Hemifacial Spasm: Results of Microvascular Decompression of the Facial Nerve in 54 Patients

This 68-year-old woman presented with repeated episodes of bilateral hemifacial spasm with headache for 5 years and with recent progression of left sided symptoms. Preoperative imaging showed a left sided tentorial meningioma with brain stem and cerebellar compression. Left facial nerve was compressed by the vertebral artery (VA) and the right facial nerve by the anterior inferior cerebellar artery (AICA). This patient underwent left side retrosigmoid craniotomy and mastoidectomy. The cisterna magna was drained to relax the brain. The tumor was very firm, attached to the tentorium and had medial and lateral lobules. The superior cerebellar artery was adherent to the lateral lobule of the tumor and dissected away. The tumor was detached from its tentorial base; we first removed the lateral lobule. Following this, the medial lobule was also completely dissected and removed. The root exit zone of cranial nerve (CN) VII was dissected and exposed. The compression was caused both by a prominent VA and AICA. Initially, the several pieces of Teflon felt were placed for the decompression. Then vertebropexy was performed by using 8–0 nylon suture placed through the VA media to the clival dura. A further piece of Teflon felt was placed between cerebellopontine angle region and AICA. Her hemifacial spasm resolved postoperatively, and she discharged home 1 week later. Postoperative imaging showed complete tumor removal and decompression of left CN VII. This video shows the complex surgery of microsurgical resection of a large tentorial meningioma and microvascular decompression with a vertebropexy procedure.The link to the video can be found at: https://youtu.be/N5aHN9CRJeM.

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P.022 Hemifacial Spasm due to dolichoectatic vertebrobasilar artery compression

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2018.124 ◽

2018 ◽

Vol 45 (s2) ◽

pp. S21-S21

Author(s):

CM Honey ◽

A Almojuela ◽

M Hasen ◽

AM Kaufmann

Keyword(s):

Facial Nerve ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Symptom Relief ◽

Retrospective Chart Review ◽

Senior Author ◽

High Rate ◽

Case Volume ◽

Vertebrobasilar Artery ◽

Final Followup

Background: Hemifacial Spasm (HFS) is rarely caused by a dolichoectatic vertebrobasilar artery (eVB) compression of the Facial Nerve. This can pose a surgical challenge when performing microvascular decompression as vessel mobilization is often difficult due to atherosclerosis, tethering from brainstem perforators, and large size. These patients are often not considered for surgery. Methods: A retrospective chart review of patients who were surgically treated by the senior author between 2003 and 2017 with an admitting diagnosis of HFS was performed. Patients with preoperative neuroimaging demonstrating eVB compression of their facial nerve/root were included. Results: During the 15-year review, 315 patients underwent microvascular decompression for HFS and 21 (6.7%) had dolichoectactic vertebrobasilar compressions. At final followup (>3 months) 19 patients (90.4%) experienced reduction in symptoms with 15 (71.4%) having complete resolution. One patient required re-operation and benefitted from subsequent symptom relief. The majority of culprit compression was found proximally on the pontine surface. Mobilization of the culprit vessel was achieved successfully in the majority of cases with Teflon pledgets. There were no perioperative strokes or death. Complications are presented Conclusions: Microvascular Decompression for Hemifacial Spasm caused by dolichoectatic vertebrobasilar artery compression can be performed with a high rate of safety and success in the setting of a high case volume centre.

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“Macrovascular” Decompression of Dolichoectatic Vertebral Artery Causing Hemifacial Spasm Using Goretex Sling: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy111 ◽

2018 ◽

Vol 16 (2) ◽

pp. 267-268 ◽

Cited By ~ 4

Author(s):

Stephan A Munich ◽

Jacques J Morcos

Keyword(s):

Facial Nerve ◽

Vertebral Artery ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Orbicularis Oculi ◽

