Vertebral artery dolichoectasia may produce a variety of clinical scenarios depending on the level of compression of several nervous structures along its course. Despite the fact that the pathophysiology is not fully clarified, it would seem that this pathologic elongation and dilation of the artery are acquired and determined by a thinning of the internal elastic lamina exposed to chronic arterial hypertension or as a result of degeneration and atherosclerosis of the arterial wall with age. When treatment is indicated, several techniques to relieve compression have been proposed, but they are usually challenging and nonstandardized. We present a case of a 78-year-old female with a 4-year history of left trigeminal neuralgia resistant to adequate dosage of multiple anticonvulsant medications and allergic to carbamazepine. She presented with a surgical history of a percutaneous microcompression of the Gasserian ganglion and 2 consecutive percutaneous radiofrequency thermorizotomies of the trigeminal nerve with transient benefit. The symptomatology was present for most of the day and impaired her quality of life, leading to severe mood decline. The patient underwent a left suboccipital retrosigmoid craniotomy (Video 1). A Teflon sling was wrapped around the vertebral artery. The 2 ends of the sling were anchored to the lateral dura by cyanoacrylate glue (Glubran 2, GEM Italy, Viareggio, Italy), pulling the vertebral artery away from the trigeminal nerve and brainstem. The patient reported complete suppression of facial pain. The case presentation, surgical anatomy, operative nuances, and postoperative course and outcome are reviewed. The patient gave written consent for participating in the procedure, surgical video, and publication of her images. Unfortunately, we did not take the picture of patient positioning for this specific case. For this reason, in order to better illustrate this surgical phase, we used the picture of another patient, who expressed her consent for publication and was operated on for a microvascular decompression with the same position as the one used for the patient described in this paper.
Keywords: Cyanoacrylate; Microvascular decompression; Neurovascular conflict; Teflon sling; Transposition; Trigeminal neuralgia; Vertebral artery dolichoectasia.
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