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ABSTRACT: Migraine headaches are a significant global health concern, frequently managed with varying levels of success. Compression of the greater occipital nerve (GON) is hypothesized to contribute to pathology in some migraine patients, making extracranial nerve decompression surgery a potential intervention for refractory cases. However, accurate methods to image the GON along its tortuous course still need to be explored. Our group has developed magnetic resonance imaging sequences to track the GON. Yet, many challenges were met, which included navigating the GON's complex anatomy, understanding anatomical variants, and designing advanced magnetic resonance imaging sequences and coils to image the posterior scalp. Addressing these hurdles is vital to capture and understand GON pathology and guide potential interventions.

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Neurovascular compression syndrome (NVCS), characterized by cranial nerve compression due to adjacent blood vessels at the root entry zone, frequently presents as trigeminal neuralgia (TN), hemifacial spasm (HFS), or glossopharyngeal neuralgia (GN). Despite its prevalence in NVCS assessment, Magnetic Resonance Tomographic Angiography (MRTA)'s limited sensitivity to small vessels and veins poses challenges. This study aims to refine vessel localization and surgical planning for NVCS patients using a novel 3D multimodal fusion imaging (MFI) technique incorporating computed tomography angiography and venography (CTA/CTV). A retrospective analysis was conducted on 76 patients who underwent MVD surgery and were diagnosed with single-site primary TN, HFS, or GN. Imaging was obtained from MRTA and CTA/CTV sequences, followed by image processing and 3D-MFI using FastSurfer and 3DSlicer. The CTA/CTV-3D-MFI showed higher sensitivity than MRTA-3D-MFI in predicting responsible vessels (98.6% vs. 94.6%) and NVC severity (98.6% vs. 90.8%). Kappa coefficients revealed strong agreement with MRTA-3D-MFI (0.855 for vessels, 0.835 for NVC severity) and excellent agreement with CTA/CTV-3D-MFI (0.951 for vessels, 0.952 for NVC). Resident neurosurgeons significantly preferred CTA/CTV-3D-MFI due to its better correlation with surgical reality, clearer depiction of surgical anatomy, and optimized visualization of approaches (p < 0.001). Implementing CTA/CTV-3D-MFI significantly enhanced diagnostic accuracy and surgical planning for NVCS, outperforming MRTA-3D-MFI in identifying responsible vessels and assessing NVC severity. This innovative imaging modality can potentially improve outcomes by guiding safer and more targeted surgeries, particularly in cases where MRTA may not adequately visualize crucial neurovascular structures.

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CASE: A 10-year-old girl presented after closed reduction of an elbow fracture dislocation. She demonstrated intact vascularity but a dense median nerve palsy. Preoperative magnetic resonance neurography (MRN) precisely mapped the median nerve entrapped within the medial epicondylar fracture. Intraoperatively, the median nerve was freed preceding reduction and fracture fixation. Postoperatively, neurological symptoms completely resolved, and she regained full elbow function. CONCLUSION: Median nerve injury can present without associated vascular injury. In this case, MRN was helpful in preoperatively illustrating the spatial relationship between the median nerve and the medial epicondyle.

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OBJECTIVE: Trigeminal neuralgia (TN) due to venous compression is far less common than that due to arterial compression, and its pathogenesis is less clear. We investigated the clinical and imaging features of TN caused by solely venous compression by measuring the morphologies of the posterior cranial fossa (PCF) and the trigeminal nerve. METHODS: We retrospectively reviewed records of TN patients who underwent microvascular decompression at our institution and extracted cases with solely arterial or solely venous compression. Preoperative magnetic resonance imaging was used to find the length (Y), width (X), height (Z), and volume (V) of the PCF, the angle between the trigeminal nerve and pons, and the distance between Meckel's cave and the root entry zone of the trigeminal nerve. RESULTS: Of 152 patients, 24 had TN caused solely by venous compression. The value of Y was significantly smaller in the venous group than the arterial group (P < 0.01). The trigeminal nerve and pons was significantly smaller in the venous group (P < 0.01). We hypothesized that TN patients with solely venous compression had a characteristic PCF morphology with a short anteroposterior diameter (Y), such that age-related changes in brain morphology could alter the course of the trigeminal nerve and cause compression by a vein. CONCLUSIONS: The morphological features of the PCF differed between patients with TN of venous and those with TN of arterial etiology. Age-related changes in brain morphology and changes of course of the trigeminal nerve may also add to the possibility of developing TN, especially of venous etiology.

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Ultrasound and magnetic resonance neurography are useful modalities to aid in the assessment of compressive neuropathies, although they are still limited in their resolution of nerve microstructure and their capacity to monitor postoperative nerve recovery. Optical coherence tomography, a preclinical imaging modality, is promising in its ability to better identify structural and potential physiologic changes to peripheral nerves, but requires additional testing and research prior to widespread clinical implementation. Further advances in nerve imaging may elucidate the ability to visualize the zone of nerve injury intraoperatively, monitor the progression of nerve regeneration, and localize problems during nerve recovery.

