J Neurosurg 108:483–490, 2008

Anatomical study of the trigeminal and facial cranial nerves

with the aid of 3.0-tesla magnetic resonance imaging
YUKINARI KAKIZAWA, M.D., PH.D., TATSUYA SEGUCHI, M.D., KUNIHIKO KODAMA, M.D.,
TOSHIHIRO OGIWARA, M.D., TETSUO SASAKI, M.D., TETSUYA GOTO, M.D., PH.D.,
AND KAZUHIRO HONGO, M.D., PH.D.

Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto; and Seguchi

Neurosurgical Hospital, Iida, Japan

Object. Neuroimages often reveal that the trigeminal or facial nerve comes in contact with vessels but does not pro-
duce symptoms of trigeminal neuralgia (TN) or hemifacial spasm (HFS). The authors conducted this study to determine
how often the trigeminal and facial nerves came in contact with vessels in individuals not suffering from TN or HFS.
They also investigated the correlation between aging and the anatomical measurements of the trigeminal and facial
nerves.
Methods. Between November 2005 and August 2006, 220 nerves in 110 individuals (60 women and 50 men; mean
age 55.1 years, range 19–85 years) who had undergone brain magnetic resonance (MR) imaging for other reasons were
studied. The lengths, angles, ratio, and contact points were measured in each individual. A correlation between each pa-
rameter and age was statistically analyzed.
Results. The mean (6 standard deviation) length of the trigeminal nerve was 9.66 6 1.71 mm, the mean distance
between the bilateral trigeminal nerves was 31.97 6 1.82 mm, and the mean angle between the trigeminal nerve and
the midline was 9.71 6 5.83°. The trigeminal nerve was significantly longer in older patients. Of 220 trigeminal nerves,
108 (49.0%; 51 women and 57 men) came in contact with vasculature. There was 1 contact point in 99 nerves (45%)
and 2 contact points in 9 nerves (4.1%). Contact without deviation of the nerve was seen in 91 individuals (43 women
and 48 men), and mild deviation was noted in 17 individuals (8 women and 9 men). There was no moderate or severe
deviation in any individual in this series. The mean length of the facial nerve was 29.78 6 2.31 mm, the mean distance
between the bilateral facial nerves was 28.65 6 2.22 mm, the angle between the nerve and midline was 69.68 6 5.84°,
and the vertical ratio at the porus acusticus was 0.467 6 0.169. Of all facial nerves, 173 (78.6%; 101 in women and 72
in men) came in contact with some vasculature. Contact without deviation was seen on 64 sides (in 37 women and 27
men), mild deviation on 98 sides (in 57 women and 41 men), and moderate deviation on 11 sides (in 7 women and 4
men). There was no severe deviation of the facial nerve in this series. The proximal length of the facial nerve, interval,
angle, and ratio against the age were significantly shorter or smaller in the older individuals.
Conclusions. The findings in asymptomatic individuals in this study will help in deciding which findings observed
on MR images may cause symptoms. In addition, the authors describe the variations of normal anatomy in older indi-
viduals. Knowledge of the normal anatomy helps to hone the diagnostic practices for microvascular decompression,
which may increase the feasible results on such surgery. (DOI: 10.3171/JNS/2008/108/3/0483)

KEY WORDS • anatomical study • facial nerve • magnetic resonance imaging •

trigeminal nerve

ITH the recent advances in modern neuroimaging,
W vessels causing TN or HFS can be detected in
patients. However, we frequently view neuroim-
ages in which the trigeminal or facial nerve comes in con-
tact with vessels but does not produce symptoms of TN
or HFS in clinical cases. Klun and Prestor17 found that 42
(32.3%) of 130 normal cadaveric specimens had neurovas-
Abbreviations used in this paper: FIESTA = fast imaging em-
ploying steady-state acquisition; HFS = hemifacial spasm; MPR =
multiplanar reconstruction; MR = magnetic resonance; MVD = mi-
crovascular decompression; REZ = root entry zone; TN = trigeminal
neuralgia; TZ = transitional zone.
cular contact on the trigeminal TZ, or Obersteiner–Redlich
zone, and 10 (7.7%) of 130 had compression; the zone is
defined as the margin where both central nervous system
and peripheral nervous system tissue are contained. Mat-
sushima et al.21 stated that 24 (68.6%) of 35 facial nerves
in cadaveric specimens came in contact with arteries, al-
though it was not mentioned if HFS existed.
There are no data on the exact normal anatomy of the
trigeminal and facial nerves in a living body. Therefore, we
conducted this study to determine how often the trigeminal
and facial nerves come in contact with vessels in individu-
als not suffering from TN or HFS. We also investigated the
correlation between aging and anatomical measurements of
the trigeminal and facial nerves by using 3.0-T MR imag-

