e035197fea.jpeg"},{"id":95010682,"identity":"0821c739-c71a-4b00-bae5-6374dd7dff29","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"jpeg","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":601321,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/e5216fdb8cc68923aecfab4b.jpeg"},{"id":95220984,"identity":"a641e252-a98e-45c0-8c95-676e2260b5c6","added_by":"auto","created_at":"2025-11-05 16:17:35","extension":"jpeg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":515344,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/34cc743fa4379ee58896a102.jpeg"},{"id":95221341,"identity":"63089ce8-d1e9-48c8-883d-9af35afe5fad","added_by":"auto","created_at":"2025-11-05 16:18:50","extension":"jpeg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":532323,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/493238dece87dff2832f35dd.jpeg"},{"id":95010695,"identity":"4ba7467c-8746-4870-b17b-ee1ba015bccb","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"jpeg","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":233147,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/f9ed1ee4f775929f6f6bf4f2.jpeg"},{"id":95010694,"identity":"bc36dd5a-80b0-4aec-875c-1026aaeaf2a4","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":259541,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/14ed709192c65342304efc26.png"},{"id":95010687,"identity":"21ab399a-cc03-4379-b0d6-6b2322654f35","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":134622,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/cc13351b4457feb13581c970.png"},{"id":95010686,"identity":"62b822c3-595d-421c-b4bf-1ee44be48beb","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":49700,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/7e0a50a2e1055799701833e6.png"},{"id":95010688,"identity":"228fb8cb-9092-405f-a6e1-1c334dea8a3e","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":151829,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/f663532c48407f48b8d03dad.png"},{"id":95221733,"identity":"0ad4ef4a-28b6-49de-9569-c3ee0952177d","added_by":"auto","created_at":"2025-11-05 16:19:38","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":133092,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/0a94640ee1f0b7c2f3fe19a0.png"},{"id":95221132,"identity":"6f26f78e-7c5a-41d5-abfc-e66139119cf9","added_by":"auto","created_at":"2025-11-05 16:18:24","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":121290,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/50465cca9d9b4bfe36ff55ff.png"},{"id":95010698,"identity":"2ada7200-b642-4069-854a-8cf7e03ecde0","added_by":"auto","created_at":"2025-11-03 10:18:31","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61477,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/4be068432e0a1c5d8795a58f.png"},{"id":95010696,"identity":"4f230dea-cf39-4d58-8a4b-55b9f8aa934c","added_by":"auto","created_at":"2025-11-03 10:18:31","extension":"xml","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73200,"visible":true,"origin":"","legend":"","description":"","filename":"c86fb8708bb14b3ca8ab11b88abef4891structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/297d6cabae60c0d15ad6832c.xml"},{"id":95221083,"identity":"e813e6b4-c506-4a25-b11f-e10790f08ce9","added_by":"auto","created_at":"2025-11-05 16:18:12","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81405,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/ec7a45b6dbee080f2d5d013f.html"},{"id":95221101,"identity":"57dce88b-518e-47b3-92c8-e12c506b0e83","added_by":"auto","created_at":"2025-11-05 16:18:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":342513,"visible":true,"origin":"","legend":"\u003cp\u003eA: MRA shows that the left VA has shifted to right and merged with the right VA to form an expansive and tortuous BA; B: Contrast-enhanced MRI​ demonstrates ​elongation and dilation of the vertebrobasilar artery​ compressing the brainstem, resulting in ​significant brainstem deformation​ and ​obliteration of the subarachnoid space ​(red △)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/982693a03933c964e9d08677.png"},{"id":95010674,"identity":"8f1151c9-4827-4599-b686-c7812b2163cf","added_by":"auto","created_at":"2025-11-03 10:18:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":166923,"visible":true,"origin":"","legend":"\u003cp\u003eA: MRI T1-weighted sequence​ demonstrates ​anomalous convergence of bilateral vertebral arteries, forming the basilar artery ​within the right CPA​（red arrow）; B: T2-weighted MRI sequences​ demonstrate ​no significant deformation of the brainstem, with ​preservation of the subarachnoid space​ between the vasculature and brainstem parenchyma​(red △)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/f31abf34db5e5ace5500ba6a.png"},{"id":95221209,"identity":"72009073-c9b3-4cb4-a3da-105e20d3802b","added_by":"auto","created_at":"2025-11-05 16:18:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":26209,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of preoperative and postoperative BNI scores in 34 patients. Red line: preoperative BNI score; Green line: postoperative BNI score.