Entrapment neuropathy of the median nerve is typically caused by compression at specific anatomical points. However, idiopathic cases, where the standard anatomical compression points are normal, pose diagnostic challenges. This report highlights a unique case discovered during an anatomical dissection of the right upper limb in a 62-year-old male cadaver, where the median nerve was compressed by an unusual branch of the brachial artery, termed the superficial brachioulnar artery (SBUA). The median nerve formed at the distal half of the arm, receiving additional components from the lateral cord, with a noted communication with the musculocutaneous nerve. The SBUA, originating from the brachial artery, passed between the roots of the median nerve and continued superficially, forming the superficial palmar arch. The coexistence of neurovascular variations is clinically significant as it may lead to nerve compression and subsequent symptoms. This case is the first documented instance of median nerve compression by an SBUA. Such variations are crucial for surgical and diagnostic procedures, as abnormal vascular structures can be mistaken for veins, leading to iatrogenic injuries. In addition, understanding these variations helps explain idiopathic median nerve neuropathies and highlights the need for thorough anatomical knowledge to prevent complications during surgical interventions.

BACKGROUND: Vestibular paroxysmia is defined by spontaneous, recurrent, short, paroxysmal episodes of vertigo. The authors present a case of vestibular paroxysmia caused by neurovascular compression of the vestibulocochlear nerve due to the subarcuate artery, which was successfully treated with microvascular decompression.
METHODS: A 46-year-old man first experienced vertigo attacks 5 years earlier. The attacks became more frequent, and left-sided tinnitus developed over the past 4 months, prompting a referral to our hospital. Carbamazepine treatment alleviated symptoms but had to be discontinued due to rash. Brain magnetic resonance imaging and angiography revealed that the left anterior inferior cerebellar artery was pressing on the cisternal segment of the left vestibulocochlear nerve. The authors diagnosed vestibular paroxysmia caused by neurovascular compression and performed microvascular decompression. During the operation, a subarcuate artery was identified as the offending vessel, with a prominent indentation on the vestibulocochlear nerve. The vertigo was completely relieved following surgery.
CONCLUSIONS: Neurovascular compression of the vestibulocochlear nerve by the subarcuate artery can result in vestibular paroxysmia. https://thejns.org/doi/abs/10.3171/CASE24239.

The aim of this study is to bring attention to a unique case and our approach to treatment in this context. We describe a case of an 11-year-old male who presented to us with an injury to his left knee following trauma with pain, swelling, shortening and deformity for one day. An X-ray revealed a transepiphyseal fracture dislocation of the left distal femur (Salter-Harris type 1 injury) and neurovascular examination was conclusive of foot drop which pointed towards injury to common peroneal nerve (CPN). The patient was taken up for closed reduction with percutaneous pinning under mobile C-arm guidance. The fracture was reduced and fixed with two cross K-wires and immobilized with the above knee anterior-posterior slab for six weeks. The wires were removed after six weeks but there was no improvement in the dorsiflexion of the left ankle. An electromyography (EMG) and nerve conduction velocity (NCV) study test was performed after 12 weeks which showed decreased amplitude and prolonged latency in the left CPN with early denervation of the muscles supplied by the left CPN. Fifteen weeks of follow-up showed complete recovery in the dorsiflexion of the left ankle with a slight lag in the extension of the left great toe making this an unusually delayed recovery of CPN palsy following a distal femur transepiphyseal fracture.

Neurovascular compression (NVC) syndromes such as trigeminal neuralgia (TN) are causally treated with microvascular decompression (MVD). Semiautomatic segmentation of high-resolution magnetic resonance imaging (MRI) data and constructive interference in steady state (CISS)/time-of-flight (TOF) sequences are utilized for the three-dimensional (3D) visualization of underlying causative vessels at the root entry zones of the relevant cranial nerves. Augmented reality (AR) of neurovascular structures was introduced especially in the resection of brain tumors or aneurysmatic operations. In this report, the potential feasibility of the implementation of microscope-based AR into the intraoperative microsurgical set-up of MVD was investigated. This article recommends the preoperative evaluation of 3D visualization besides the microscopical view of the surgeon. The implementation of multiple imaging data by AR into the operating microscope may afflict the experienced surgeon\'s view, which should be examined prospectively.