J. Neurosurg. / Volume 108 / March 2008 483


ing. To our knowledge, such a study has not been previous-
ly performed.
Clinical Material and Methods
The study was approved by the ethical committee in
Seguchi Neurosurgical Hospital. One hundred ten healthy
individuals (60 women and 50 men) were included in this
study. These individuals had undergone brain MR imaging
examination for other reasons. The mean age at the time
of MR imaging was 55.1 6 13.6 years (6 standard devia-
tion) (range 19–85 years). In total, 220 trigeminal and fa-
cial nerves were investigated.
Between November 2005 and August 2006 all MR im-
aging studies were performed using a 3.0-T MR imaging
system (Signa Excite 3.0 T, GE Healthcare Japan Branch)
at Seguchi Neurosurgical Hospital. The FIESTA axial se-
quencing of the entire brain was performed with the follow-
ing parameters: TR 5.5 msec, TE 2.5 msec, slice thickness
0.4 mm with no gap, matrix size 224 3 224, field of view
14 cm, flip angle 50°, number of excitations 1, and band-
width 62.50. Time-of-flight spoiled gradient recalled acqui-
sition in the steady state, 3D MR angiography was per-
formed in the axial plane by using the following parameters:
TR 25 msec, TE 3.3 msec, flip angle 20°, matrix size 512 3
224, field of view 18 cm, slice thickness 0.5 mm with no
gap, number of excitations 1.0, and bandwidth 31.25.
The Digital Imaging and Communications in Medicine
(DICOM) MR images were imported to the worksta-
tion for MPR parallel to the trigeminal nerve and facial
nerve (we refer to them as the oblique sagittal and oblique
coronal planes, respectively) in each individual. Another
MPR plane parallel to the long axis of the bilateral nerves
(oblique axial) was used. The FIESTA MPR images were
used to evaluate the neurovascular contact in each individ-
ual. The MPR images created from MR angiograms were
used to determine whether the vessels were arteries.
Measurement of the Trigeminal Nerve
The length of the cisternal segment of the trigeminal
nerve (from the REZ to the narrowest aperture of the
Meckel cave) in the oblique sagittal plane, the interval of the
bilateral nerves (distance between bilateral medial surfaces
of the trigeminal nerve at the point where the nerve emerged
the from the pons), and the angle between the midline and
the long axis of the trigeminal nerve both in the oblique ax-
ial planes were all measured (Fig. 1 upper left and right).
Measurement of the Facial Nerve
Length 1 of the facial nerve was defined as the curved
length between the superior margin of the supraolivary fos-
sette and the root exit zone in which the facial nerve sepa-
rated from the pons. Length 2 was defined as the total length
of the cisternal and meatal segment of the facial nerve (the
distance between the root exit zone and the point where the
facial nerve entered the facial canal in the internal auditory
canal). The entire length was defined as the sum of Length
1 and Length 2 in the oblique coronal plane. We also mea-
sured the interval of bilateral facial nerves (distance be-
tween bilateral medial aspects of facial nerves), the angle
between the midline and the long axis of the seventh nerve