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/98d7c2c97a559f95bb0b2109.png"},{"id":95221221,"identity":"bf6ee71d-2029-4e71-a80c-d2ac91ee3139","added_by":"auto","created_at":"2025-11-05 16:18:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":23822,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative pain relief time in 34 patients,\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/c736817286488681196649bd.png"},{"id":95221645,"identity":"46a764ed-cc6d-4b7f-8ebb-9a26af6db44f","added_by":"auto","created_at":"2025-11-05 16:19:30","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":437950,"visible":true,"origin":"","legend":"\u003cp\u003eA: Tortuous and dilated vertebral arteries (VA)​​ are observed ​compressing the brainstem and vestibulocochlear nerve (VIII)​. Following ​arachnoid dissection, a ​Teflon felt​ is implanted between the VA and brainstem (yellow arrow); B：The microsurgical dissection was advanced in space II (yellow *)​, where ​distal vertebral artery (VA)​​ was isolated. ​A Teflon felt was subsequently interposed​between the decompressed VA and the brainstem; C： Following mobilization of the distal vertebral artery with Teflon felt interposition, ​the surgical corridor between the trigeminal nerve (NV) and tentorium cerebelli (TT) was exposed. ​The SCA was then meticulously dissected and padded away​ from the brainstem; D： A Teflon felt was interposed between the basilar artery (BA) and the trigeminal nerve trunk (NV)​​ to achieve definitive decompression\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/a97b13a5ede27371b9ea3bc9.png"},{"id":95221602,"identity":"9395026c-5f77-4088-b181-750a3d8377c2","added_by":"auto","created_at":"2025-11-05 16:19:28","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":299013,"visible":true,"origin":"","legend":"\u003cp\u003eA: Within the space II, ​the arachnoid membrane between the basilar artery (BA) and the brainstem surface was meticulously dissected, followed by ​interposition of a Teflon felt (yellow arrow)​​; B: Following mobilization of the basilar artery, ​the operative corridor between the trigeminal nerve (NV) and tentorium cerebelli (TT) was significantly widened, ​allowing meticulous dissection of the SCA. ​A Teflon felt was then interposed between the SCA and the brainstem surface​; C: A Teflon felt was definitively interposed between the basilar artery (BA) and the trigeminal nerve trunk (NV)​, ​achieving complete decompression.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/e1a09e0776da54882c064d0d.png"},{"id":101151694,"identity":"f7fb7aef-d5ee-4e4e-a562-d31a1824a7d3","added_by":"auto","created_at":"2026-01-26 16:01:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2933331,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7400143/v1/84cbe741-d05f-42a5-b9ea-0ff56d2f78e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Microvascular Decompression for Vertebrobasilar Dolichoectasia-Related Primary Trigeminal Neuralgia: Surgical Strategies, Technical Nuances, and Clinical Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary trigeminal neuralgia (PTN), defined by the International Association for the Study of Pain (IASP), manifests as \u003cstrong\u003eunilateral, paroxysmal, electric-shock-like pain\u003c/strong\u003e within the trigeminal distribution [1]. Attacks are triggered by innocuous stimuli (e.g., brushing teeth, chewing) and progressively increase in frequency/severity, impairing nutrition, sleep, and psychological well-being [2,3]. Over 90% of PTN involves \u003cstrong\u003eneurovascular compression (NVC)\u003c/strong\u003e causing focal demyelination and ectopic signaling [4,5]. Microvascular decompression (MVD) remains the \u003cstrong\u003eonly etiologically targeted treatment\u003c/strong\u003e, achieving \u0026gt;95% long-term pain relief [6].\u003c/p\u003e\n\u003cp\u003eVertebrobasilar dolichoectasia (VBD)—a rare vasculopathy characterized by \u003cstrong\u003eelongation (\u0026gt;10 mm beyond midline), dilation (diameter \u0026gt;4.5 mm), and tortuosity\u003c/strong\u003e of vertebral/basilar arteries—induces PTN via direct compression at the root entry zone (REZ), leading to demyelination or ischemia [7]. VBD-related PTN accounts for \u003cstrong\u003e≤3% of all PTN cases\u003c/strong\u003e, substantially less frequent than superior cerebellar artery (SCA) or anterior inferior cerebellar artery (AICA) compression [8]. MVD for VBD-PTN poses \u003cstrong\u003eheightened technical challenges\u003c/strong\u003e due to:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eMassive, tortuous vessels occupying deep cerebellopontine angle (CPA) spaces [9]\u003c/li\u003e\n \u003cli\u003eHigh REZ pressure with risk of adhesion or Teflon displacement\u003c/li\u003e\n \u003cli\u003eIncreased recurrence and brainstem injury risks [10].