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1.  Intraoperative early change of latencies in Facial nerve function during Microvascular Decompression studied in patients with Hemifacial Spasm 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 89.
Primary hemifacial spasm (HFS) is reported mainly as a result of cross compression of blood vessel and facial nerve at its root exit zone (REZ). Generation of HFS could be due to hyperexcitability of facial nerve since microvascular decompression (MVD) has been an effective treatment in clinical experince of authors. Multimodal Intraoperative monitoring (MIOM) has been frequently used for care and constant evaluation of facial nerve during MVD. In HFS patients F waves of the facial muscle which is known to be induced from backfiring of facial motor nucleus, Blink reflexes and Lateral spread (abnormal muscle responses) before, during and after MVD have been used to evaluate the excitability of the facial motor nucleus and the treatment outcome after MVD procedure.
In 9 female HFS cases with abnormal lateral spread in their facial Electromyography (EMG), patients history, preoperative physical examination, electrodiagnosis and MIOM were perfored using a Moltimodal 40 channels electrophysiologic monitoring system (Nicolet Endeavor, VIASYS Healthcare, 2005, USA). Free run EMG, Stimulated EMG, bilateral blink reflexes and facial F waves were set for MIOM as indicators of MVD effectiveness.
Bilateral Orbicularis Oris/Oculi muscles were used for surface EMG recordings. Antidromic stimulatin of facial nerve branches and direct bipolar stimulation of the nerve in REZ, before and after its vascular contact at the site of operation applied by surgen. In all subjects, recordings were scheduled a week before, intaoperatively and every 2 weeks up to 3 months after operation.
In affected side of the face before MVD, threshold of F wave was reduced and excitability of blink reflex EMG responses were enhanced compared to the normal side. These responses remaind the same intraoperatively. In post operation recordings F waves and Blink reflex responses were as before in 7 subjects up to fourth week after the surgery, although with lower amplitude of the responses. These responses and Lateral spread of EMGs disappeared completely after 6 weeks. In 2 other subject these abnormal findings reduced slowly and subsequently disappeared after 12 weeks. In all cases, introperative recordings of F wave latencies and the latencies of R1 and R2 responses of blink reflexes were reduced significantly even before 20 minutes of decompression (P less than 0.03).
Propofol or Propofol/Ketamine mixture plus narcotic is suitable to obtain stable reproducible F waves and EMGs. Atracurium or other nondepolarizing muscle relaxant should be avoided. Muscle relaxants, mean arterial pressure (MAP) below 70 mmHg may cause bilateral reduction or loss of reflex responces and EMGs. In all cases, there was no postoperative clinically detectable complication.
MIOM could be useful technique in all patients undergoing any procedures around cranial nerves. Monitoring can practically reduce possibilities of neurologic deficit and reduce the potential risk of interventions around facial REZ. We conclude that in MVD for HFS, the use of stimulated EMGs for evaluating involved facial nerve is not sufficent because, practically, it could be limited to the efferent nerve fibers not the nucleuses.In these settings and similar procedures, if monitoring systems are avaiable, alternative multimodal methods with greater sensitivity and efficacy should be explored. MVD seems to be effective procedure for treatment of HFS and monitoring would help to optimise the MVD.
The study also supports the hypothesis that the hyperexcitability of the facial motor nucleus may be the main cause of hemifacial spasm. To aquire and maintain MIOM modalities, close collaboration of the anesthesioloist is nessesary.
Hemifacial spasm, Microvascular decompression, Multimodal intraoperative monitoring
PMCID: PMC3571615
2.  The Efficacy and Safety of Microvascular Decompression for Hemifacial Spasm in Elderly Patients 
The purpose of this study was to examine the efficacy and safety of microvascular decompression (MVD) for hemifacial spasm (HFS) in elderly patients.
Between 1997 and June 2008, 1,174 patients had undergone MVD for HFS at our institute. Among these, 53 patients were older than 65 years. We retrospectively reviewed and compared the complication and the cure rates of these patients with those of younger patients.
