Staged Bilateral Microvascular Decompression for Simultaneous Bilateral Trigeminal Neuralgia Associated With Dolichoectatic Neurovascular Conflict: A Case Report and Literature Review

Trigeminal neuralgia is most commonly unilateral and caused by neurovascular compression at the trigeminal root entry zone. Bilateral trigeminal neuralgia is rare, and simultaneous bilateral involvement is exceptionally uncommon, particularly when associated with dolichoectatic arterial conflict. A 72-year-old man presented with a five-year history of medically refractory simultaneous bilateral trigeminal neuralgia. Right-sided pain involved the V1, V2, and V3 divisions and consisted of high-intensity, electric shock-like paroxysms occurring more than seven times daily, followed by continuous pain lasting up to three hours. Pain severity was rated as Barrow Neurological Institute score 5 and Numerical Rating Scale 8 out of 10. Left-sided pain developed one year later, affected the V3 division, and manifested as more than five daily paroxysms of severe intensity (Barrow score 4; pain scale 10 out of 10), markedly limiting mastication and daily activities. Carbamazepine 600 mg/day was ineffective and poorly tolerated, and symptom progression led to depression, anxiety, avoidance behaviors, and suicidal ideation, with a Karnofsky Performance Status of 60. High-resolution MRI with contrast-enhanced T2-weighted fast imaging employing steady-state acquisition (FIESTA) sequences demonstrated bilateral neurovascular compression with a dolichoectatic superior cerebellar artery (SCA) and multiple neurovascular conflicts. The patient underwent staged bilateral microvascular decompression via mini-retrosigmoid approaches during a single hospitalization, with the right side operated on first due to more disabling continuous pain. Both procedures achieved immediate, complete, and complication-free pain relief, allowing withdrawal of medication and functional recovery (Karnofsky Performance Status of 90). Simultaneous bilateral trigeminal neuralgia with dolichoectatic neurovascular conflict poses a significant diagnostic and therapeutic challenge. This case supports staged bilateral microvascular decompression within a single admission as a safe and effective option for carefully selected patients with clear bilateral neurovascular compression.