\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eLarge-scale MVD series for VBD-PTN remain scarce. This study analyzed 34 VBD-related PTN patients undergoing MVD, proposing an etiological classification system and tailored surgical strategies. Long-term follow-up demonstrated satisfactory outcomes, as detailed below.\u003c/p\u003e"},{"header":"​​Materials and methods","content":"\u003cp\u003e\u003cstrong\u003eGeneral information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 34 patients, 24 were male and 10 female. Pain was left-sided in 19 and right-sided in 15. Mean age at onset was 59.8 \u0026plusmn; 8.1 years (range: 33\u0026ndash;76). Symptom duration: Median 2.5 years (IQR: 1\u0026ndash;5). All patients were assessed using the Barrow Neurological Institute (BNI) Pain Intensity Score preoperatively. Preoperative cranial CT and MRI confirmed vertebrobasilar dolichoectasia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;(1) Facial pain consistent with classic PTN features: trigeminal distribution, sharp/electric shock-like quality, identifiable trigger points, initial carbamazepine response waning over time.\u003cbr\u003e\u0026nbsp;(2) Good general health with no surgical contraindications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures utilized the lateral decubitus position with the affected side up and mastoid prominence highest. A 4cm straight incision was made within the hairline. Following routine disinfection, draping, and layered dissection, a craniotomy was performed, extending anteriorly to the sigmoid sinus and superiorly to the transverse sinus. The dura was incised curvilinearly and retracted. Gentle cerebellar retraction along the horizontal fissure released cerebrospinal fluid. Access to the cerebellopontine angle (CPA) was gained via the tentorium-trigeminal corridor. Trigeminal nerve arachnoid membranes were dissected to expose the nerve.\u003c/p\u003e\n\u003cp\u003eBased on preoperative imaging and intraoperative findings, compression patterns were classified using the CPA four-space system:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eSpace I:\u003c/strong\u003e Tentorium-trigeminal\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSpace II:\u003c/strong\u003e Trigeminal-facial/acoustic nerve complex\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSpace III:\u003c/strong\u003e Facial/acoustic-lower cranial nerves\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSpace IV:\u003c/strong\u003e Below lower cranial nerves\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eType I:\u003c/strong\u003e Space II compressed by elongated, tortuous VBD (predominantly vertebral artery). Imaging showed significant brainstem deformation with obliterated arachnoid space (Fig 1A, B).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eType II:\u003c/strong\u003e Space II compressed by elongated, dilated VBD (predominantly basilar artery). Imaging showed no/minimal brainstem deformation with preserved arachnoid space (Fig 2A, B).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMeticulous hemostasis was achieved. The dura was closed, the bone defect repaired with a titanium plate, then muscle/skin sutured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome Assessment and Follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative pain was assessed using the BNI Pain Intensity Score [5]. A score \u0026le; II defined excellent/good outcome; \u0026gt; II defined poor outcome. In-person scoring occurred within 7 days postoperatively; subsequent follow-up utilized outpatient visits and telephone calls to track BNI scores and complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Statistics (Table 1)\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003ePain Distribution:\u003c/strong\u003e V2+V3: 16 cases (47.1%); V2: 11 (32.4%); V3: 5 (14.6%); V1+V2: 2 (5.9%).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIsolated PTN:\u003c/strong\u003e 28 cases (82.4%); PTN with other cranial neuropathies: 6 cases (17.6%).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePrior Failed Interventions:\u003c/strong\u003e Balloon compression/radiofrequency: 13 cases (38.2%); Recurrent MVD: 3 cases (8.8%).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePreoperative BNI Scores:\u003c/strong\u003e Grade V: 8 cases (23.5%); Grade IV: 26 cases (76.5%).