There were 38 females and 15 males. The mean duration of symptoms of HFS of these patients was 94.6 months (range, 12-360 months), compared with 67.2 months (range, 3-360 months) in the younger group. The overall cure rate in elderly patients who underwent MVD for HFS during this period was 96.2%. Permanent cranial nerve dysfunctions, such as hearing loss and facial palsy, were seen in 2 patients (3.8%, 2/53) in the elderly group and 19 patients (1.7%, 19/1121) in the younger group. The difference in permanent cranial nerve dysfunction between the two groups was not statistically significant. There was no operative mortality in either group.
Microvascular decompression is the most effective surgical modality available for the treatment of HFS. Results of this study indicate that such technique can be performed in the elderly without higher rates of morbidity or mortality. Any patient with HFS, whose general health is acceptable for undergoing general anesthesia, should be considered as a candidate for MVD.
PMCID: PMC2899032  PMID: 20617090
Microvascular decompression; Hemifacial spasm; Elderly patients
3.  Bell's palsy 
BMJ Clinical Evidence  2011;2011:1204.
Bell's palsy is characterised by an acute, unilateral, partial, or complete paralysis of the face (i.e., lower motor neurone pattern). The weakness may be partial (paresis) or complete (paralysis), and may be associated with mild pain, numbness, increased sensitivity to sound, and altered taste. Bell's palsy remains idiopathic, but a proportion of cases may be caused by reactivation of herpes viruses from the geniculate ganglion of the facial nerve. Bell's palsy is most common in people aged 15 to 40 years, with a 1 in 60 lifetime risk. Most make a spontaneous recovery within 1 month, but up to 30% show delayed or incomplete recovery.
Methods and outcomes
We conducted a systematic review to answer the following clinical question: What are the effects of treatments in adults and children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiviral treatment, corticosteroids (alone or plus antiviral treatment), hyperbaric oxygen therapy, facial nerve decompression surgery, and facial retraining.
Key Points
Bell's palsy is an idiopathic, unilateral, acute paresis or paralysis of facial movement caused by dysfunction of the lower motor neurone. Up to 30% of people with acute peripheral facial palsy have an alternative cause diagnosed at presentation or during the course of their facial palsy. Alternative causes are higher in children (>50%), warranting specialist evaluation at presentation. Severe pain, vesicles (ear or oral), and hearing loss or imbalance, suggest Ramsay Hunt syndrome caused by herpes zoster virus infection, which requires specialist management. Most people with paresis (partial weakness) make a spontaneous recovery within 3 weeks. Up to 30% of people, typically people with paralysis (complete palsy), have a delayed or incomplete recovery.
Corticosteroids alone improve rate of recovery and the proportion of people who make a full recovery, and reduce cosmetically disabling sequelae, motor synkinesis, and autonomic dysfunction compared with placebo or no treatment.
Antiviral treatment alone is no more effective than placebo and is less effective than corticosteroid treatment at improving recovery of facial motor function and at reducing the risk of disabling sequelae.
For people with paresis at presentation (about 70%), there is no evidence of a clinically important additive effect of adding antivirals to corticosteroid therapy. For people who develop paralysis (about 30%), and may demonstrate a trend towards complete degeneration on electrophysiological testing, it is unknown whether adding antiviral treatment to corticosteroid therapy has a significant additive or synergistic effect.
Hyperbaric oxygen may improve time to recovery and the proportion of people who make a full recovery compared with corticosteroids; however, the evidence for this is weak.
We don't know whether facial nerve decompression surgery is beneficial in Bell's palsy.
Facial retraining may improve recovery of facial motor function scores including stiffness and lip mobility, and may reduce the risk of motor synkinesis in Bell's palsy, but the evidence is too weak to draw conclusions.
Clinical guide Good evidence exists that corticosteroid therapy improves facial palsy in people with Bell's palsy independent of severity at presentation. Treatment is likely to be more effective when started within 72 hours of onset, and less effective after 7 days. Contraindications to corticosteroid therapy exist and adverse effects are more likely following 7 days of treatment. Combination therapy with a corticosteroid and antiviral is no more effective than corticosteroid therapy alone for Bell's palsy; however, combination therapy should be considered when there is evidence of viral infection with herpes zoster, such as zoster sine herpete and Ramsay Hunt syndrome. People presenting with complete facial paralysis should be offered a choice of combination therapy with a corticosteroid and antiviral, because the evidence for therapy without antivirals is not yet definitive for this group and antivirals have few adverse effects. In people presenting with mild facial paresis from Bell's palsy, there is a high rate of spontaneous resolution without treatment. Bell's palsy is a diagnosis of exclusion and clinicians should remain mindful of the causes of facial palsy, including tumour and infection. All children presenting with facial palsy and adults with delayed recovery should be referred for assessment by an otolaryngologist - head and neck surgeon or other appropriate specialist. The authors believe that facial palsy should not be treated only by protocol-driven practice. Bell's palsy is a diagnosis of exclusion, although a search for other causes of facial palsy must not delay treatment of likely Bell's palsy. Patients should have the opportunity to participate in an informed choice in their management where relevant.