Vertebrobasilar dolichoectasia (VBD) is a rare anatomical abnormality of the vertebral artery system, defined as irregular expansion, elongation, and tortuosity of vertebral arteries. Anomalies of the vertebrobasilar artery can have a wide variety of clinical presentations, ranging from simple headaches to debilitating strokes. We present the case of an atypical presentation of VBD which mimicked trigeminal neuralgia by compressing the trigeminal nerve. There are currently no guidelines concerning the management of VBD, nor is there evidence of a definitive cure. This case invoked discussions among the medical team as to whether management should be medically or surgically focused, as well as long-term outcomes for patients with VBD. The superiority of medical versus surgical treatment of this issue is still a debated topic. This patient trialed medical management with dexamethasone and carbamazepine with no improvement in symptoms. He then underwent surgical gamma knife treatment but even this invasive measure was unsuccessful at relieving his symptoms. We hope that by presenting this case, we can display how the therapies available for VBD are limited and often unsuccessful in relieving the disease burden in patients with VBD.

Aim of the present study was to conduct a comprehensive review of surgical strategies that can be offered to patients with trigeminal neuralgia undergoing microvascular decompression (MVD) surgery and without intraoperative evidence of neurovascular conflict, with a high pre-operative suspicion of conflict lacking intraoperative confirmation, or individuals experiencing recurrence after previous treatment. This systematic review followed established guidelines (PRISMA) to identify and critically appraise relevant studies. The review question was formulated according to the PICO (P: patients; I: intervention; C: comparison; O: outcomes) framework as follows. For patients with trigeminal neuralgia (P) undergoing MVD surgery (I) without demonstrable preoperative neurovascular conflict, high suspicion of conflict but no intraoperative confirmation or recurrence after previous treatment (C), do additional surgical techniques (nerve combing, neurapraxia, arachnoid lysis) (O) improve pain relief outcomes (O)? The search of the literature yielded a total of 221 results. Duplicate records were then removed (n = [76]). A total of 143 papers was screened, and 117 records were excluded via title and abstract screening; 26 studies were found to be relevant to our research question and were assessed for eligibility. Upon full-text review, 17 articles were included in the review, describing the following techniques; (1) internal neurolysis (n = 6) (2) arachnoid lysis/adhesiolysis (n = 2) (3) neurapraxia (n = 3) (4) partial rhizotomy of the sensory root (n = 4) (5) pontine descending tractotomy (n = 2). The risk of bias was assessed using the ROBINS-I (Risk of Bias in Non-randomized Studies - of Interventions) assessment tool. While the described techniques hold promise, further research is warranted to establish standardized protocols, refine surgical approaches, and comprehensively evaluate long-term outcomes.