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Clinical Characteristics of 34 Patients with PTN Related to VBD\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eItem\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e59.8\u0026plusmn;8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e24（70.6%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e10（29.4%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease Duration (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eMedian（Q1，Q3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2.5（1，5）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffected Side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Left\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e19（55.9%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Right\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e15（44.1%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain Distribution\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eV2 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e11（32.4%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eV3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e5（14.6%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eV2+V3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e16（47.1%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eV1+V2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2（5.9%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith Comorbid NVC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; TN+FS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e4（11.8%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;TN+GPN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2（5.9%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBNI Pain Intensity Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; V级\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e8（23.5%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; IV级\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e26（76.5%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eClassification\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of VBD\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCompression\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eType I:\u003c/strong\u003e 16 cases (VA+SCA: 8; VA+AICA+SCA: 5; VA+AICA: 3).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eType II:\u003c/strong\u003e 18 cases (VBD+SCA: 13; VBD+AICA+SCA: 2; VBD+AICA: 2; Pure VBD: 1).\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Results","content":"\u003cp\u003eMedian follow-up: 7.5 months (IQR: 4-25.75).\u003c/p\u003e\n\u003cp\u003ePain Relief: Complete resolution (BNI I): 31 cases (91.2%); Significant improvement (BNI II): 3 cases (8.8%). Overall excellent/good rate: 100% (Fig 3).Time to Relief: Immediate: 30 cases (88.3%); 1\u0026ndash;3 months: 2 cases (5.9%); 1 month: 1 case (2.9%); 6 months: 1 case (2.9%) (Fig 4).\u003c/p\u003e\n\u003cp\u003eComplications: Facial hypoesthesia (7 cases, 20.6%); Hearing impairment (3, 8.8%); Tinnitus (2, 5.9%); Diplopia (3, 8.8%); Contralateral hemisensory disturbance (1, 2.9%). Following neurotrophic/hyperbaric oxygen therapy: 2 hearing impairments resolved completely; 1 hemisensory disturbance resolved completely; 2 hearing impairments and 5 facial hypoesthesia showed partial improvement.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eClinical characteristics of VBD-related PTN\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVBD-related PTN is exceptionally rare. As reported by Rodrigo, VBD accounts for \u0026le;3% of causative vessels in all PTN cases [11]. Chelmis F further indicated through literature review that the population-based incidence of VBD-related PTN is \u0026lt;0.05%, classifying it as a rare disease [12]. These patients typically present with medically refractory pain, which can be alleviated by MVD surgery to relieve neurovascular compression. Zheng analyzed clinical data from 918 PTN patients over 5 years [13], identifying 61 VBD-related cases (6.6%). In our cohort of 1,214 PTN patients, 34 cases (2.8%) were attributed to VBD, consistent with existing literature.\u003c/p\u003e\n\u003cp\u003eOwing to the rarity of this condition, large-sample studies on VBD-related PTN remain limited, with most reports being isolated case studies. Zheng described the largest cohort to date (61 patients), yet without classifying VBD compression patterns. Given the elongation, dilatation, and tortuosity of vertebrobasilar arteries\u0026mdash;which may even cause brainstem compression or displacement\u0026mdash;a uniform \u0026quot;stepwise\u0026quot; MVD technique is insufficient to address diverse compression types and severity levels.\u003cbr\u003eChai analyzed imaging data from 44 VBD-related PTN patients over 7 years, revealing significantly reduced cerebellopontine cistern volume on the affected side compared to the contralateral side, thereby increasing the probability of neurovascular contact and compression[14]. However, their study lacked analysis of MVD surgical implications, limiting its clinical utility for surgical guidance.