in the oblique axial plane, and the vertical ratio at the nar-
484
Y. Kakizawa et al.
rowest space near the porus acusticus (we defined the ratio
calculated using the following equation: upper surface of
the internal acoustic canal to the facial nerve/the distance
from the lower surface of the internal acoustic canal to the
facial nerve in the oblique coronal plane [Fig. 1 lower left
and right]).
Statistical analysis was performed using JMP software
(JMP 6.0, SAS Institute).
To ascertain the nature of cranial nerves in older patients,
we analyzed the correlation between the age of individuals
and each measured result of the parameters described ear-
lier. The results were compared between women and men
by using an unpaired t-test.
Nerve distortion or deviation was also evaluated. No
deviation of the long axis of the nerve but with some con-
tact with the vessels was defined as “contact.” Deviation
vertical to the long axis of the nerve within the thickness
of its nerve was classified as “mild deviation.” Deviation
beyond the thickness of its nerve was defined as “moderate
deviation.” Deviation causing brainstem rotation by vessels
was deemed “severe deviation.”
Results
The Trigeminal Nerve
Measurement. The mean length of the trigeminal nerve
was 9.66 6 1.71 mm (range 5.53–14.1 mm; 9.15 6 1.52
mm in women and 10.27 6 1.57 mm in men [significant
difference between sexes, p , 0.0001]). The mean distance
between the medial surfaces of the bilateral trigeminal
nerves was 31.97 6 1.82 mm (range 28.03–36.43 mm;
31.60 6 2.14 mm in women and 32.41 6 2.72 mm in men
[significant difference between sexes, p = 0.0195]). The
mean angle between the trigeminal nerve and the midline
was 9.71 6 5.83° (range 23.41–33.07°; 9.65 6 5.01° in
women and 9.80 6 6.24° in men) (Table 1).
Contact Point. Of all 220 trigeminal nerves, 108 (49.0%)
came in contact with some vessels in 51 women and 57
men. There was 1 contact point on 99 sides (45%), and
there were 2 contact points on 9 sides (4.1%). The nerves
came in contact with arteries at 101 points and veins at 16
points. Locations of contact are illustrated in Fig. 2 upper.
The degrees of deviation of the trigeminal nerve are shown
in Table 2. Contact without deviation was seen on 91 sides
(43 women and 48 men), and mild deviation on 17 sides (8
women and 9 men). No moderate or severe deviation was
noted in any individual in this series.
Aging. There was no statistically significant correlation
between age and the interval of bilateral trigeminal nerves
and angle. However, there was a significant correlation be-
tween age and length of the trigeminal nerve. The trigemi-
nal nerve was significantly longer in older individuals (Fig.
3 and Table 3).
The Facial Nerve
Measurement. The mean measurement of Length 1 of the
facial nerve was 8.41 6 1.12 mm (range 5.69–12.21 mm;
8.32 6 1.00 mm in women and 8.53 6 1.15 mm in men).
The mean measurement of Length 2 was 21.37 6 2.26 mm
(range 15.91–28.28 mm; 20.88 6 2.07 mm in women and
21.95 6 2.11 mm in men [statistically significant difference
J. Neurosurg. / Volume 108 / March 2008
3.0-T MR imaging of trigeminal and facial nerves

