Fenestrated Aneurysm Clip Trigeminal Decompression after CyberKnife Treatment Failure

Objective  This article describes a novel technique for trigeminal nerve decompression in the setting of refractory trigeminal neuralgia (TN). Design  Technical note with an illustrative case example and operative video. Setting  Outpatient, inpatient, and operating room of a quaternary neurosurgical referral center. Participant  A woman in her early 70s who had previously undergone linear accelerator-based stereotactic radiotherapy (i.e., CyberKnife) and achieved 2 years of partial pain relief. However, facial pain, numbness, and parasympathetic dysfunction returned and became unbearable. Main Outcome Measure  Durable relief of TN. Results  Microvascular decompression was recommended for refractory TN. Intraoperatively, the trigeminal nerve was markedly attenuated from previous irradiation, with the superior cerebellar artery (SCA) loop embedded in the nerve at its root entry zone. The arterial loop was mobilized into a new position superior to the nerve, thus liberating it from the impingement. The tentorium was incised, and a fenestrated aneurysm clip was positioned such that the SCA loop was transmitted via the fenestration. The clip was applied across the tentorium, thus suspending the artery in a kink-free orientation that made no contact with the nerve. Conclusion  This procedure provided excellent neurovascular decompression without placing mechanical strain on the nerve, relieving the patient's persistent postirradiation TN. The technique could have broader applications for other challenging or atypical microvascular decompression procedures.