\u003cbr\u003eOur cohort of 34 patients demonstrated three key clinical characteristics of VBD-related PTN:\u003c/p\u003e\n\u003cp\u003e(1) Severe pain intensity: All patients had preoperative BNI grade IV or higher pain (grade V: n=8; grade IV: n=26). This may stem from higher wall contact pressure exerted by dilated and tortuous VBD vessels on the REZ compared to SCA or AICA compression, resulting in more severe trigeminal nerve injury [15,16]. (2) High comorbidity with multiple cranial neuropathies: Takei identified 10 cases of concurrent PTN and hemifacial spasm in 8 case reports (2013\u0026ndash;2023), all attributed to VBD [15]. In our cohort, 17.6% (6/34) exhibited multi-cranial nerve involvement. (3) Poor efficacy of non-MVD therapies: Chelmis F [12] and Takei M [15] reported suboptimal pain control with high-dose carbamazepine in VBD-related PTN patients. Additionally, 38.2% (13/34) of our cohort underwent percutaneous balloon compression (PBC) or radiofrequency rhizotomy (RF) with unsatisfactory outcomes, indicating more complex pathophysiology in VBD-related PTN\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics and Types of Vascular Compression in VBD-related PTN\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn patients with VBD-related PTN is frequently accompanied by simultaneous compression from the SCA, AICA, or petrosal veins. As reported by Feng [17], 76.7% (23/30) of cases exhibited concurrent compression by additional causative vessels: VBD+SCA (n=6), VBD+SCA+AICA (n=5), and VBD+AICA (n=12). Zheng [13] observed that 77% (47/61) of VBD patients had multi-vessel compression, including venous compression in 4.9% (3/61). In our cohort of 34 patients, isolated VBD compression occurred in only 1 case (2.9%), while combined VBD+SCA compression was present in 82.4% (28/34) and VBD+AICA in 32.4% (11/34). Therefore, although VBD reduces the ipsilateral cerebellopontine angle space\u0026mdash;particularly obscuring the Space I\u0026mdash;it is imperative to initially mobilize the VBD toward the skull base and lower cranial nerves via the Space II. This maneuver allows the trigeminal nerve, displaced toward the tentorium, to reposition and expand the Space I. Subsequent exploration and decompression of the SCA are critical to avoid missing compressive vessels and ensure long-term efficacy.\u003c/p\u003e\n\u003cp\u003ePreoperative multimodal imaging is critical for delineating spatial relationships among VBD, brainstem, and trigeminal nerve, thereby guiding intraoperative maneuvers. Based on imaging and surgical findings, we first propose a classification of VBD-related PTN compression patterns and corresponding tailored decompression strategies:\u003c/p\u003e\n\u003cp\u003eType I Compression (High Vascular Tension with Brainstem Deformation)\u003c/p\u003e\n\u003cp\u003eCharacterized by elevated vascular tension and significant brainstem distortion, direct mobilization of VBD is extremely challenging. A four-step strategy is required:\u003c/p\u003e\n\u003cp\u003e(1) Dissection of the Space III arachnoid; Elevation of the proximal vertebral artery (VA) with Teflon felt insertion; Reduces distal VA tension in the Space II and increases space between VA and brainstem/trigeminal root .\u003c/p\u003e\n\u003cp\u003e(2) Felt insertion in the distal VA of Space II; Mobilization of VA toward the skull base.\u003c/p\u003e\n\u003cp\u003e(3) Expansion of the Space I; Arachnoid dissection; Isolation and decompression of the SCA with felt placement.\u003c/p\u003e\n\u003cp\u003e(4) Final isolation of VA-trigeminal root contact with thin-layered felt (Fig. 5A-D).\u003c/p\u003e\n\u003cp\u003eType II Compression (Moderate Brainstem Compression with Arachnoid Space Preservation)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Mobilization of the VBD within the Space II is relatively straightforward due to the presence of a preserved arachnoid plane between the vessel and brainstem, coupled with minimal local brainstem compression. Consequently, only the final three steps of the decompression protocol established for Type I lesions are required (Fig. 6A-C).\u003c/p\u003e\n\u003cp\u003eIt must be emphasized that the initial step for Type I is not routinely performed, as it introduces additional mechanical stimulation to the facial (CN VII) and vestibulocochlear (CN VIII) nerves, thereby increasing the risk of hearing impairment and facial paralysis.\u003cbr\u003eFurthermore, during felt implantation, three critical principles should be observed:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;(1) Adhere to the \u0026quot;pier-and-girder principle\u0026quot; by implanting felt at multiple points to distribute focal pressure exerted by the vessel on the brainstem.