Fuminari Komatsu

Background/Objectives: The incidence of trigeminal neuralgia (TN) rises steeply with age, yet reluctance to offer posterior fossa surgery to patients aged 85 years and older persists, and no series of fully endoscopic microvascular decompression (e-MVD) confined to this group has been reported. To address this, we assessed the technical feasibility, perioperative course, and early pain outcomes of keyhole fully endoscopic microvascular decompression in patients aged ≥85 years with medically refractory TN. Methods: Six patients aged ≥85 years were treated at a single institution between May 2024 and October 2025. Procedures utilized a 3.5–4 cm retrosigmoid incision, a 1.5 cm keyhole craniotomy, a 4 mm 0° endoscope, retraction-free cerebellar relaxation, and continuous brainstem auditory evoked potential monitoring. Pain was graded via the Barrow Neurological Institute (BNI) score. Results: The median patient age was 87 years, the median operative time was 66 min, and estimated blood loss was minimal (0–5 mL) with zero transfusions. Preoperative BNI scores were V in five patients and IV in one. At a median follow-up of 12 months, scores improved to I in five patients and II in one (100% BNI I–II, p = 0.031) with zero recurrences. Conclusions: Fully endoscopic microvascular decompression is technically achievable at ≥85 years with short operative times and excellent pain relief. This demonstrates that chronological age alone is an insufficient reason to withhold definitive decompression from physiologically suitable patients.

The incidence of trigeminal neuralgia (TN) rises steeply with age, yet reluctance to offer posterior fossa surgery to patients aged 85 years and older persists, and no series of fully endoscopic microvascular decompression (e-MVD) confined to this group has been reported. To address this, we assessed the technical feasibility, perioperative course, and early pain outcomes of keyhole fully e-MVD in six patients aged ≥85 years with medically refractory TN treated at a single institution between May 2024 and October 2025. Procedures utilized a 3.5–4 cm retrosigmoid incision, a 1.5 cm keyhole craniotomy, a 4 mm 0° endoscope, retraction-free cerebellar relaxation, and continuous brainstem auditory evoked potential monitoring, with pain graded via the Barrow Neurological Institute (BNI) score. The median patient age was 87 years, the median operative time was 66 minutes, and estimated blood loss was minimal (0–5 mL) with zero transfusions. Preoperative BNI scores were V in five patients and IV in one; at a median follow-up of 12 months, scores improved to I in five patients and II in one (100% BNI I–II, p = 0.031) with zero recurrences. Fully endoscopic microvascular decompression is technically achievable at ≥85 years with short operative times and excellent pain relief, demonstrating that chronological age alone is an insufficient reason to withhold definitive decompression from physiologically suitable patients.

Contrast-induced encephalopathy (CIE) is a rare adverse complication of various diagnostic and therapeutic angiographic procedures following iodinated contrast media administration. Disruption of the blood–brain barrier is the center point of underlying mechanism. It mimics subarachnoid hemorrhage (SAH) on computed tomography (CT) scan. Patient usually present early with wide range of symptoms of neurological deficit; however, late presentations have been documented in literatures. Most of these cases are transient resolving within 48 hours but fatal outcomes have been reported. The purpose of this article was to report three cases who underwent endovascular intervention at our center and developed CIE. All these three patients had untreated hypertension. Iopamidol as contrast agent was used in all these cases. All three patients developed stroke-like symptoms in the postoperative period and radiological investigations revealed a picture of SAH with dual-energy iodinated CT confirming CIE. All patients were managed according to our institutional protocol and made recovery. It is paramount to recognize this potentially devastating complication early after carefully excluding thromboembolic and hemorrhagic causes. Once diagnosed, early initiation of conservative treatment include hydration therapy, anticonvulsants, institute selective use of steroids, and osmotherapy such as mannitol. Adequate preoperative management of hypertension may play an important role in the prevention of CIE. Future use of contrast should include meticulous risk assessment and exhaustive patient and relatives counseling.

Background: Vertebrobasilar dolichoectasia (VBDE) is an uncommon cause of trigeminal neuralgia (TN), in which an ectatic vertebral artery (VA) compresses the root entry zone (REZ), while perforators may limit safe transposition. Methods: Fully endoscopic microvascular decompression with VA transposition was performed. Preservation of all arterial branches was achieved and confirmed endoscopically. Conclusion: In VBDE-related TN, VA transposition may be the preferred decompressive strategy because of the characteristics of the ectatic vessel. Endoscopy offers a wide-angle view of the REZ, facilitating safe mobilization under full visualization of branch vessels.