PMCID: PMC3275144  PMID: 21375786
4.  Time Course of Symptom Disappearance after Microvascular Decompression for Hemifacial Spasm 
This study is to investigate time course of symptom disappearance in patients whose spasm relieved completely after microvascular decompression (MVD).
Of 115 patients with hemifacial spasm (HFS) who underwent MVD from April 2003 to December 2006, 89 patients who had no facial paralysis after operation and showed no spasm at last follow-up more than 1.5 years after operation were selected. Symptom disappearance with time after MVD was classified into type 1 (symptom disappearance right after operation), type 2 (delayed symptom disappearance) and type 3 (unusual symptom disappearance). Type 2 was classified into type 2a (with postoperative silent period) and type 2b (without silent period).
Type 1, type 2a, type 2b and type 3 were 38.2%, 48.37%, 12.4% and 1.1%, respectively. Delayed disappearance group (type 2) was 60.7%. Post-operative symptom duration in all cases ranged from 0 to 900 days, average was 74.6 days and median was 14 days. In case of type 2, average post-operative symptom duration was 115.1 days and median was 42 days. Five and 3 patients required more than 1 year and 2 years, respectively, until complete disappearance of spasm. In type 2a, postoperative silent period ranged from 1 to 10 days, with an average of 2.4 days.
Surgeons should be aware that delayed symptom disappearance after MVD for HFS is more common than it has been reported, silent period can be as long as 10 days and time course of symptom disappearance is various as well as unpredictable.
PMCID: PMC2588317  PMID: 19096685
Hemifacial spasm; Microvascular decompression; Delayed resolution
5.  Repeat microvascular decompression for hemifacial spasm 
Objective: To report our experience with repeat microvascular decompression (MVD) for hemifacial spasm (HFS) in patients who have failed their first operation.
Methods: The authors describe 41 redo MVDs for HFS in 36 patients performed over a 3 year period. Seven patients underwent early re-operation after an aborted seventh nerve decompression. Eight patients underwent early re-operation for clinical failure. Eighteen patients underwent late re-operation for spasm recurrence long after their original MVD. Eight MVDs were performed on patients who had already undergone at least two prior operations.
Results: Twenty four patients experienced complete spasm resolution (70.6%), eight patients had near total resolution (23.5%), and two patients failed re-operation (5.9%). Two patients were lost to follow up (5.6%). A favourable outcome was reported by 82.4% of patients at a mean follow up interval of 18 months. A total of 91.7% of patients 50 years of age or younger were cured at follow up versus 59.1% of patients older than 50 (p = 0.04). Patients undergoing early re-operation were significantly more likely to be cured or improved than patients undergoing late re-operation (p = 0.03).
Conclusions: Repeat MVD for HFS is effective in experienced hands. Younger patients respond better to repeat MVD. Late repeat MVD for HFS is a reasonable treatment option, although results are less favourable than for early re-operation.
PMCID: PMC1739385  PMID: 16227555
6.  Efficacy of the Disappearance of Lateral Spread Response before and after Microvascular Decompression for Predicting the Long-Term Results of Hemifacial Spasm Over Two Years 
The purpose of this large prospective study is to assess the association between the disappearance of the lateral spread response (LSR) before and after microvascular decompression (MVD) and clinical long term results over two years following hemifacial spasm (HFS) treatment.
Continuous intra-operative monitoring during MVD was performed in 244 consecutive patients with HFS. Patients with persistent LSR after decompression (n=22, 9.0%), without LSR from the start of the surgery (n=4, 1.7%), and with re-operation (n=15, 6.1%) and follow-up loss (n=4, 1.7%) were excluded. For the statistical analysis, patients were categorized into two groups according to the disappearance of their LSR before or after MVD.
