Background: To explore the efficacy and optimal modality of three-dimensional (3D) MRI sequences in the preoperative detection of neurovascular compressions (NVCs) in patients with trigeminal neuralgia (TN). Materials and Methods: Forty-nine cases of typical unilateral TN had undergone 3D time-of-flight magnetic resonance angiography (3D-TOF MRA), 3D fast imaging employing steady-state acquisition (3D-FIESTA), and contrast-enhanced 3D spoiled gradient-recalled sequence (3D-SPGR) on a 3 Tesla MR scanner. Neurovascular relationships (including neurovascular contact and position and the nature of the offending vessels) on MR images were reviewed by a neuroradiologist who was unaware of the clinical findings. Subsequently, microvascular decompression (MVD) surgery was performed on all patients. Comparison was made between the imaging results and surgical findings. Results: MVD verified NVC in 48 (98%) symptomatic nerves, while 3D-TOF MRA, 3D-FIESTA, and 3D-SPGR revealed NVC in 38 (78%), 48 (98%), and 47 (96%) cases, respectively. Agreement between the position of NVC, as defined by 3D-FIESTA (κ = 0.86) or 3D-SPGR (κ = 0.83) and surgical findings, was excellent. Moreover, excellent agreement was confirmed between the nature of compressing vessels as defined by 3D-FIESTA in combination with 3D-TOF MRA (κ = 0.95) or contrast-enhanced 3D-SPGR in combination with 3D-TOF MRA (κ = 0.92) and surgical findings. Conclusions: NVCs were visualized with good sensitivity and specificity with 3D MRI sequences in TN. We propose that 3D-FIESTA combined with 3D-TOF MRA is a safe, convenient, and efficacious MRI sequence for revealing NVCs and is crucial for the preoperative diagnosis and surgical planning of MVD.