• Krishna Kumar, Kuntal Kanti Das, Suyash Singh, Deepak Khatri, Harsh Deora, Jaskaran Singh, Kamlesh Bhaisora, Arun K Srivastava, Awadhesh K Jaiswal, and Sanjay Behari.
• Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
• World Neurosurg. 2019 Jul 1; 127: e366-e375.

BackgroundVascular loop compression remains the most accepted theory for trigeminal neuralgia (TN). Apart from the normal adjoining vascular loops, certain unusual vascular loops incriminated in TN such as vertebrobasilar dolichoectasia and pure venous compressions do not truly fit into the traditional classification. Moreover, vascular diseases such as cavernoma and aneurysms causing TN are considered as secondary TNs. There is a lack of unified classification for TN with underlying vascular offenders, otherwise amenable to microvascular decompression.MethodsWe classified vascular offenders in TN (n = 53) into the usual offenders such as superior cerebellar artery or anterior inferior cerebellar artery loop with (n = 4) or without (n = 34) superior petrosal vein loop (n = 38, group I). The unusual vascular offenders (n = 15, group II) comprised unusual arterial loops (n = 4, IIa), pure venous compressions (n = 8, IIb) and vascular diseases (n = 3, IIc). The clinical symptoms, pain severity scores, and surgical outcomes were compared.ResultsA right-sided preference and male predominance typified the unusual group. The incidence of atypical pain and sensory impairment was higher in group II. Group II also showed a less favorable immediate pain outcome, particularly the patients in group IIb. Group IIb also showed a higher incidence of postoperative hemorrhagic complications. However, long-term outcomes did not differ significantly.ConclusionsUnusual vascular offenders in TN do constitute a significant population. They differ from the usual group with respect to the type of pain, gender, and side of involvement and tend to have more complications with similar pain outcomes after microvascular decompression.Copyright © 2019 Elsevier Inc. All rights reserved.

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