Intra-operatively, the LSR was checked during facial electromyogram monitoring in 199 (81.5%) of the 244 patients. The mean follow-up duration was 40.9±6.9 months (range 25-51 months) in all the patients. Among them, the LSR disappeared after the decompression (Group A) in 128 (64.3%) patients; but in the remaining 71 (35.6%) patients, the LSR disappeared before the decompression (Group B). In the post-operative follow-up visits over more than one year, there were significant differences between the clinical outcomes of the two groups (p<0.05).
It was observed that the long-term clinical outcomes of the intra-operative LSR disappearance before and after MVD were correlated. Thus, this factor may be considered a prognostic factor of HFS after MVD.
PMCID: PMC3488647  PMID: 23133727
Clinical outcome; Hemifacial spasm; Lateral spread response; Microvascular decompression
7.  The Treatment Outcome of Elderly Patients with Idiopathic Trigeminal Neuralgia : Micro-Vascular Decompression versus Gamma Knife Radiosurgery 
This study was designed to compare the efficacy of micro-vascular decompression (MVD) and Gamma knife radiosurgery (GKRS) for elderly idiopathic trigeminal neuralgia patients by analyzing the clinical outcome.
In the past 10 years, 27 elderly patients were treated with MVD while 18 patients were treated with GKRS (>65-years-old). We reviewed their clinical characteristics and clinical courses after treatment as well as the treatment outcomes. For patients who were treated with MVD, additional treatment methods such as rhizotomy were combined in some areas. In GKRS, we radiated the root entry zone (REZ) with the mean maximum dose of 77.8 (70-84.3) Gy and one 4 mm collimator.
The mean age was 68.1 years for MVD, and 71.1 years for GKS group. The average time interval between first presenting symptom and surgery was 84.1 (1-361) months, and 51.4 (1-120) months, respectively. The mean follow-up period after the surgery was 35.9 months for MVD, and 33.1 months for GKRS. According to Pain Intensity Scale, MVD group showed better prognosis with 17 (63%) cases in grade I-II versus 10 (55.6%) cases in GKRS group after the treatment. The pain recurrence rate during follow up did not show much difference with 3 (11.1%) in MVD, and 2 (11.1%) in GKRS. After the treatment, 2 cases of facial numbness, and 1 case each of herpes zoster, cerebrospinal fluid (CSF) leakage, hearing disturbance, and subdural hematoma occurred in MVD Group. In GKRS, there was 1 (5.6%) case of dysesthesia but was not permanent. Three cases were retreated by GKRS but the prognosis was not as good as when the surgery was used as primary treatment, with 1 case of grade I-II, and 1 case of recurrence. The maximal relieve of pain was seen just after surgery in MVD group, and 1 year after treatment in GKRS group.
For trigeminal neuralgia patients with advanced age, MVD showed advantages in immediately relieving the pain. However, in overall, GKRS was preferable, despite the delayed pain relief, due to the lower rate of surgical complications that arise owing to the old age.
PMCID: PMC2588323  PMID: 19096677
Elderly patient; Idiopathic trigeminal neuralgia; Micro-vascular decompression; Gamma knife radiosurgery
8.  Hemifacial Spasm and Neurovascular Compression 
The Scientific World Journal  2014;2014:349319.
Hemifacial spasm (HFS) is characterized by involuntary unilateral contractions of the muscles innervated by the ipsilateral facial nerve, usually starting around the eyes before progressing inferiorly to the cheek, mouth, and neck. Its prevalence is 9.8 per 100,000 persons with an average age of onset of 44 years. The accepted pathophysiology of HFS suggests that it is a disease process of the nerve root entry zone of the facial nerve. HFS can be divided into two types: primary and secondary. Primary HFS is triggered by vascular compression whereas secondary HFS comprises all other causes of facial nerve damage. Clinical examination and imaging modalities such as electromyography (EMG) and magnetic resonance imaging (MRI) are useful to differentiate HFS from other facial movement disorders and for intraoperative planning. The standard medical management for HFS is botulinum neurotoxin (BoNT) injections, which provides low-risk but limited symptomatic relief. The only curative treatment for HFS is microvascular decompression (MVD), a surgical intervention that provides lasting symptomatic relief by reducing compression of the facial nerve root. With a low rate of complications such as hearing loss, MVD remains the treatment of choice for HFS patients as intraoperative technique and monitoring continue to improve.