Entry Zone ◽

Common Cause ◽

Root Entry Zone ◽

Offending Artery ◽

Key Steps

Abstract Hemifacial spasm is characterized by painless and involuntary spasms of the muscles supplied by the facial nerve, most commonly involving the orbicularis oculi. The most common cause of hemifacial spasm is compression of the facial nerve's root by the anterior inferior, or posterior inferior, cerebellar arteries (AICA or PICA). However, in <1% of cases, the compression can be due to a dolichoectatic vertebral artery. Microvascular decompression using Teflon patties may be sufficient when the offending artery is small (eg, AICA or PICA). However, the size and tortuosity of the vertebral artery (especially one that is dolichoectatic) may require a more robust means of decompression (ie, “macrovascular decompression”). In this operative video we demonstrate our technique for managing a patient with hemifacial spasm due to a dolicoectatic vertebral artery. We use a Goretex® (W.L. Gore & Associates Inc, Newark, Delaware) sling secured to the dura of the posterior petrous ridge to suspend the vertebral and posterior inferior cerebellar arteries, thereby decompressing the root entry zone of the facial nerve. Teflon felt pieces are added as a second layer of security. Key steps to this technique include: (1) visualization of the root entry zone, (2) extensive arachnoid dissection to allow adequate mobilization of the vertebral artery, 12 and (3) securing the sling in a trajectory that prevents kinking of the vertebral artery and its branches.

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Hemifacial spasm

Journal of Neurosurgery ◽

10.3171/jns.1982.57.6.0753 ◽

1982 ◽

Vol 57 (6) ◽

pp. 753-756 ◽

Cited By ~ 77

Author(s):

Tsutomu Iwakuma ◽

Akihisa Matsumoto ◽

Nishio Nakamura

Keyword(s):

Facial Nerve ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Nerve Root ◽

Posterior Inferior Cerebellar Artery ◽

Content Type ◽

Stylomastoid Foramen ◽

Root Exit Zone ◽

Selective Neurectomy ◽

Fine Print

✓ Patients with hemifacial spasm were treated by three different surgical procedures: 1) partial sectioning of the facial nerve just distal to the stylomastoid foramen; 2) selective neurectomy of facial nerve branches; and 3) microvascular decompression. A retromastoid craniectomy with microvascular decompression was most effective in relieving hemifacial spasm and synkinesis. In a postmorten examination on one patient, microscopic examination of the facial nerve, which was compressed by an arterial loop of the posterior inferior cerebellar artery at the cerebellopontine angle, revealed fascicular demyelination in the nerve root. On the basis of surgical treatment, electromyography, and neuropathological findings, the authors conclude that compression of the facial nerve root exit zone by vascular structures is the main cause of hemifacial spasm and synkinesis.

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Outcome following retrosigmoid microvascular decompression of the facial nerve for hemifacial spasm

The Journal of Laryngology & Otology ◽

10.1258/002221505774481255 ◽

2005 ◽

Vol 119 (10) ◽

pp. 779-783 ◽

Cited By ~ 15

Author(s):

D A Moffat ◽

V S P Durvasula ◽

A Stevens King ◽

R De ◽

D G Hardy

Keyword(s):

Hearing Loss ◽

Facial Nerve ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Retrospective Review ◽

Facial Palsy ◽

Complete Resolution ◽

Symptom Control ◽

Short Term

This paper evaluates the outcome of retrosigmoid microvascular decompression of the facial nerve in a series of patients suffering from hemifacial spasm who had been referred to the skull-base team (comprising senior authors DAM and DGH). The paper is a retrospective review of 15 patients who underwent retrosigmoid microvascular decompression of the facial nerve at Addenbrooke's Hospital between 1985 and 1995. In this series it was possible to obtain complete resolution of hemifacial spasm in 93.3 per cent of cases in the short term and in 80 per cent in the long term. Twelve patients (80 per cent) were symptom-free post-operatively. Two patients had minor recurrence of symptoms occurring within six months of the procedure. One patient with no identifiable vascular impingement of the facial nerve had no improvement following surgery. Three patients suffered sensorineural hearing loss. Two patients complained of post-operative tinnitus, and transient facial palsy was noted in one patient.Retrosigmoid microvascular decompression of the facial nerve provides excellent long-term symptom control in a high percentage of patients with hemifacial spasm.

