Predictors of Microvascular Decompression Stratified by Arterial, Venous, and Mixed Neurovascular Conflicts

Introduction: Microvascular decompression (MVD) is an effective treatment for trigeminal neuralgia (TN), but durability of pain relief may vary depending on the type of neurovascular compression. However, the factors within these subpopulations that predict pain response remain limited. The aim of this study was to compare long-term pain outcomes after MVD in arterial versus venous versus mixed arterial and venous compression and evaluate clinical predictors of pain relief within each group. Methods: A retrospective analysis of MVD for patients with TN from 2022–2025 at a single institution was conducted. Demographics at presentation and operative data were collected. Patients were stratified by intraoperative findings as arterial ( n = 132), venous ( n = 19), or mixed arterial and venous ( n = 32) compression. The primary outcome was long-term pain relief, defined as absence of pain (BNI pain score ≤ IIIa) at last follow-up. Univariate and multivariable Cox proportional hazards regression and Kaplan-Meier survival analysis assessed prognostic factors for long-term pain relief. Results: One hundred eighty-three patients underwent MVD for TN, including 132 (72.9%) with arterial compression, 32 (17.7%) with mixed arterial and venous compression, and 19 (10.5%) with only venous compression. Among the 183 patients, there were 23 (12.6%) patients with concomitant continuous/dull pain. Interestingly, subgroup analysis showed there to be a significantly higher proportion of patients with concomitant continuous/dull pain in the venous compression group compared with the arterial and mixed compression groups (36.8% versus 11.6% versus 3.1%, p = 0.002). There were no statistically significant differences found when comparing the duration of long-term pain relief for each of the arterial, venous, or mixed subgroups (median duration of long-term pain relief: 91.1 versus 59.1 versus 55.1 months, p = 0.42) ( Fig. 1A ). For patients with arterial compression, however, there was a non-significant trend observed for improved long-term pain relief compared with those with venous compression (median duration of long-term pain relief: 91.1 versus 59.1 months, p = 0.22) ( Fig. 1A ). Within the arterial compression group, multivariable analysis showed that female sex (HR:3.93;95%CI:[1.29–12.0]; p = 0.03) was associated with higher risk of long-term pain recurrence, while V3 involvement was associated with improved long-term pain relief (HR:0.30;95%CI:[0.12–0.76]; p = 0.025) ( Fig. 1B-C ). Within the mixed compression subgroup, multivariable analysis showed V2 involvement was associated with improved long-term pain relief (HR:0.038; 95%CI:[0.01–0.54]; p = 0.004) while cardiovascular disease trended toward higher risk of long-term pain recurrence (HR:4.42;95%CI:[0.72–27.0]; p = 0.07) ( Fig. 1D-E ). There were no predictors found for long-term pain recurrence in the venous compression subgroup. Conclusion: Patients with arterial compression had a trend toward longer durations of pain relief compared with venous compression subtypes undergoing MVD. For patients with arterial neurovascular compression, female sex was associated with higher risk of long-term pain recurrence, while V3 involvement was predictive of long-term pain relief. For patients with mixed arterial and venous neurovascular compression, V2 involvement was associated with improved long-term pain relief. Lastly, there was a higher proportion of patients who had concomitant continuous/dull pain for those with venous compression. Fig. 1 Kaplan-Meier survival curves of long-term pain relief stratified by ( A ) neurovascular compression type. Subgroup analysis was conducted on ( B-C ) arterial compression and ( D-E ) mixed compression groups. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany