Navigating the neurovascular maze of trigeminal neuralgia

Tic douloureux, also known as trigeminal neuralgia, is distinguished by recurrent episodes of severe, lancinating pain that affects one or more branches of the trigeminal nerve, representing a prevalent pain syndrome. This condition has an annual incidence rate of 27 per 100,000 individuals. Nevertheless, direct compression caused by vertebrobasilar dolichoectasia (VBD) represents a considerably less frequent etiology of trigeminal neuralgia, with an estimated overall incidence of about 1%. A 65-year-old female patient with a history of diabetes mellitus and hypertension presented with a severe, paroxysmal headache and lancinating pain localized to the right facial regions corresponding to the V2 and V3 trigeminal distributions, persisting for 3 years. MRI imaging indicated that the right trigeminal nerve is sandwiched between right superior cerebellar artery and hypertrophied right transverse pontine vein s/o left vertebral and basilor dolichoectasia with entrapment of trigeminal nerve between right SCA and right transverse pontine vein- (TYPE IV neurovascular compression). Vertebrobasilar dolichoectasia represents an uncommon etiology of neurovascular compression affecting the trigeminal and facial nerves, which may result in the development of trigeminal neuralgia and facial hemispasm. Magnetic resonance imaging (MRI) is the optimal modality for elucidating TN aetiology. Precise preoperative detection of neurovascular conflict enhances surgical efficiency and minimizes operative time. Initially, medical management should be pursued, as it may yield significant therapeutic benefits and potentially eliminate the necessity for surgical interventions.