PMCID: PMC4227371  PMID: 25405219
9.  The Effect of Microvascular Decompression for Hemifacial Spasm Caused by Vertebrobasilar Dolichoectasia 
Hemifacial spasm (HFS) caused by vertebrobasilar dolichoectasia (VBD) is very rare, and in theses cases, it is difficult to decompress the nerve from its vascular compression. The objective of this study was to investigate the outcome of microvascular decompression (MVD) for HFS caused by VBD.
There were 10 patients of HFS caused by VBD at our hospital between September 1978 and September 2008. We evaluated magnetic resonance angiography (MRA) and time of flight magnetic resonance imaginge (TOF MRI) findings using the criteria for VBD. We compared the clinical outcomes of MVD for the 10 patients with VBD with the overall outcomes of the total 2058 MVDs performed for HFS.
The results of MVD for HFS caused by VBD were successful in 90.9% of cases. The postoperative complication rate in VBD was 45.5%. Offending vessels in patients with VBD were identified visually during surgery. Adverse effects after MVD were found in 4 patients. We found that the diameter of VBD was significantly greater in patients with complications than in those with no complications (p=0.028).
Our data shows that MVD may be a good treatment modality for HFS caused by VBD but care must be taken to avoid adverse effects from the procedure. It is important to detach the dolichoectatic artery from its surrounding structures sufficiently to allow it to be easily movable. In addition, attempts should be made to lessen the retraction of the cerebellum during release of the dolichoectatic artery.
PMCID: PMC3467381  PMID: 23091664
Microvascular decompression; Hemifacial spasm; Vertebrobasilar dolichoectasia
10.  Delayed Unilateral Soft Palate Palsy without Vocal Cord Involvement after Microvascular Decompression for Hemifacial Spasm 
Microvascular decompression is a very effective and relatively safe surgical modality in the treatment of hemifacial spasm. But rare debilitating complications have been reported such as cranial nerve dysfunctions. We have experienced a very rare case of unilateral soft palate palsy without the involvement of vocal cord following microvascular decompression. A 33-year-old female presented to our out-patient clinic with a history of left hemifacial spasm for 5 years. On postoperative 5th day, patient started to exhibit hoarsness with swallowing difficulty. Symptoms persisted despite rehabilitation. Various laboratory work up with magnetic resonance image showed no abnormal lesions. Two years after surgery patient showed complete recovery of unitaleral soft palate palsy. Various etiologies of unilateral soft palate palsy are reviewed as the treatment and prognosis differs greatly on the cause. Although rare, it is important to keep in mind that such complication could occur after microvascular decompression.
PMCID: PMC3756130  PMID: 24003372
Microvascular decompression; Hemifacial spasm; Lower cranial nerve; Soft palate palsy; Vocal cord
11.  Intractable Hemifacial Spasm Treated by Pulsed Radiofrequency Treatment 
The Korean Journal of Pain  2013;26(1):62-64.
Hemifacial spasm is defined as unilateral, involuntary, irregular twitching of all or parts of the muscles innervated by facial nerves. Here, we present a case of recurrent hemifacial spasm after microvascular decompression (MVD) treated with pulsed radiofrequency (PRF) treatment with good results. A 35-year-old woman suffered from recurrent hemifacial spasm after MVD that was refractory to medical treatment and botulinum toxin injections. We attempted a left facial nerve block twice. Then, we applied PRF at a maximum temperature of 42℃ for 120 sec. Some response was observed, so we applied PRF two additional times. The frequency of twitch decreased from 3-4 Hz to < 0.5 Hz, and subjective severity on a visual analogue scale also decreased from 10/10 to 2-3/10. PRF treatment might be an effective medical treatment for refractory hemifacial spasm and has fewer complications and is less invasive compared with those of surgery.
PMCID: PMC3546213  PMID: 23342210
facial nerve; hemifacial spasm; pulsed radiofrequency treatment
12.  Monitoring of abnormal muscle response and facial motor evoked potential during microvascular decompression for hemifacial spasm 
To determine whether the monitoring of abnormal muscle response (AMR) and facial motor evoked potential (FMEP) during microvascular decompression (MVD) for hemifacial spasm (HFS) might be useful for predicting the postoperative clinical course and final outcomes.
