Endovascular transverse sinus stenting for pressure-dependent trigeminal neuralgia: illustrative case.

BACKGROUND: Trigeminal neuralgia (TN) is most commonly attributed to neurovascular compression at the trigeminal root entry zone. However, a subset of patients present without clear compressive pathology or with refractoriness to standard therapies, suggesting alternative mechanisms. Emerging evidence implicates intracranial pressure (ICP) dysregulation and venous outflow obstruction as potential contributors to a pressure-dependent form of TN, although this association remains incompletely defined. OBSERVATIONS: The authors report the case of a 33-year-old female with medically refractory TN and no radiographic evidence of classical neurovascular compression. Imaging demonstrated features suggestive of intracranial hypertension and severe right transverse sinus stenosis with contralateral sinus hypoplasia. Lumbar puncture revealed elevated opening pressure with transient symptom relief. Cerebral venography confirmed a significant transstenotic pressure gradient. Following endovascular transverse sinus stenting, there was immediate and sustained resolution of facial pain, with discontinuation of all medications and durable improvement at follow-up. LESSONS: TN may, in selected patients, represent a pressure-dependent disorder related to intracranial hypertension and venous outflow obstruction rather than isolated arterial compression. Recognition of this phenotype is important, as ICP-targeted therapies, including venous sinus stenting (VSS), may provide effective treatment in appropriately selected patients. However, current evidence remains limited, and careful diagnostic and hemodynamic evaluation is essential before considering VSS. https://thejns.org/doi/10.3171/CASE26456.