{"id":53522,"date":"2023-12-31T09:58:14","date_gmt":"2023-12-31T09:58:14","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=53522"},"modified":"2024-01-05T08:06:14","modified_gmt":"2024-01-05T08:06:14","slug":"slow-chronic-progressive-hydrocephalus-as-complication-of-microvascular-decompression-for-trigeminal-neuralgia-a-case-report","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol16no4\/slow-chronic-progressive-hydrocephalus-as-complication-of-microvascular-decompression-for-trigeminal-neuralgia-a-case-report\/","title":{"rendered":"Slow-Chronic Progressive Hydrocephalus as Complication of Microvascular Decompression for Trigeminal Neuralgia: A Case Report"},"content":{"rendered":"\n

Introduction<\/strong><\/p>\n\n\n\n

Idiopathic trigeminal\nneuralgia (TN) is a pathological condition caused by demyelination of the root\nentry zone of the fifth cranial nerve around the Obersteiner-Redlich zone. This\nzone is the transition between peripheral and central myelin, as this central\nmyelin is vulnerable to injury, this neurovascular contact may then lead to the\ndemyelination process.1<\/sup> Microvascular decompression (MVD) is one of\nthe well-established treatment options for trigeminal neuralgia that may\ninclude in posterior fossa surgery. However, due to its surgical nuances with\nminimal disruption of the surrounding neurovascular anatomy on the posterior\nfossa compartment, this procedure is thought to differ from conventional\nposterior fossa surgeries.2<\/sup> Several complications were noted as being\npart of posterior fossa surgery and hydrocephalus is very rare to occur\nespecially the slow-chronic onset type. Here we report a case of slow-chronic hydrocephalus\nrelated to MVD procedure.2,3<\/sup><\/p>\n\n\n\n

Case\nReport<\/strong><\/p>\n\n\n\n

A 66-years old male patient came with a chief complaint of unilateral\nface pain on the left side for the last 3 months. He had a history of taking\nanalgesia for the last 3 weeks but the symptoms persist. On physical\nexamination, we found an electric-like shock over the distribution of the left\ntrigeminal nerve. From radiological examination using magnetic resonance\nangiography, we found a neurovascular conflict between the left superior\ncerebellar artery with the left trigeminal nerve (figure 1) that led to his\nsymptoms. We then performed MVD and the symptoms fully resolved after the\nsurgery (figure 2).<\/p>\n\n\n\n\n\n
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Figure 1: <\/strong>MRA result, there is a contact of the left Superior Cerebral Artery<\/em> with the Trigeminal Nerve at the nerve root entry zone and pontine segment (white arrow).<\/strong><\/p>\n

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Figure 2:<\/strong> Microvascular Decompression Procedure. The superior cerebellar artery was found to be in contact with the trigeminal nerve on superior-lateral projection.<\/strong><\/p>\n

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On the second month of post-operative follow-up, he complained about\nprogressive headaches with memory disturbance. This complaint starts about 1\nmonth after the surgery. Further evaluation using a head computed tomography\n(CT) scan revealed acute hydrocephalus (Figure 3). Ventriculoperitoneal (VP)\nshunt was performed using medium opening pressure. Immediately after the\nsurgery, the patient’s complaints were resolved and he was discharged on the\nthird postoperative day without any morbidity. <\/p>\n\n\n\n\n\n
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Figure 3:<\/strong> Head CT scan 2 months post microvascular decompression surgery (Left).<\/strong><\/p>\n

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Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

Discussion                   <\/strong><\/p>\n\n\n\n

Trigeminal\nneuralgia is an idiopathic pathological condition that is caused by compression\nof the fifth cranial nerve’s root entry zone. This condition is defined by\nrepeated stabbing pain on the trigeminal nerve branch. MVD is a\nwell-established surgical technique to treat trigeminal neuralgia with minimal\ncomplications.<\/p>\n\n\n\n

Several\ncomplications were mentioned in posterior fossa surgery including cerebellar\nhematoma, infections, CSF leakage, cranial nerve injury, and hydrocephalus.2,4<\/sup> Among all the\ncomplications mentioned above, hydrocephalus is one of the rarest complications\nthat occur with posterior fossa surgery.2,5,6<\/sup> Hydrocephalus\nrelated to posterior fossa surgery was reported either as obstructive or\ncommunicating. Certain etiology mentioned as the causes of hydrocephalus are\ncerebellar hematoma, cerebellar swelling, and blood dispersion in\nsubarachnoidal space.2,6<\/sup><\/p>\n\n\n\n