We analyzed 45 HFS patients who underwent both AMR and FMEP monitoring during MVD. Patients were divided into two groups on the basis of post-MVD disappearance (group AMR-A) or persistence (group AMR-B) of AMR. With regard to FMEPs, patients were classified into one of the two groups according to the ratio of the final to baseline FMEP amplitudes recorded for the orbicularis oculi muscle: one group with a ratio of <50% (group FMEP-A), and the other with a ratio of ≥50% (group FMEP-B).
Twenty-one of the 26 (81%) patients in group AMR-A were assigned to group FMEP-A, whereas 9 of the 17 (53%) patients in group AMR-B were assigned to FMEP-B (P < 0.05). In 38 of the 40 (95%) patients in whom the AMRs disappeared or persisted at amplitudes <50% that at the baseline, HFS had subsided at the final follow-up. Forty of the 42 (95%) patients whose FMEP amplitude ratios indicated reduction in the amplitudes from the baseline, had complete relief of the symptoms. Nineteen of the 20 (95%) patients whose AMRs disappeared after MVD experienced immediate relief of their symptoms after the operation. With regard to 14 of the 20 (70%) patients whose AMRs persisted at the final recordings, the symptoms of HFS improved over time and eventually subsided (P < 0.001).
Intraoperative monitoring of both AMR and FMEP during MVD may be useful in predicting the postoperative outcomes in HFS patients. The AMR-related findings may help to predict whether HFS disappears immediately after surgery or some time later.
PMCID: PMC3512340  PMID: 23226604
Abnormal muscle response; facial-motor evoked potential; hemifacial spasm; microvascular decompression
13.  Hemifacial spasm: a prospective long-term follow up of 83 cases treated by microvascular decompression at two neurosurgical centres in the United Kingdom. 
OBJECTIVE--To evaluate the use of microvascular decompression (MVD) for the treatment of hemifacial spasm (HFS). METHODS--Eighty three patients with HFS who underwent MVD via a suboccipital craniectomy are presented. RESULTS--Seventy two out of seventy eight patients available for follow up remained free of any spasms at a mean follow up period of eight years. Two patients continued to have minor intermittent muscle twitches and three had recurrence of HFS. One patient's operation was not completed. Twenty had a transient complication and eight were left with permanent postoperative deficits, the commonest being unilateral sensorineural deafness. Seventy one patients declared themselves satisfied with the procedure. A causative vessel was found on the root exit zone of the seventh cranial nerve in 81 patients. CONCLUSION--The procedure seems to provide lasting relief for most patients. The correct operative technique is essential if complications are to be avoided.
PMCID: PMC486193  PMID: 8558156
14.  Presurgical evaluation of hemifacial spasm and spasmodic torticollis caused by a neurovascular conflict from AICA with 3T MRI integrated by 3D drive and 3D TOF image fusion: A case report and review of the literature 
Hemifacial spasm (HS) and spasmodic torticollis (ST) are well-known disorders that are caused by a neurovascular conflict. HS is characterized by irregular, involuntary muscle contractions on one side of the face due to spasms of orbicularis oris and orbicularis oculi muscles, and is usually caused by vascular compression of the VII cranial nerve. ST is an extremely painful chronic movement disorder causing the neck to involuntary turn to the side, upward and/or downward. HS is usually idiopathic but it is rarely caused by a neurovascular conflict with the XI cranial nerve.
Case Description:
We present a case of a 36-year-old woman with a 2-year history of left hemifacial spasm and spasmodic torticollis. Pre-surgical magnetic resonance imaging MRI examination was performed with 3TMRI integrated by 3Ddrive and 3DTOF image fusion. Surgery was performed through a left suboccipital retrosigmoid craniectomy. The intraoperative findings documented a transfixing artery penetrating the facial nerve and a dominant left anteroinferior cerebellar artery (AICA) in contact with the anterior surface of the pons and lower cranial nerves. Microvascular decompression (MVD) was performed. Postoperative course showed the regression of her symptoms.
Transfixing arteries are rarely reported as a cause of neurovascular conflicts. The authors review the literature concerning multiple neurovascular conflicts.
