Background: The clinical data of patients with trigeminal neuralgia who received treatment were retrospectively analyzed, and the surgical strategy for cases without vascular compression was investigated. Methods: Clinical data from 98 patients with trigeminal neuralgia who underwent MVD surgery were retrospectively analyzed. All patients underwent preoperative examinations of 3D-TOF-MRA and 3D-CISS to identify the offending vessel and its site of compression of the trigeminal nerve. Results: In 21 cases (21.5%), no direct vascular compression of the trigeminal nerve was found intraoperatively. Of these cases, 17 showed thickened arachnoid adhere, the trigeminal nerve traveled at an angle and twisted, and five showed vascular adhesions with the trigeminal nerve at an angle by the arachnoid. An additional three cases showed unknown sinus vein compression on the dura of the outer arachnoid of the trigeminal nerve at the lower edge of Meckel's cave. Finally, one case showed suprameatal nodular hypertrophy, with direct compression of the trigeminal nerve by the bony structure together with the unknown vessel. The patients in each group were followed for 3-24 months, and one case showed recurrence during follow-up, yielding a recurrence rate of 1.0%. Conclusion: Vascular compression on the trigeminal nerve is the main cause of trigeminal neuralgia, but vascular compression may not be found during surgery. In this case, complete isolation of the cisternal segment in the trigeminal nerve and restoration of the normal traveling morphology of the trigeminal nerve can effectively treat trigeminal neuralgia.