Microvascular\ndecompression (MVD) is one of the well-established treatment options for\ntrigeminal neuralgia that may include posterior fossa surgery. However, due to\nits surgical nuances with minimal disruption of the surrounding neurovascular\nanatomy on the posterior fossa compartment, this procedure is thought to differ\nfrom conventional posterior fossa surgeries.2<\/sup> This concept is also supported by the fact\nthat MVD had a lower rate of complications and morbidity compared to posterior\nfossa surgery. Generally, in posterior fossa surgery, hydrocephalus may occur\ndue to cerebellar hemorrhage, cerebellar edema due to surgical manipulation,\nblood dispersion on a subarachnoidal layer, cerebellar ischemia, and infections.1,2,7<\/sup><\/p>\n\n\n\n

Two\nstudies from Hanakita3<\/sup> and Barker8<\/sup>, reported a total of 2 cases of acute hydrocephalus from\neach study that related to cerebellar swelling and cerebellar hematoma. Slow-chronic type of postoperative hydrocephalus\nwith MVD surgery may relate to the leptomeningeal inflammatory response, which\nmay lead to a gradual rise in CSF outflow resistance. As in this case, even\nthough there is no subarachnoid blood dispersion, cerebellar hematoma nor\ninfection occurs. Muratorio and colleagues explained that hydrocephalus may\noccur due to inflammatory substances that release after the surgery leading to\nan increasing CSF outflow pathway.2<\/sup> This mechanism is similar to experimental\nhydrocephalus.<\/p>\n\n\n\n

There are still\nminimal data regarding the slow-chronic hydrocephalus. This may be explained\nthat most studies are focusing on short-term complications of MVD. Case series\nby Muratorio found the incidence of postoperative hydrocephalus was 3.5% with\nthe mean time between MVD and the development of hydrocephalus being about 3\nmonths.2<\/sup> Similar result was found in a study by\nLegnani and colleagues that found that hydrocephalus occurs in about 4% of\ncraniotomy cases.7<\/sup> Sinus exposure during craniotomy that lead to\nsinus injury increases the risk of postoperative hydrocephalus.7<\/sup><\/p>\n\n\n\n

Conclusion<\/strong><\/p>\n\n\n\n

MVD procedure is already a standard surgical procedure to treat trigeminal neuralgia. Hydrocephalus as a complication after an MVD procedure has been reported infrequently. Slow-chronic hydrocephalus can be a potential long-term complication of MVD surgery. The pathophysiology is still unclear, but surgeons and patients must be warned about this possible surgical adverse event.<\/p>\n\n\n\n

Conflicts of Interest<\/strong><\/p>\n\n\n\n

There are no conflicts of interest<\/p>\n\n\n\n

Funding Source<\/strong><\/p>\n\n\n\n

There is no funding source.<\/p>\n\n\n\n

References<\/strong><\/p>\n\n\n\n

  1. Fessler RG, Sekhar LN, eds. Microvascular Decompression for Cranial Nerves and Brainstem Compression Syndrome. In: Atlas of Neurosurgical Techniques<\/em>. 2nd ed. Thieme; 2005:655-674.<\/li>
  2. Muratorio F, Tringali G, Levi V, Ligarotti GKI, Nazzi V, Franzini AA. Hydrocephalus: an underrated long-term complication of microvascular decompression for trigeminal neuralgia. A single institute experience. Acta Neurochir (Wien)<\/em>. 2016;158(11):2203-2206. doi:10.1007\/S00701-016-2911-4
     CrossRef <\/a><\/li>
  3. Hanakita J, Kondo A. Serious complications of microvascular decompression operations for trigeminal neuralgia and hemifacial spasm. Neurosurgery<\/em>. 1988;22(2):348-352. doi:10.1227\/00006123-198802000-00012
    CrossRef <\/a><\/li>
  4. Dubey A, Sung WS, Shaya M, et al. Complications of posterior cranial fossa surgery–an institutional experience of 500 patients. Surg Neurol<\/em>. 2009;72(4):369-375. doi:10.1016\/J.SURNEU.2009.04.001
     CrossRef <\/a><\/li>
  5. Hammett T, Teale A, Kumaria A, Basu S. Hydrocephalus Following Microvascuar Decompression – an Under-Recognised Complication. In: CNS Annual Meeting<\/em>. ; 2016:48.<\/li>
  6. Fayed ZY, Afify H. Long \u2011 term follow \u2011 up of microvascular decompression for management of trigeminal neuralgia. Egypt J Neurosurg<\/em>. 2022;37(30). doi:10.1186\/s41984-022-00171-z
     CrossRef <\/a><\/li>
  7. Legnani FG, Saladino A, Casali C, et al. Craniotomy vs. craniectomy for posterior fossa tumors: a prospective study to evaluate complications after surgery. Acta Neurochir (Wien)<\/em>. 2013;155(12):2281-2286. doi:10.1007\/S00701-013-1882-Y
     CrossRef <\/a><\/li>
  8. Barker FG, Jannetta PJ, Bissonette DJ, Larkins M V., Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med<\/em>. 1996;334(17):1077-1084. doi:10.1056\/NEJM199604253341701
    CrossRef <\/a><\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"

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