BACKGROUND: Neurovascular compression syndromes (NVCS), encompassing conditions such as trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia, significantly impair patient quality of life through abnormal vascular compression and micro-pulsation of vasculature on cranial nerves at the Obersteiner-Redlich zone. The modulation of pulsatile flow dynamics via endovascular stents presents a novel research frontier for alleviating these syndromes.
OBJECTIVE: The primary aim of this investigation was to delineate the impact of various endovascular stents on pulsatile flow within an in vitro model of a blood vessel, thereby elucidating their potential applicability in the therapeutic management of NVCS.
METHODS: A simple in vitro analog of a posterior circulation artery was developed, employing an intravenous pump to replicate cardiac-induced blood flow. Within this model, alterations in pulsatile flow were quantitatively assessed following the introduction of three categorically distinct endovascular stents, varying in size. This assessment was facilitated through the employment of both micro-Doppler and Doppler ultrasound methodologies.
RESULTS: The Pipeline 5x35 mm stent (Medtronic, Minneapolis, MN) demonstrated the most significant reductions in peak systolic velocity (Vmax) and pulsatility index (PI), PI especially over the stent, suggesting its potential for drastically altering blood flow dynamics. Similarly, Neuroform Atlas 4.5x30 mm and Neuroform Atlas 4x24 mm stents (Stryker, Kalamazoo, MI) also showed notable decreases in hemodynamic parameters, albeit to different extents. Statistical analysis confirmed that these changes were significantly different from the control (P < 0.0001 for PI and Vmax; P < 0.05 for inter-stent comparisons), except for proximal PI means, which did not significantly differ from the control (P = 0.2777).
CONCLUSIONS: These findings affirm the potential of endovascular stents to substantially modulate arterial pulsatility. The observed decrease in pulsatile flow resultant from endovascular stent application has the potential to attenuate ectopic nerve excitation, a hallmark of NVCS. Consequently, this research highlights the prospective utility of endovascular stents in developing minimally invasive therapeutic approaches for NVCS.

UNASSIGNED: This study aimed to explore the risk factors and potential causes of unilateral classical or idiopathic trigeminal neuralgia (C-ITN) by comparing patients and healthy controls (HCs) with neurovascular compression (NVC) using machine learning (ML).
UNASSIGNED: A total of 84 C-ITN patients and 78 age- and sex-matched HCs were enrolled. We assessed the trigeminal pons angle and identified the compressing vessels and their location and severity. Machine learning was employed to analyze the cisternal segment of the trigeminal nerve (CN V).
UNASSIGNED: Among the C-ITN patients, 53 had NVC on the unaffected side, while 25 HCs exhibited bilateral NVC, and 24 HCs showed unilateral NVC. By comparing the cisternal segment of CN V between C-ITN patients on the affected side and HCs with NVC, we identified the side of NVC, the compressing vessel, and certain texture features as risk factors for C-ITN. Additionally, four texture features differed in the structure of the cisternal segment of CN V between C-ITN patients on the unaffected side and HCs with NVC.
UNASSIGNED: Our findings suggest that the side of NVC, the compressing vessel, and the microstructure of the cisternal segment of CN V are associated with the risk of C-ITN. Furthermore, microstructural changes observed in the cisternal segment of CN V on the unaffected side of C-ITN patients with NVC indicate possible indirect effects on the CN V to some extent.

Trigeminal neuralgia (TN) is characterized by sudden, brief intense pain in the distribution of the unilateral trigeminal nerve (TGN). Neurovascular compression (NVC) of the TGN is the most common cause of TN. Recent studies have suggested that a structural anomaly of the posterior cranial fossa might be involved in the development of TN, and several studies have documented the association between NVC-related TN and congenital posterior cranial deformities in adults. We present the case of a 56-year-old woman with NVC-related TN and unilateral lambdoid synostosis (ULS), along with a literature review, to investigate the relationship between TN and structural anomalies of the posterior fossa. This is the first report of TN in an adult with ULS. Mild and asymptomatic cases of lambdoid synostosis might have a higher incidence of NVC-related TN in association with posterior cranial fossa deformities.

A 51-year-old man with a history of cisplatin treatment for a right testicular tumor underwent microvascular decompression for hemifacial spasm. At an early stage in the surgical procedure, the intraoperative auditory brainstem response (ABR) was diminished despite a relatively minimally invasive approach, resulting in irreversible hearing loss. Cisplatin is known to cause dose-dependent hearing impairment primarily affecting the cochlea, but it can also induce neurotoxicity. In the present case, prior cisplatin administration may have caused fragility of the cochlear nerve as well. Patients with a history of ototoxic and neurotoxic drugs such as cisplatin require more careful manipulation and thorough intraoperative auditory monitoring during neurosurgical procedures that may affect hearing, such as those for hemifacial spasms.