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Intraoperative monitoring of the facial nerve during decompressive surgery for hemifacial spasm

Journal of Neurosurgery ◽

10.3171/jns.1991.74.2.0254 ◽

1991 ◽

Vol 74 (2) ◽

pp. 254-257 ◽

Cited By ~ 51

Author(s):

Stephen J. Haines ◽

Fernando Torres

Keyword(s):

Facial Nerve ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Intraoperative Monitoring ◽

Circumstantial Evidence ◽

Etiological Factor ◽

Content Type ◽

Abnormal Response ◽

Facial Nerve Decompression ◽

Fine Print

✓ In 11 consecutive patients, intraoperative electromyographic (EMG) recordings were made from the facial muscles during microvascular decompression for hemifacial spasm. In one patient, recordings could not be obtained for technical reasons, and two patients had no abnormality. In the remaining eight patients, the abnormal response resolved before decompression in two, resolved immediately at the time of decompression in five, and failed to resolve in one. All patients were relieved of their hemifacial spasm. In the five patients whose abnormalities resolved at the time of decompression, there was a precise intraoperative correlation between decompression of the nerve and disappearance of the abnormal EMG response. In three cases, this was a useful guide to the need to decompress more than one vessel. These results confirm the findings of Mailer and Jannetta, support the use of this technique for intraoperative monitoring of facial nerve decompression procedures, and provide strong circumstantial evidence that vascular cross-compression is an important etiological factor in hemifacial spasm.

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Loss of auditory function in microvascular decompression for hemifacial spasm

Journal of Neurosurgery ◽

10.3171/jns.1985.63.1.0017 ◽

1985 ◽

Vol 63 (1) ◽

pp. 17-20 ◽

Cited By ~ 52

Author(s):

Margareta B. Møller ◽

Aage R. Møller

Keyword(s):

Hearing Loss ◽

Facial Nerve ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Auditory Function ◽

Profound Hearing Loss ◽

Content Type ◽

Vascular Abnormalities ◽

Hearing Function ◽

Before And After

✓ Auditory function was studied before and after surgery in 143 consecutive patients who were operated on for hemifacial spasm by microvascular decompression of the intracranial portion of the facial nerve. The acoustic middle ear reflex was abnormal preoperatively in 41% of the patients, indicating that the vascular abnormalities that caused the hemifacial spasm also affected the auditory nerve. Three patients suffered a profound hearing loss in the ear on the operated side, and one lost hearing function totally. In addition, 24 patients had a moderate elevation in the pure-tone threshold at one or more octave frequencies. Of these, 16 patients experienced a hearing loss at only one frequency (8000 Hz), while eight had a threshold evaluation of no more than 20 dB in the speech frequency range (500, 1000, and 2000 Hz). Two patients were deaf on the side of the spasm before the operation. Three patients were not tested postoperatively, and one patient was tested only after surgery. Thus, in this series of 143 patients, only 2.8% suffered a significant hearing loss as a complication of facial nerve decompression to relieve hemifacial spasm.

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Outcome of Endoscope-Assisted Microvascular Decompression in Patients With Hemifacial Spasm Caused by Severe Indentation of the Brain Stem at the Pontomedullary Sulcus by the Posterior Inferior Cerebellar Artery

Operative Neurosurgery ◽

10.1093/ons/opab008 ◽

2021 ◽

Author(s):

Ehab El Refaee ◽

Steffen Fleck ◽

Marc Matthes ◽

Sascha Marx ◽

Joerg Baldauf ◽

...