FIG. 1. Illustrations showing structures and measurements studied. Upper Left: Oblique sagittal view parallel to the
trigeminal nerve. Upper Right: Oblique axial view parallel to the long axis of the trigeminal nerve. Lower Left: Oblique
coronal view parallel to the facial nerve. Lower Right: Oblique axial view parallel to the facial nerve. a = the length of
the trigeminal nerve; b = the interval between bilateral trigeminal nerves; c = the angle between the midline and long axis
of trigeminal nerve; d = Length 1, defined as the distance from the superior margin of the supraolivary fossette to the root
exit zone of the facial nerve along the lower surface of the pons; e = Length 2, defined as the length of the cisternal and
meatal segments of the facial nerve; f = the interval between bilateral facial nerves; g = the angle between the midline and
long axis of the facial nerve; h = the narrowest distance near the porus acusticus; i = the distance from the upper surface
of the meatus to the middle point of the facial nerve on the line defined as h.

between sexes, p = 0.0004]). The mean entire length of both
segments was 29.78 6 2.31 mm (range 23.92–37.73 mm;
29.20 6 2.02 mm in women and 30.48 6 2.25 mm in
men [statistically significant difference between sexes, p ,
0.0001]). The mean distance between the bilateral facial
nerves was 28.65 6 2.22 mm (range 21.6–33.97 mm;
28.38 6 3.09 mm in women and 28.97 6 2.79 mm in men).
The mean angle between the nerve and the midline was
69.68 6 5.84° (range 50.58–87.61°; 69.57 6 5.398 in
women and 69.81 6 5.798 in men). The mean vertical ra-
tio at the porus acusticus was 0.467 6 0.169 (range 0–1;
0.48 6 0.17 in women and 0.45 6 0.15 in men) (Table 1).
Contact Point. Of all facial nerves 173 (78.6%) (101 in
women and 72 in men) came in contact with some ves-
sels or structures. There was 1 point on 121 sides (55%), 2
points on 40 sides (18.2%), and $ 3 points on 12 sides
(5.4%). The structures coming in contact with the facial
nerves were arteries (223 points), veins (7 points), the dura
mater (5 points), and other cranial nerves (4 points). Figure
2 lower depicts the location of contact sites of all 173 sides.
The degrees of deviation of the facial nerve are shown in
Table 2. Contact without deviation was seen on 64 sides
(37 women and 27 men), mild deviation on 98 sides (57
women and 41 men), and moderate deviation on 11 sides (7
women and 4 men). All the MR images of these 11 sides
are shown in Fig. 4. There were no cases of severe devia-
tion in any patient in this series.
Aging. A statistical correlation was observed in Length 1,

TABLE 1
Results of each measurement in women and men
Mean 6 Standard Deviation

No. of Women Men

Nerve Nerves (120 nerves) (100 nerves) Overall (range) p Value

trigeminal
length (mm) 220 9.15 6 1.52 10.27 6 1.57 9.66 6 1.71 (5.53–14.1) ,0.0001*
interval (mm) 110 31.60 6 2.14 32.41 6 2.72 31.97 6 1.82 (28.03–36.43) 0.0195*
angle (°) 220 9.65 6 5.01 9.80 6 6.24 9.71 6 5.83 (23.41–33.07) 0.8492
facial
Length 1 (mm) 220 8.32 6 1.00 8.53 6 1.15 8.41 6 1.12 (5.69–12.21) 0.1683
Length 2 (mm) 220 20.88 6 2.07 21.95 6 2.11 21.37 6 2.26 (15.91–28.28) 0.0004*
total length (mm) 220 29.20 6 2.02 30.48 6 2.25 29.78 6 2.31 (23.92–37.73) ,0.0001*
interval (mm) 110 28.38 6 3.09 28.97 6 2.79 28.65 6 2.22 (21.6–33.97) 0.1628
angle (°) 220 69.57 6 5.39 69.81 6 5.79 69.68 6 5.84 (50.58–87.61) 0.757
ratio 220 0.48 6 0.17 0.45 6 0.15 0.467 6 0.169 (0–1) 0.1744
* Statistically significant.

J. Neurosurg. / Volume 108 / March 2008 485

 Y. Kakizawa et al.

FIG. 2. Graphs demonstrating the points of all objects in which the nerve contacts with vessels. Upper: Trigeminal
nerve contacts. Lower: Facial nerve contacts. Vertical bars indicate the contact area, not the points, along the long axis
of the nerves. The y axis shows the distances distally from the REZ or root exit zone.

the interval of bilateral facial nerves, angle, and orifice ratio
against age. However, the correlation of Length 2, and the
total length against age revealed no significant difference.
Length 1 of the facial nerve, interval, angle, and ratio
against the age were significantly shorter or smaller in
older patients (Fig. 5 and Table 3).
from and enter the brainstem or the spinal cord.33 The REZ
is distinctly different from the TZ by its definition. The TZ
lies more peripherally in sensory than in motor nerves, but
in both, the apex of the TZ is described as a glial dome
whose convex surface is directed distally.
The Trigeminal Nerve

Discussion As described earlier, the TZ of the “sensory” trigeminal

nerve is more distal than that of the facial nerve; it has been
Regarding the TZ, transition between the central nervous reported that the TZ of the trigeminal nerve is located 2–
system and the peripheral nervous system usually occurs a 10 mm distally from the brainstem.10,19,25,28,32,34,40 Authors of
certain distance from the point at which nerve roots emerge previous clinical reports mentioned that MVD performed

FIG. 3. Scatterplots showing the correlation between age and each parameter of the trigeminal nerve (V). The circles
indicate the 95% density ellipse, the horizontal lines the average of the parameters, and the tilted lines the major axis of
the ellipse.

