Extended Retrosigmoid Craniotomy and Approach Through the Glossopharyngeal Cochlear Triangle for Clipping of a High-Riding Vertebral-Posterior Inferior Cerebellar Artery Aneurysm: 2-Dimensional Operative Video

The far lateral transcondylar (FL) craniotomy is the standard approach for posterior inferior cerebellar artery (PICA) aneurysm exposure through microsurgical dissection in the vagoaccessory triangle (VAT).1,2 However, the extended retrosigmoid (eRS) craniotomy and dissection through the glossopharyngeal-cochlear triangle (GCT) may be more appropriate when the patient has an aneurysm arising from a high-riding vertebral artery (VA)—PICA origin.3-5 We present a case of a 41-yr-old woman with hypertension presenting with left occipital pain and left-side hearing loss and past facial spasm and pain. Computed tomography angiography and digital subtraction angiography demonstrated an unruptured 8.4 × 9.0 × 10.2 mm saccular aneurysm at the left VA-PICA junction. Surgical clipping was chosen over endovascular therapy given the relationship of the PICA origin to the aneurysm neck as well as the history of cranial neuropathy. It was noted that the VA-PICA junction and aneurysm was high-riding at the level of the internal auditory canal. An eRS craniotomy was performed with dissection through the GCT, and the aneurysm was clipped as shown in the accompanying 2-dimensional operative video. Postoperative angiography demonstrated complete occlusion of the aneurysm and patency of the left VA and PICA without stenosis, and the patient had a favorable postoperative course although her left-sided hearing remained diminished. The eRS craniotomy allowed direct exposure via the GCT for clipping of the high-riding VA-PICA junction aneurysm and decompression of the cranial nerves. The traditional FL craniotomy and exposure through the VAT would likely have resulted in a less desirable inferior trajectory. The patient gave informed consent for the operation depicted in the video. Animation at 2:43 in video is used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Giant chondrosarcoma of the falx in an adolescent: A case report

Background: Intracranial chondrosarcomas are slowly growing malignant cartilaginous tumors that are especially rare in adolescents. Case Description: A 19-year-old woman with no medical history presented with symptoms of intermittent facial twitching and progressive generalized weakness for 6 months. The patient’s physical examination was unremarkable. Imaging revealed a large bifrontal mass arising from the falx cerebri, with significant compression of both cerebral hemispheres and downward displacement of the corpus callosum. The patient underwent a bifrontal craniotomy for gross total resection of tumor. Neuropathologic examination revealed a bland cartilaginous lesion most consistent with low-grade chondrosarcoma. Her postoperative course was uneventful, and she was discharged to home on postoperative day 3. Conclusion: This is an unusual case of an extra-axial, non-skull base, low-grade chondrosarcoma presenting as facial spasm in an adolescent patient.

A pacemaker-assisted microvascular decompression for a patient with left primary facial spasm and arrhythmia: a case report

Background Primary facial spasm accompanied by arrhythmia is a rare clinical phenomenon and has not been reported before. We describe this phenomenon and discuss its mechanism and treatment. Case presentation We herein present a rare case of a patient with left primary facial spasm and a third-degree atrioventricular block (III degree AVB), who was implanted with a temporary cardiac pacemaker to receive microvascular decompression (MVD) because of refusal of a permanent cardiac pacemaker. The symptoms of facial spasm disappeared after MVD. The temporary cardiac pacemaker was removed on the second day after surgery. Her ECG still showed the third-degree atrioventricular block after a follow-up period of 5 months. Conclusions We are the first to report a patient with facial spasm and arrhythmia who was implanted with a temporary cardiac pacemaker to receive MVD. This case report demonstrated that the concomitant presence of a III degree AVB maybe not a contraindication for MVD, and the etiology of this facial spasm was the actual vascular compression of the facial nerve entry zone that was not related to the atrioventricular block.

The Utility of Intraoperative Lateral Spread Recording in Microvascular Decompression for Hemifacial Spasm: A Systematic Review and Meta-Analysis

BACKGROUND Microvascular decompression (MVD) is the surgical treatment of choice for hemifacial spasm (HFS). During MVD, monitoring of the abnormal lateral spread response (LSR), an evoked response to facial nerve stimulation, has been traditionally used to monitor adequacy of cranial nerve (CN) VII decompression. OBJECTIVE To assess the utility of LSR monitoring in predicting spasm-free status after MVD postoperatively. METHODS We searched PubMed, Web of Science, and Embase for relevant publications. We included studies reporting on intraoperative LSR monitoring during MVD for HFS and spasm-free status following the procedure. Sensitivity of LSR, specificity, diagnostic odds ratio, and positive predictive value were calculated. RESULTS From 148 studies, 26 studies with 7479 patients were ultimately included in this meta-analysis. The final intraoperative LSR status predicted the clinical outcome of MVD with the following specificities and sensitivities: 89% (0.83- 0.93) and 40% (0.30- 0.51) at discharge, 90% (0.84-0.94) and 41% (0.29-0.53) at 3 mo, 89% (0.83-0.93) and 40% (0.30-0.51) at 1 yr. When LSR persisted after MVD, the probability (95% CI) for HFS persistence was 47.8% (0.33-0.63) at discharge, 40.8% (0.23-0.61) at 3 mo, and 24.4% (0.13-0.41) at 1 yr. However, when LSR resolved, the probability for HFS persistence was 7.3% at discharge, 4.2% at 3 mo, and 4.0% at 1 yr. CONCLUSION Intraoperative LSR monitoring has high specificity but modest sensitivity in predicting the spasm-free status following MVD. Persistence of LSR carries high risk for immediate and long-term facial spasm persistence. Therefore, adequacy of decompression should be thoroughly investigated before closing in cases where intraoperative LSR persists.

A rare case of unilateral hemifacial spasm and facial palsy associated with an abnormal anatomical variant of the posterior basilar circulation

Tortuous vertebral arteries are a rare anatomical variant. Mild tortuosity is usually asymptomatic whereas severe tortuosity may present with ischaemic symptoms or compressive symptoms (focal neurological deficit). While a resulting hemifacial spasm has been previously described, sparse literature exists for its association with facial palsy. We present a rare case of facial spasm along with facial palsy in a 67-year-old woman who was found to have an anatomical variant in the posterior basilar circulation with an ectatic basilar artery and significantly displaced posterior vertebral artery impinging on the facial nerve.

Ayurvedic management of Bells Palsy - A Case Report

Bells palsy an acute paresis of facial mimetic muscles is most common in the third decade of life with an incidence of about 20 cases per 1,00,000 population. The complete recovery rates within 3 months vary from 80-85%. Major complications of the condition include chronic loss of taste, chronic facial spasm, facial pain, corneal infections making early intervention essential. Ardita clinically correlates to Bells palsy. Its cause is mainly vitiated Vata due to Avarana or Dhatukshaya and management is primarily based on Vatahara and Urdhva Sharira Chikitsa. Methods: The current report is based on a case of Bells palsy that presented as left sided facial paresis with deviated angle of mouth to the right, diagnosed as Ardita due to Vata and Kapha Anubandha. Treatment included Nasya Karma, Shiro Pichu, Mukhabhyanga followed by Panasa Patra Sweda and internal medications. Result: Improvement in motor functioning was noticed from day 3 of treatment. Speech enhancement and sensory perception was also noted. Discussion: Ayurvedic management with Ardita Chikitsa provided brisk results in this case.