Resolution of refractory trigeminal neuralgia after endoscopic decompression of the foramina rotundum and ovale in a patient with bilateral petrous apex cephaloceles: illustrative case.

BACKGROUND

Petrous apex cephaloceles (PACs) are rare cystic lesions that can present with increased intracranial pressure and bony remodeling of the skull. PACs may be associated with trigeminal neuralgia (TN); however, direct causality is not clear. To the author's knowledge, this is the first case reporting bony decompression of the foramina ovale and rotundum via an extended endoscopic endonasal approach (EEA) for the management of TN in the presence of concurrent PACs.

OBSERVATIONS: Herein, the authors present the case of a 19-year-old male with bilateral PACs and severely refractory TN surgically managed with decompression of the foramina ovale and rotundum and surrounding bony regions near the maxillary nerve (cranial nerve [CN] V2) and mandibular nerve (CNV3). Prior to EEA, he trialed ten medications and underwent cerebrospinal fluid diversion trials, two microvascular decompressions, and stereotactic radiosurgery with variable symptom relief. Complete resolution of TN occurred 4 months after EEA, and he was weaned off of medication.

LESSONS: An extended EEA to decompress CNV divisions at the foramina rotundum and ovale may be effective in refractory cases. PACs and associated bony dehiscence may complicate the understanding of TN etiology and impair radiographic visualization of CNV and surrounding structures. There is no clear evidence to support surgical management of PACs and symptom resolution. https://thejns.org/doi/10.3171/CASE24283.