486 J. Neurosurg. / Volume 108 / March 2008

3.0-T MR imaging of trigeminal and facial nerves

TABLE 2 45% of 579 cases, and near the Meckel cave in 10%. On the
Frequency of the nerves contacting various structures, other hand, no vessels compressing the trigeminal nerve
contacting points, and degree of deviation of the nerves were found in the operative field in 7.5% of all 3256 cas-
es in another report.9 After MVD, favorable results were
No. (%) attained in at most 70% of cases.4,7,9 These results can be
Parameter Trigeminal Nerve Facial Nerve explained as indirect injury occurring at the TZ by se-
vere nerve root traction at any cisternal segment3,31 or focal
contact frequency 108/220 (49.0) 173/220 (78.6) chronic demyelination due to ischemic changes at the TZ
women 51/120 (42.5) 101/120 (84.2)
men 57/100 (57) 72/100 (72)
caused by long-standing TN.6,14,20,27 Other reasons for inef-
no. of contact points fective MVD may be due to other intracranial conditions
1 99 (45) 121 (55) such as multiple sclerosis.
2 9 (4.1) 40 (18.2) In the present study, nearly half of all nerves came in
3 0 10 (4.5) contact with vessels at various portions in the cisternal seg-
4 0 2 (1) ment; however, these contacts were not thought to cause
severity of nerve deviation [F/M]
contact 91 (41.4) [43:48] 64 (29.1) [37:27]
the TN. Knowing that these findings were present in indi-
mild 17 (7.7) [8:9] 98 (44.5) [57:41] viduals who did not have symptoms is valuable for decid-
moderate 0 11 (5) [7:4] ing which is the offending artery in patients. Anderson et
severe 0 0 al.2 have confirmed that nerves with more severe compres-
contacting structure sion are more likely to be pathognomonic and that com-
artery 101 223 pression of the nerve is more likely to be associated with an
vein 16 7
dura mater 0 5
artery than a vein. We speculate that symptoms do not
nerve 0 4 occur when the trigeminal nerve barely touches the vessels
and there is no deviation or deformation of the nerve. How-
ever, we must take care when the nerve is pinched by ves-
only at the TZ of the trigeminal nerve was sufficient.8,18,36 sels on both sides; in this situation the nerve might not devi-
However, McLaughlin et al.22 described that the TZ of the ate.
trigeminal nerve as extending to a more distal portion of
the nerve. Therefore, the nerve should be examined in all The Facial Nerve
cisterns, and all vessels should be treated. Sindou et al.31 Ordinarily, the TZ of the facial nerve is reported to be
reported that the compression site was located at the mid- 1–3 mm distal to the REZ.1,32 The TZ of the nerve was dif-
dle part of the cisternal portion of the trigeminal nerve in ficult to measure because the root of the nerve tangentially

FIG. 4. Magnetic resonance

images obtained using FIES-
TA demonstrating all 11 facial
nerves that were moderately
distorted by the vessels.

J. Neurosurg. / Volume 108 / March 2008 487

 Y. Kakizawa et al.

FIG. 5. Scatterplots showing the correlation between age and each parameter of the facial nerve (VII). The circles indi-
cate the 95% density ellipse, the horizontal lines the average of the parameters, and the tilted lines the major axis of the
ellipse.