\u0026nbsp;(2) Ensure both the offending vessel and felt remain distant from the trigeminal nerve trunk and its root entry zone (REZ) to prevent adhesion.\u0026nbsp;(3) Limit the volume of implanted felt to avoid local overcompression, which may exacerbate brainstem compression or compromise surgical efficacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMVD for VBD-PTN is technically demanding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMVD for VBD-PTN poses significant technical challenges. Singh demonstrated that the compressive force exerted by tortuous and elongated VBD vessels on neural structures substantially exceeds that of the SCA, necessitating a greater volume of felt and an extended decompression range to achieve effective vascular displacement. This approach, however, escalates the risks of cranial nerve injury and brainstem infarction [18,19]. Furthermore, the CPA cistern on the affected side is often anatomically constrained, demanding advanced microsurgical skills [14]. Precise quantification of implanted felt is critical: insufficient placement fails to alleviate compression, while excessive volume may induce brainstem compression, manifesting as facial paralysis, diplopia, contralateral limb motor deficits, or sensory disturbances.\u0026nbsp;Long-term follow-up data from our cohort revealed the following postoperative complications: facial hypoesthesia (20.6%), hearing impairment (8.8%), diplopia (8.8%), tinnitus (5.9%), and hemisensory loss (2.9%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTailored MVD for VBD-PTN with high overall efficacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our cohort, 91.2% (31/34) of patients achieved BNI grade I pain relief, and 8.8% (3/34) reached BNI grade II, resulting in an overall excellent outcome rate of 100%. Moreover, immediate postoperative pain resolution occurred in the majority of patients (88.3%, 30/34), with residual symptoms typically subsiding within six months. Davide\u0026apos;s meta-analysis of 2,102 PTN patients undergoing MVD reported BNI grade I outcomes in 82.9% and grades II\u0026ndash;III in 14.5% [20], indicating a lower overall efficacy compared to our cohort. We propose that tailored MVD strategies based on VBD compression patterns ensure thorough decompression and contribute to superior surgical outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, VBD-related PTN is clinically rare and typically manifests with severe pain that responds poorly to pharmacological therapy. Based on intraoperative findings during MVD, two distinct compression patterns can be identified. Tailoring surgical strategies to these specific etiological subtypes is critical for achieving safe and effective outcomes. Furthermore, enhancing comprehension of MVD principles and refining operative techniques are pivotal measures to minimize complications and optimize therapeutic efficacy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Beijing-Tianjin-Hebei cooperation project, H2024206573.\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXKZ: date acquisition and analysis and drafting and writing of the manuscript; XLX: date analysis and important revisions to the manuscript; XS: date collection; YBY: work concept or design and important revisions to the manuscript. The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003eThis study (2023-KY-102) was granted by the Institutional Review Board in compliance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eRados I\u003c/strong\u003e (2022) Treatment options for trigeminal neuralgia. \u003cem\u003eActa Clin Croat\u003c/em\u003e 61(Suppl 2):96\u0026ndash;102. https://doi.org/10.20471/acc.2022.61.s2.12\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eChow A, Haider I, Athanaselos A, Patel M\u003c/strong\u003e (2024) In-hospital management of acute trigeminal neuralgia pain crises. \u003cem\u003eClin Med Res\u003c/em\u003e 22(4):215\u0026ndash;221. https://doi.org/10.3121/cmr.2024.1945\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLiang Y, Zhao Q, Hu Z, Bo K, Meyyappan S, Neubert J, et al\u003c/strong\u003e (2023) Imaging the neural substrate of trigeminal neuralgia pain using deep learning. \u003cem\u003eFront Hum Neurosci\u003c/em\u003e 17:1144159. https://doi.org/10.3389/fnhum.2023.1144159\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMousavi SH, Lindsey JW, Westlund KN, Alles SRA\u003c/strong\u003e (2024) Trigeminal neuralgia as a primary demyelinating disease: potential multimodal evidence and remaining controversies. \u003cem\u003eJ Pain\u003c/em\u003e 25(2):302\u0026ndash;311. https://doi.org/10.1016/j.jpain.2023.08.012\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eYang L, Cheng H\u003c/strong\u003e (2022) Surgical technique