Microvascular decompression (MVD) is now a standard treatment for trigeminal neuralgia (tic douloureux). The goal of MVD is to decompress the trigeminal root from offending vessels, aiming at a permanent cure with no or little sensory deficit. Preoperative identification of neurovascular compression, therefore, has potentially important implications for patient selection, surgical planning, and outcomes. In this study, enhanced three-dimensional fast spoiled gradient recalled MRI and three-dimensional magnetic resonance angiography with a 3.0-Tesla MRI system were used to detect the anatomic relationship of neural and vascular structures at the trigeminal root entry zone (TREZ) preoperatively. In 27 of 29 patients (93%), surgical findings were consistent with the imaging results. All patients treated with MVD achieved complete pain relief. The usefulness of high-resolution MRI in revealing the neurovascular contact at the TREZ was demonstrated, and it could be used to facilitate the selection of treatment modality. Thus, MVD can be chosen for patients who are most likely to benefit from this intracranial procedure.