Ruptured dissecting aneurysms (DAs) of the anterior cerebral artery (ACA), particularly at the A1–A2 junction, are rare and diagnostically challenging, especially in young patients. Conventional treatment options may be limited due to anatomical constraints and the lesion's fragility. We report the case of a 23-year-old male who presented with diffuse subarachnoid hemorrhage and seizure. Initial imaging failed to identify the bleeding source. On follow-up, computed tomography angiography revealed subtle findings suggestive of a dissection at the right A1–A2 junction, which was subsequently confirmed by digital subtraction angiography. Considering the lesion's morphology and location, the aneurysm was treated with a flow diverter (Pipeline Flex with Shield Technology) following clinical stabilization. The patient recovered without neurological deficits and was discharged in good functional condition. This case highlights the potential of flow diversion as an effective treatment strategy for ruptured DAs in the distal ACA. Early recognition through repeat imaging and individualized multidisciplinary planning may contribute to favorable outcomes in anatomically complex lesions.

Background: Hemifacial spasm (HFS) is a clinical syndrome associated with motor dysfunction of the facial nerve as a result of conflict with surrounding vessels. Narrowing of the cerebellopontine angle (CPA) cistern by the abnormality of its bony boundaries has been postulated to increase the risk of such neurovascular conflict (NVC). Case Description: We present a case of a 61-year-old man with clinical features of a right-sided HFS of 1-year duration. Brain magnetic resonance imaging and computed tomography angiography with 3D fusion images revealed compression of the right CNVII by a loop of the anterior inferior cerebellar artery at the root entry zone. There was also a finding of an enlarged jugular tubercle causing narrowing of the cerebellopontine cistern, which we postulated to be the underlying cause of the NVC. He had endoscopic keyhole microvascular decompression with resolution of symptoms. Conclusion: Bony enlargement of the jugular tubercle or other bony structures in the CPA could narrow the cerebellopontine cistern and bring the nerve and blood vessels into closer proximity, potentially increasing the incidence of NVC.

Background The superior petrosal vein (SPV) frequently impedes surgical access to the trigeminal nerve (TN) during microvascular decompression for trigeminal neuralgia. Distinguishing arterial structures, such as the trigeminocerebellar artery (TCA), from SPV venous tributaries presents a significant challenge. Method In this case, intraoperative indocyanine green (i-ICG) angiography precisely identified the TCA. We then safely transposed it using fibrin glue to establish an optimal surgical field. Conclusion Routine i-ICG application may improve neurovascular differentiation, enabling preservation of critical structures and facilitating effective endoscopic microvascular decompression(e-MVD) of the trigeminal nerve.

Background Anterior inferior cerebellar artery (AICA) compression is a common cause of hemifacial spasm (HFS). Endoscopic-assisted microvascular decompression (eMVD) offers several advantages, including minimal invasiveness, wide viewing angles, and clear visualization. Methods The surgical procedure was performed under a four-step endoscopic technique. Step 1: A 0° endoscope was used to dissect the cerebellopontine cistern and release cerebrospinal fluid for decompression. Step 2: A 30° endoscope was employed to dissect the arachnoid around the facial nerve and expose the root exit zone (REZ). Step 3: The AICA was identified, carefully dissected, and transposed away from the REZ. Step 4: Adequate decompression and hemostasis were confirmed. Conclusion The four-step endoscopic approach can achieve effective decompression in cases of HFS caused by AICA compression, providing favorable surgical outcomes.

Background This study evaluated the safety and efficacy of a treatment strategy for Posterior communicating artery (PCOM) aneurysms using first-line Woven EndoBridge (WEB), supplemented by Flow diverter (FD) in selected cases. Methods This retrospective study included patients who underwent endovascular treatment for PCOM aneurysms between January 2021 and March 2025. Aneurysms were categorized as fetal or non-fetal. A first-line WEB strategy was adopted when morphology was suitable. Radiological and clinical outcomes were assessed. Results Forty-six PCOM aneurysms met the criteria: 14 fetal-type and 32 non-fetal-type. All previously untreated fetal-type aneurysms were treated with WEB (n = 9). In the non-fetal group, the initial treatments included WEB (n = 14), FD (n = 10), and coiling (n = 4). All recurrent fetal-type aneurysms were retreated with FD (n = 5), whereas non-fetal recurrences were managed with FD (n = 3) or coiling (n = 1), depending on prior treatment. At a median follow-up of 21 months, complete occlusion was achieved in 66.7% of fetal-type and 59.4% of non-fetal-type aneurysms (P = 0.739), and adequate occlusion was achieved in 75.0% and 90.6%, respectively (P = 0.321). Retreatment was required in two cases (4.3%): one in the fetal group (7.1%) and one in the non-fetal group (3.1%) (p = 0.512). No modified Rankin Scale worsening or major complications occurred. No significant differences in treatment efficacy were observed among modalities selected under the WEB first-line strategy. Conclusion A first-line WEB strategy is safe and effective for PCOM aneurysms, including fetal-type variants, with outcomes for fetal-type aneurysms comparable to non-fetal-type aneurysms.