emerged from the curved lower surface of the pons. As a structures, especially in women (84.2%), which may result
solution to this issue, Tomii et al.38 measured the distance in a female predominance for HFS.
from the supraolivary fossette to the TZ by using a micro- Tomii et al.38 also reported that 80% of contact points
scope. They found this distance to be 9.9 mm. Our finding were located , 6 mm distal from the most proximal point
was similar to theirs. We measured the distance from the of the facial nerve. However, we found that the vessels dif-
supraolivary fossette to the REZ and found it to be 8.4 mm. fusely contacted the nerve in the cisternal and meatal seg-
This is a useful landmark for performing MVD at the TZ of ments. We also found that there were some individuals in
the facial nerve. whom the contact point was at the TZ and only caused mild
Previous authors have stated that significant compres- deviation.
sion was observed in 8% of autopsies conducted in asymp- Ryu et al. 29 reported a rare case of HFS that was caused
tomatic individuals.12,17 Our study has demonstrated that by vascular compression on the distal portion rather than
5% of asymptomatic persons have a moderately deviated the TZ. We are not sure whether compression of the dis-
facial nerve. However, there were several individuals in tal portion of the facial nerve causes HFS given that in the
whom the TZ was slightly compressed. It is speculated that present study there were individuals with such findings but
HFS is not caused by slight compression of the TZ. The no symptoms.
nerves in ~ 80% of individuals came in contact with some
Magnetic Resonance Imaging
TABLE 3 In the past, the use of conventional MR imaging has not
proved useful in determining which patients with vascular
Correlation between age and each parameter*
contact might benefit from MVD because of a high preva-
Equation lence of neurovascular compression in control individu-
Parameter (age [x] vs measurement [y]) Correlation p Value als.35 In addition, a study of the combination of sequences
trigeminal nerve
on 1.5-T MR images for increasing accuracy of diagnosing
length (mm) y = 0.028x 1 8.14 0.220 0.001† neurovascular compression has not been perfected.2,5,13,27,39
interval (mm) NA 20.102 0.2893 Recently, 3.0-T MR imaging has become available in
angle (°) NA 0.010 0.8797 clinical cases. With 3.0-T MR imaging, the resolution is
facial nerve twice as high as that obtained with 1.5-T MR imaging. In
Length 1 (mm) y = 20.015x 1 9.21 20.176 0.0087† other words, we should reconfirm any MR imaging find-
Length 2 (mm) NA 20.035 0.6041 ings of neurological diseases by using 3.0-T MR imaging.
length total (mm) NA 20.120 0.0762
interval (mm) y = 20.032x 1 30.42 20.197 0.0387† In this study, the trigeminal and facial nerves were clearly
angle (°) y = 20.062x 1 73.077 20.141 0.0329† observed on 3.0-T MR images in all individuals. Cadavers
ratio y = 20.0048x 1 0.732 20.388 ,0.0001† have been previously used for anatomical studies, but the
* Correlations can be seen in the scatterplots in Figs. 3 and 5. Abbrevi-
data obtained in cadavers may be different from those
ation: NA = not applicable. obtained in living individuals because of fixation or manip-
† Statistically significant. ulation during dissection. For these reasons, we believe that

488 J. Neurosurg. / Volume 108 / March 2008

3.0-T MR imaging of trigeminal and facial nerves
3.0-T MR imaging must produce images superior to those
produced using 1.5-T MR imaging.
We also emphasize that vertical (sagittal/coronal) MR
images can increase the accuracy of diagnosis as previous-
ly described by others.5,23,24 Most of the neurovascular com-
pression in cases of TN and HFS is in the vertical plane. We
should confirm these findings on vertical images at first,
and then on axial images for ascertaining the amount of
compression. Reconstructed 3D MR images are also use-
ful.16
Effects of Aging
Results of MVD in older individuals were similar com-
pared with those of younger patients in the literature.15,30
However, some authors have stated that MVD in older in-
dividuals is easier to perform and a better outcome is
attained than in the young because of brain atrophy and
larger cisterns in the former, which minimize the retraction-
related complications.7,26,37 Our results support these find-
ings; brainstem atrophy may result in longer trigeminal
nerves, a shorter distance between bilateral facial nerves,
and a shorter measurement of Length 1 of facial nerves in
older individuals.
Other authors have stated that TN occurred with a high-
er frequency in the elderly population.11 Given that we did
not include symptomatic patients in our study, further study
is needed with 3.0-T MR imaging.
Conclusions
Of 220 trigeminal nerves, 108 (49.0%) in 51 women and
57 men came in contact with vasculature. The length of the
trigeminal nerve was significantly longer in the older indi-
viduals. Of facial nerves, 173 (78.6%) in 101 women and
72 men came in contact with vasculature. The proximal
length of the facial nerve, interval, angle, and ratio were
significantly shorter or smaller in older individuals than in
younger individuals. Knowing the normal anatomy helps
us to hone our diagnostic practices for MVD, which may
increase the favorable results achieved after MVD surgery.
We expect that further advances in MR imaging hardware
and refinement of sequences will improve visualization of
trigeminal/facial compression and provide additional pre-
operative details important for MVD procedures.
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Manuscript submitted February 5, 2007.
Accepted July 11, 2007.
Address correspondence to: Yukinari Kakizawa, M.D., Ph.D.,
Department of Neurosurgery, Shinshu University School of Medi-
cine, 3-1-1 Asahi, Matsumoto 390-8621, Japan. email: kakizawa@
hsp.md.shinshu-u.ac.jp.
J. Neurosurg. / Volume 108 / March 2008