Keyword(s):

Facial Nerve ◽

Brain Stem ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Posterior Inferior Cerebellar Artery ◽

Transitional Zone ◽

Effective Treatment Option ◽

Cerebellar Artery ◽

The Brain

Abstract BACKGROUND Microvascular decompression (MVD) is the most effective treatment option for hemifacial spasm (HFS). However, deeply located forms of compression would require proper identification to allow for adequate decompression. OBJECTIVE To describe the usefulness of endoscopic visualization in one of the most challenging compression patterns in HFS, where the posterior inferior cerebellar artery (PICA) loop is severely indenting the brain stem at the proximal root exit zone of facial nerve along the pontomedullary sulcus. METHODS Radiological and operative data were checked for all patients in whom severe indentation of the brainstem by PICA at pontomedullary sulcus was recorded and endoscope-assisted MVD was performed. Clinical correlation and outcome were analyzed. RESULTS A total of 58 patients with HFS were identified with radiological and surgical evidence proving brainstem indentation at the VII transitional zone. In 31 patients, PICA was the offending vessel to the facial nerve. In 3 patients, the PICA loop was mobilized under visualization of a 45° endoscope. A total of 31 patients had a mean follow-up duration of 52.1 mo. The mean duration between start of complaints and surgery was 7.2 yr. In the last follow-up, all patients had remarkable spasm improvement. A total of 5 patients had more than 90% disappearance of spasms and 26 patients experienced spasm-free outcome. CONCLUSION Although severe indentation of brain stem implies morphological damage, outcome after MVD is excellent. A 45° endoscope is extremely helpful to identify compression down at the pontomedullary sulcus. Deeply located compression site can easily be missed with microscopic inspection alone.

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Vertebral artery pexy for microvascular decompression of the facial nerve in the treatment of hemifacial spasm

Journal of Neurosurgery ◽

10.3171/2010.12.jns10891 ◽

2011 ◽

Vol 114 (6) ◽

pp. 1800-1804 ◽

Cited By ~ 20

Author(s):

Manuel Ferreira ◽

Brian P. Walcott ◽

Brian V. Nahed ◽

Laligam N. Sekhar

Keyword(s):

Facial Nerve ◽

Vertebral Artery ◽

Hemifacial Spasm ◽

Microvascular Decompression ◽

Cranial Nerve ◽

Anterior Inferior Cerebellar Artery ◽

Careful Study ◽

Venous Compression ◽

Select Group ◽

Far Lateral Approach

Object Hemifacial spasm (HFS) is caused by arterial or venous compression of cranial nerve VII at its root exit zone. Traditionally, microvascular decompression of the facial nerve has been an effective treatment for posterior inferior and anterior inferior cerebellar artery as well as venous compression. The traditional technique involves Teflon felt or another construct to cushion the offending vessel from the facial nerve, or cautery and division of the offending vein. However, using this technique for severe vertebral artery (VA) compression can be ineffective and fraught with complications. The authors report the use of a new technique of VA pexy to the petrous or clival dura mater in patients with HFS attributed to a severely ectatic and tortuous VA, and detail the results in a series of patients. Methods Six patients with HFS due to VA compression underwent a retrosigmoid craniotomy, combined with a far-lateral approach in some patients. On identification of the site of VA compression, the vessel was mobilized adequately for the decompression. Great care was taken to avoid kinking the perforating vessels arising from the VA. Two 8-0 nylon sutures were passed through to the wall of the VA and then through the clival or petrous dura, and then tied to alleviate compression on cranial nerve VII. Results Patients were followed for at least 1 year postoperatively (mean 2.7 years, range 1–4 years). All 6 patients had complete resolution of their HFS. Facial function was tested postoperatively, and was stable when compared with the preoperative baseline. Two of the 3 patients with preoperative tinnitus had resolution of this symptom after the procedure. Postoperative imaging demonstrated VA decompression of the facial nerve and no evidence of stroke in all patients. One patient suffered from hearing loss, another developed a postoperative transient unilateral vocal cord paralysis, and a third patient developed a pseudomeningocele that resolved with the placement of a lumbar drain. Conclusions Hemifacial spasm and other neurovascular syndromes are effectively treated by repositioning the compressing artery. Careful study of the preoperative MR images may identify a select group of patients with HFS due to an ectatic VA. Rather than traditional decompression with only pledget placement, these patients may benefit from a VA pexy to provide an effective, safe, and durable resolution of their symptoms while minimizing surgical complications.

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