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Suprascapular nerve entrapment (SNE) syndrome is a commonly overlooked cause of shoulder weakness and pain. It frequently causes weakness over the posterior and lateral and posterior aspects of the shoulder, as well as pain of infraspinatus muscles. Therefore, we considered that the infraspinatus muscle cross-sectional area (IMCSA) might be a new morphological parameter to analyze SNE syndrome. We assumed that the IMCSA is an important morphologic parameter in SNE syndrome diagnosis. We acquired infraspinatus muscle data from 10 patients with SNE syndrome and from 10 healthy subjects who had undergone magnetic resonance imaging of the shoulder and who revealed no evidence of SNE syndrome. We analyzed the infraspinatus muscle thickness (IMT) and IMCSA at the shoulder on the imaging of the shoulder using our image analysis program. The IMCSA was measured as the whole infraspinatus muscle cross-sectional area that was most atrophied in the sagittal S-MR images. The IMT was measured as the thickest level of infraspinatus muscle. The mean IMT was 29.17 ±â€…2.81 mm in the healthy subjects and 25.22 ±â€…3.19 mm in the SNE syndrome group. The mean IMCSA was 1321.95 ±â€…175.91 mm2 in the healthy group and 1048.38 ±â€…259.94 mm2 in the SNE syndrome group. SNE syndrome patients had significantly lower IMT (P < .001) and IMCSA (P < .001) than the healthy group. The ROC curve shows that the optimal cutoff point of the IMT was 26.74 mm, with 70.0% sensitivity, 70.0% specificity, and an AUC of 0.83 (95% CI, 0.65-1.00). The best cutoff value of the IMCSA was 1151.02 mm2, with 80.0% sensitivity, 80.0% specificity, and AUC of 0.87 (95% CI, 0.69-1.00). The IMT and IMCSA were both significantly associated with SNE syndrome. And the IMCSA was a highly sensitive diagnostic tool.

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CASE: We present a case of type II (intraosseous) entrapment of the median nerve in a patient who was diagnosed based on clinical examination and magnetic resonance imaging and who was treated with medial epicondyle osteotomy, neurolysis, and transposition of the nerve to its anatomical position within a month of injury. Our patient made a complete motor and sensory recovery at 5 months with complete functionality and grip strength. CONCLUSION: Median nerve entrapment after posterolateral elbow dislocation is a rare complication with roughly 40 cases reported in the literature. This case illustrates the importance of prompt diagnosis and treatment.

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CASE: This case report describes a patient with paresthesia in the distribution of the superficial sensory branch of the radial nerve that was treated with surgery. Intraoperatively, there was a unique cause of internal compression by a rare superficial radial artery variant running adjacent to it. The nerve was mobilized from the artery with fascial releases. The patient had symptom resolution postoperatively. CONCLUSION: To our knowledge, this cause of compression has not been described before and should be considered in a differential diagnosis. In addition, clinicians should be aware of this anatomical variant during venipunctures and surgical approaches.

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Peripheral nerve entrapment is an underdiagnosed pathology when it is not the most common syndromes such as carpal tunnel syndrome or cubital tunnel syndrome. The symptomatic lesion of the superficial peroneal nerve (SPN) has a low incidence, being its diagnosis sometimes complex. It is based on a exhaustive physical examination and imaging tests such as ultrasound (US) or magnetic resonance imaging (RMI). Conservative treatment may sometimes not be sufficient, requiring surgical techniques in refractory cases. We present a patient diagnosed with superficial peroneal nerve entrapment by ultrasound and diagnostic nerve block that was subsequently resolved by hydrodissection technique at the level of the deep crural fascia tunnel. The results were satisfactory with a complete resolution of the clinical process since the application of this technique.

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CASE: A 65-year-old female patient presented with complaints of diffuse pain and swelling in her right wrist with paresthesia in her right hand with thenar wasting. Her magnetic resonance imaging scan was suggestive of flexor tenosynovitis of the wrist with compression of the median nerve with multiple rice bodies. She underwent excisional biopsy along with median nerve decompression. Mycobacterium tuberculosis was detected by polymerase chain reaction (GeneXpert), and histopathology identified caseous granulomas. The patient was started on antitubercular chemotherapy postoperatively. CONCLUSION: In endemic countries such as India, tuberculous flexor tenosynovitis must always be a differential diagnosis in cases of wrist swelling with rice bodies.