management of microvascular decompression for trigeminal neuralgia. \u003cem\u003eIdeggyogy Sz\u0026nbsp;\u003c/em\u003e75(11-12):369-375. https://doi.org/10.18071/isz.75.0369\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHerber S, Zimmerman RS, Chen A, Yang M, Martinez F\u003c/strong\u003e (2024) Teflon granuloma with active inflammation: a cause of recurrent trigeminal neuralgia after microvascular decompression. \u003cem\u003eClin Nucl Med\u003c/em\u003e 49(12):1105\u0026ndash;1108. https://doi.org/10.1097/RLU.0000000000005444\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eWang Y, Yu J\u003c/strong\u003e (2022) Prospects and dilemmas of endovascular treatment for vertebrobasilar dolichoectasia. \u003cem\u003eFront Neurol\u003c/em\u003e 13:895527. https://doi.org/10.3389/fneur.2022.895527\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVisocchi M, Zeoli F, Signorelli F\u003c/strong\u003e (2024) Microvascular decompression for trigeminal neuralgia secondary to vertebrobasilar dolichoectasia. \u003cem\u003eJ Clin Med\u003c/em\u003e 13(21):6342. https://doi.org/10.3390/jcm13216342\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAmagasaki K, Takusagawa Y, Tatebayashi K, Nakaguchi H\u003c/strong\u003e(2022) Macrovascular decompression with transposition method using Teflon sling for trigeminal neuralgia. \u003cem\u003eWorld Neurosurg\u003c/em\u003e 167:1395\u0026ndash;1401. https://doi.org/10.1016/j.wneu.2022.09.049\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSun J, Wang J, Jia J, Cao Z, Li Z, Zhang C, et al\u003c/strong\u003e (2024) Fully endoscopic microvascular decompression for trigeminal neuralgia caused by vertebrobasilar artery. \u003cem\u003eOper Neurosurg\u003c/em\u003e 26(4):433\u0026ndash;441. https://doi.org/10.1227/ons.0000000000000998\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eUribe-Pacheco R, Sangrador-Deitos MV, Guinto-Nishimura GY, Villalonga JF, Baldoncini M, et al\u003c/strong\u003e (2025) Transposition of megadolichoectatic basilar artery in trigeminal neuralgia. \u003cem\u003eWorld Neurosurg\u003c/em\u003e 193:225. https://doi.org/10.1016/j.wneu.2024.11.015\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eChelmis F, Pakataaridis P, Sorotou I,\u003c/strong\u003e\u003cstrong\u003eTzineris A, Ranguelov C\u003c/strong\u003e (2024). Microvascular Decompression: An Effective Approach for Trigeminal Neuralgia Caused by a Dolichoectatic Basilar Artery after Multiple Treatment Failures. \u003cem\u003eJ Neurol Surg Rep\u0026nbsp;\u003c/em\u003e85(3):156-160. \u0026nbsp;https://doi.org/10.1055/a-2342-4086\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eZheng W, Wang L, Wang H, Zhou H, Du Q\u003c/strong\u003e (2023) Trigeminal neuralgia caused by vertebrobasilar dolichoectasia: efficacy of stepwise decompression technique. \u003cem\u003eActa Neurochir\u003c/em\u003e 165(10):3019\u0026ndash;3026. https://doi.org/10.1007/s00701-023-05691-7\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eChai S, Cheng R, Yang J, Shen L, Fu K, Zhou J, et al\u003c/strong\u003e (2023) Cerebellopontine angle cistern volumetric differences in trigeminal neuralgia. \u003cem\u003eNeurosurg Rev\u003c/em\u003e 46(1):243. https://doi.org/10.1007/s10143-023-02141-x\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTakei M, Takizawa K, Okada A, Otani N, Noma N\u003c/strong\u003e (2023) Trigeminal neuralgia with concomitant continuous pain due to vertebrobasilar dolichoectasia. \u003cem\u003eCureus\u003c/em\u003e 15(12):49953. https://doi.org/10.7759/cureus.49953\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBethamcharla R, Abou-Al-Shaar H, Maarbjerg S, Chang Y, Gacka CN, Sekula RF\u003c/strong\u003e (2023) Percutaneous glycerol rhizolysis for trigeminal neuralgia. \u003cem\u003eEur J Neurol\u003c/em\u003e 30(10):3307\u0026ndash;3313. https://doi.org/10.1111/ene.15977\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFeng Y, Jia Y, Lu PG, Zhao ZY, Zhang YQ, Men XZ\u003c/strong\u003e(2022) Microvascular decompression by interposition method for vertebrobasilar dolichoectasia. \u003cem\u003eNeurosurg Rev\u003c/em\u003e 45(4):2709\u0026ndash;2715. https://doi.org/10.1007/s10143-022-01776-6\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSingh H, da Silva HB, Zeinalizadeh M, Elarjani T, Straus D, Sekhar L\u003c/strong\u003e(2018) Basilar artery ectasia causing trigeminal neuralgia. \u003cem\u003eOper Neurosurg\u003c/em\u003e 14(2):194\u0026ndash;199. https://doi.org/10.1093/ons/opx087\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFerreira M, Walcott BP, Nahed BV, Sekhar LN\u003c/strong\u003e(2011) Vertebral artery pexy for microvascular decompression. \u003cem\u003eJ Neurosurg\u003c/em\u003e 114(6):1800\u0026ndash;1804. https://doi.org/10.3171/2010.12.JNS10891\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDi