Endoscopic-Assisted Microvascular Decompression of the Trigeminal and Facial Nerve

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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Novel Techniques for Trigeminal Neuralgia Including Trigeminal Neurostimulators

Effective Techniques for Managing Trigeminal Neuralgia - Advances in Medical Diagnosis, Treatment, and Care ◽

10.4018/978-1-5225-5349-6.ch006 ◽

2018 ◽

pp. 118-138

Author(s):

Arvin R. Wali ◽

Christian Lopez ◽

Peter Abraham ◽

Michael G. Brandel ◽

David R. Santiago-Dieppa ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Facial Nerve ◽

Patient Selection ◽

Microvascular Decompression ◽

Published Data ◽

Gasserian Ganglion ◽

Therapeutic Modalities ◽

Trigeminal Nerve Stimulation ◽

Surgical Options ◽

Novel Therapeutic

Several innovative surgical options for the management of trigeminal neuralgia have emerged over the past 40 years. In addition to microvascular decompression, other techniques have been introduced for the treatment of trigeminal neuralgia and facial nerve pain. This chapter describes the following novel therapeutic modalities: endoscopic microvascular decompression, radiosurgery, radiofrequency, thermocoagulation, glycerol rhizotomoy, balloon compression, Gasserian ganglion stimulation, and subcutaneous trigeminal nerve stimulation. For each of these techniques, this chapter provides a description of the procedure, criteria for patient selection, and discusses published data regarding patient outcomes.

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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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Estimation of Intraoperative Stimulation Threshold of the Facial Nerve in Patients Undergoing Microvascular Decompression

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1677538 ◽

2019 ◽

Vol 80 (06) ◽

pp. 599-603

Author(s):

Rafey A. Feroze ◽

Michael M. McDowell ◽

Jeffrey Balzer ◽

Donald J. Crammond ◽

Partha Thirumala ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Facial Nerve ◽

Microvascular Decompression ◽

Nerve Conduction ◽

Tumor Burden ◽

Constant Current ◽

Facial Weakness ◽

Stimulation Threshold ◽

Compound Muscle Action Potentials ◽

Facial Nerves

Introduction Facial weakness can result from surgical manipulation of the facial nerve. Intraoperative neuromonitoring reduces functional impairment but no clear guidelines exist regarding interpretation of intraoperative electrophysiological results. Most studies describe subjects with facial nerves encumbered by tumors or those with various grades of facial nerve weakness. We sought to obtain the neurophysiological parameters and stimulation threshold following intraoperative facial nerve triggered electromyography (t-EMG) stimulation during microvascular decompression for trigeminal neuralgia to characterize the response of normal facial nerves via t-EMG. Methods Facial nerve t-EMG stimulation was performed in seven patients undergoing microvascular decompression for trigeminal neuralgia. Using constant current stimulation, single stimulation pulses of 0.025 to 0.2 mA intensity were applied to the proximal facial nerve. Compound muscle action potentials, duration to onset, and termination of t-EMG responses were recorded for the orbicularis oculi and mentalis muscles. Patients were evaluated for facial weakness following the surgical procedure. Results Quantifiable t-EMG responses were generated in response to all tested stimulation currents of 0.025, 0.05, 0.1, and 0.2 mA in both muscles, indicating effective nerve conduction. No patients developed facial weakness postoperatively. Conclusions The presence of t-EMG amplitudes in response to 0.025 mA suggests that facial nerve conduction can take place at lower stimulation intensities than previously reported in patients with tumor burden. Proximal facial nerve stimulation that yields responses with thresholds less than 0.05 mA may be a preferred reference baseline for surgical procedures within the cerebellopontine angle to prevent iatrogenic injury.

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

Mayo Clinic Proceedings ◽

10.1016/s0025-6196(12)62028-x ◽

1986 ◽

Vol 61 (8) ◽

pp. 640-644 ◽

Cited By ~ 65

Author(s):

RAYMOND G. AUGER ◽

DAVID G. PIEPGRAS ◽

EDWARD R. LAWS

Keyword(s):

Facial Nerve ◽

Hemifacial Spasm ◽

Microvascular Decompression

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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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