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BACKGROUND AND OBJECTIVE: Lateral femoral cutaneous nerve (LFCN) decompression and transposition are surgical treatment options for meralgia paresthetica. Identifying the LFCN during surgery may be challenging, and preoperative localization is a valuable adjunct in this case. The objective of this study was to explore a new technique using preoperative ultrasound-guided clip localization (USCL) of the LFCN. METHODS: After Institutional Review Board approval, data were collected on patients who underwent both preoperative ultrasound-guided wire localization (USWL) and USCL over the past 13 years. Skin-to-nerve time was calculated prospectively. RESULTS: Fifty-six patients were identified, 51 had USWL and 5 had USCL; the skin-to-nerve median time was 7.5 and 6 minutes, respectively. Six wires were misplaced, and this was at the beginning of utilization of the USWL technique. There were no nerve injury, infection, or bleeding complications related to either wire or clip placement. CONCLUSION: USWL or USCL is safe and time-efficient in LFCN surgeries.

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There are many lesions that cause compression of nerves and vessels in the head and neck, and they can often be overlooked in the absence of adequate history or if not suspected by the radiologist. Many of these lesions require a high index of suspicion and optimal positioning for imaging. While a multimodality approach is critical in the evaluation of compressive lesions, an MRI utilizing high-resolution (heavily weighted) T2-weighted sequence is extremely useful as a starting point. In this review, we aim to discuss the radiological features of the common and uncommon compressive lesions of the head and neck which are broadly categorized into vascular, osseous, and miscellaneous etiologies.

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BACKGROUND: Suprascapular nerve entrapment is a rare disorder that is frequently misdiagnosed as another disease. The suprascapular nerve is commonly entrapped at the following two sites: the suprascapular and spinoglenoid notches. Nerve entrapment at the spinoglenoid notch causes infraspinatus muscle weakness and atrophy. Patients present with posterior shoulder pain and weakness. Magnetic resonance imaging is used to confirm the diagnosis of a spinoglenoid cyst and nerve compression. Open or arthroscopic aspiration or decompression is indicated for patients with cysts in whom conservative treatment has failed and those with cysts associated with suprascapular nerve compression. CASE PRESENTATION: Herein, we describe the case of a 49-year-old man with suprascapular nerve entrapment caused by a large cyst, namely, a hematoma, in the superior scapular and spinoglenoid notches. Open surgical decompression of the suprascapular nerve was performed owing to an intact rotator cuff and glenoid labrum. CONCLUSION: Posterior shoulder pain promptly resolved without complications.

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BACKGROUND: Neurovascular compression syndromes (NVCSs) are a group of neurological disorders characterized by compression of a cranial nerve and include trigeminal neuralgia (TN), hemifacial spasm, geniculate neuralgia, glossopharyngeal neuralgia, vestibular paroxysmia, and trochlear palsy. The European Academy of Neurology recommends constructive interference in steady-state/fast imaging employing steady-state (CISS/FIESTA) magnetic resonance imaging (MRI) in the evaluation of medically intractable TN, but similar recommendations do not exist for the remaining NVCSs. METHODS: We conducted a retrospective chart review of 300 patients with an NVCS who underwent microvascular decompression (MVD) by a single neurosurgeon from 2004 to 2021. Data were collected on preoperative diagnosis, pre- and postoperative symptoms, presence/absence of preoperative high-spatial-resolution CISS/FIESTA MRI, and intraoperative findings. Rates of symptomatic improvement were used as a correlate of surgical success. RESULTS: The rate of symptomatic improvement in the patients with a preoperative CISS/FIESTA MRI was 5.8% greater than those without preoperative high-spatial-resolution neuroimaging (98.8% vs. 93%, respectively; P = 0.008). Stratified by diagnosis, patients with TN had the greatest difference in surgical success between the 2 groups (99.3% vs. 92.9%, n = 268; P = 0.006). No statistically significant differences were observed in the other NVCSs, although positive trends were noted. CONCLUSIONS: Preoperative CISS/FIESTA MRI correlated with greater rates of surgical success in cases of medically intractable TN; however, definitive conclusions could not be made regarding the remaining NVCSs. We support the recommendation that this imaging modality be included as part of the standard of practice for the evaluation and management of TN and encourage future studies to further elucidate this relationship for the less common NVCSs using a larger cohort.

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Hemifacial spasm (HFS) is a motor disorder caused by the vascular compression of the facial nerve in the posterior fossa. The cochleovestibular nerve is close to the facial nerve and shares the same entry to the periphery, also has disorders caused by vascular compression. We evaluated the cochleovestibular nerve function in patients with HFS based on the hypothesis that vascular compression, which causes HFS, can also affect the nearby cochleovestibular nerve function. The medical charts of 49 patients with surgically confirmed HFS were reviewed retrospectively. The results of the pure-tone threshold, auditory brainstem response (ABR), video head impulse test (vHIT), and magnetic resonance imaging were analyzed. In each patient, the HFS side and the unaffected side were compared in the paired manner. The anterior inferior cerebellar artery was the major offending vessel (69.4%). There were no significant differences in the pure-tone threshold, properties of ABR waves, and vHIT gain. There was no evidence of cochleovestibular nerve compression syndrome in all patients. The angulation of the nerve by the offending vessel was more frequently identified in the HFS side than in the unaffected side (p = 0.040). The effect of HFS on cochleovestibular nerve function is limited.

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