Carlo DT, Benedetto N, Perrini P\u003c/strong\u003e (2022) Clinical outcome after microvascular decompression for trigeminal neuralgia: a systematic review and meta-analysis. \u003cem\u003eNeurosurg Rev\u003c/em\u003e 46(1):8. https://doi.org/10.1007/s10143-022-01922-0\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Vertebrobasilar Dolichoectasia, Primary Trigeminal Neuralgia, Microvascular decompression, Surgical Strategies, Clinical Outcomes","lastPublishedDoi":"10.21203/rs.3.rs-7400143/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7400143/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e To investigate the surgical strategies, technical key points, and clinical efficacy of microvascular decompression (MVD) in treating primary trigeminal neuralgia (PTN) associated with vertebrobasilar dolichoectasia (VBD).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective analysis was conducted on 34 consecutive VBD-related PTN patients treated by a single neurosurgeon at the China-Japan Friendship Hospital between January 2020 and April 2025. VBD compression patterns were classified into two types:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e​Type I: Imaging \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;showing significant brainstem deformation and obliterated arachnoid space \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;by VBD (n=16, 47.1%).\u003c/li\u003e\n \u003cli\u003e​Type II: Imaging \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;confirming VBD presence without or with minimal brainstem deformation and \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;preserved arachnoid space (n=18, 52.9%).\u003cbr\u003e\n \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Type-specific MVD techniques were applied: a four-step \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;approach for Type I and a three-step approach for Type II. \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Outcomes were evaluated using the Barrow Neurological Institute Pain \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Intensity Scale (BNI) during follow-up (range: 2–64 months).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among 1,214 PTN patients treated during the study period, 34 (2.8%) had VBD-related PTN. ​Preoperative BNI grades: Grade V in 8 patients (23.5%); Grade IV in 26 patients (76.5%). 17.6% (6/34) had comorbid cranial neuropathies. ​Postoperative outcomes: BNI Grade I: 91.2% (31/34)，BNI Grade II: 8.9% (3/34)，Overall success rate (BNI ≤ II): 100%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e VBD-related PTN is a rare clinical entity characterized by severe refractory pain. Based on VBD compression morphology (Type I vs. Type II), tailored MVD strategies provide a safe and effective surgical approach, achieving excellent pain relief.\u003c/p\u003e","manuscriptTitle":"Microvascular Decompression for Vertebrobasilar Dolichoectasia-Related Primary Trigeminal Neuralgia: Surgical Strategies, Technical Nuances, and Clinical Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-03 10:18:25","doi":"10.21203/rs.3.rs-7400143/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-09T02:17:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-31T21:14:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-29T13:01:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276066050590289292251058830449844479962","date":"2025-10-27T13:22:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80455024735811607174762453433347862108","date":"2025-10-25T13:01:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116113210717369455184067932893061690656","date":"2025-10-25T10:09:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59710777870842307756342208283967378825","date":"2025-10-22T21:20:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-22T12:15:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-22T12:14:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-22T02:33:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2025-08-18T13:14:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"63302f42-7748-4cc6-8021-880cd369bd0f","owner":[],"postedDate":"November 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:00:04+00:00","versionOfRecord":{"articleIdentity":"rs-7400143","link":"https://doi.org/10.1007/s10143-025-04057-0","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2026-01-19 15:57:20","publishedOnDateReadable":"January 19th, 2026"},"versionCreatedAt":"2025-11-03 10:18:25","video":"","vorDoi":"10.1007/s10143-025-04057-0","vorDoiUrl":"https://doi.org/10.1007/s10143-025-04057-0","workflowStages":[]},"version":"v1","identity":"rs-7400143","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7400143","identity":"rs-7400143","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}