PMCID: PMC4123266  PMID: 25101203
Hemifacial spasm; microvascular decompression; neurovascular conflict; spasmodic torticollis; transfixing artery
15.  A comparison of three induction regimens using succinylcholine, vecuronium, or no muscle relaxant: impact on the intraoperative monitoring of the lateral spread response in hemifacial spasm surgery: study protocol for a randomised controlled trial 
Trials  2012;13:160.
Surgical microvascular decompression (MVD) is the curative treatment for hemifacial spasm (HFS). Monitoring MVD by recording the lateral spread response (LSR) intraoperatively can predict a successful clinical outcome. However, the rate of the LSR varies between trials, and the reason for this variation is unclear. The aim of our trial is to evaluate the rate of the LSR after intubation following treatment with succinylcholine, vecuronium, or no muscle relaxant.
Methods and design
This trial is a prospective randomised controlled trial of 96 patients with HFS (ASA status I or II) undergoing MVD under general anaesthesia. Patients are randomised to receive succinylcholine, vecuronium, or no muscle relaxant before intubation. Intraoperative LSR will be recorded until dural opening. The primary outcome of this study is the rate of the LSR, and the secondary outcomes are post-intubation pharyngolaryngeal symptoms, the rate of difficult intubations, the rate of adverse haemodynamic events and the relationship between the measurement of LSR or not, and clinical success rates at 30 days after surgery.
This study aims to evaluate the impact of muscle relaxants on the rate of the LSR, and the study may provide evidence supporting the use of muscle relaxants before intubation in patients with HFS undergoing MVD surgery.
Trials registration ChiCTR-TRC-11001504 Date of registration: 24 June, 2011.
The date the first patient was randomised: 30 September, 2011.
PMCID: PMC3502586  PMID: 22958580
Hemifacial spasm; Microvascular decompression; Muscle relaxant; Succinylcholine; Vecuronium; Intraoperative monitoring; Lateral spread response
16.  Delayed Progressive Extradural Pneumatocele due to Incomplete Sealing of Opened Mastoid Air Cell after Micro-Vascular Decompression 
A case of delayed progressive extradural pneumatocele after microvascular decompression (MVD) is presented. A 60-year-old male underwent MVD for hemifacial spasm; the mastoid air cell was opened and sealed with bone wax during surgery. One month after surgery, the patient complained of tinnitus, and progressive extradural pneumatoceles without cerebrospinal fluid (CSF) leakage was observed. Revision surgery was performed and the opened mastoid air cell was completely sealed with muscle patch and glue. The patient's symptoms were resolved, with no recurrence of pneumatoceles at 6 month follow up. Progressive extradural pneumatocele without CSF leakage after posterior fossa surgery is a very rare complication. Previous reports and surgical management of this rare complication are discussed.
PMCID: PMC2899041  PMID: 20617099
Pneumatocele; Posterior fossa surgery; Hemifaical spasm; Mastoid air cell
17.  Infranuchal Infrafloccular Approach to the More Vulnerable Segments of the Facial Nerve in Microvascular Decompressions for the Hemifacial Spasm 
We investigated the locations of compressing vessels in hemifacial spasm. To approach compression sites, we described and evaluated the efficacy of the infranuchal infrafloccular (INIF) approach.
A retrospective review of 31 consecutive patients who underwent microvascular decompression (MVD) through INIF with a minimum follow-up of 1 year was performed. Along the intracranial facial nerve, we classified the compression sites into the transitional zone (TRZ), the central nervous system (CNS) segment and the peripheral nervous system (PNS) segment. The INIF approach was used to inspect the CNS segment and the TRZ. Subdural patch graft technique was used in order to achieve watertight dural closure. The cranioplasty was performed using polymethylmethacrylate. The outcome and procedure-related morbidities were evaluated.
Twenty-nine patients (93%) showed complete disappearance of spasm. In two patients, the spasm was resolved gradually in 2 and 4 weeks, respectively. Late recurrence was noted in one patient (3%). The TRZ has been identified as the only compression site in 19 cases (61.3%), both the TRZ and CNS segment in 11 (35.5%) and the CNS segment only in 1 (3.2%). There was no patient having a compressing vessel in the PNS segment. Infection as a result of cerebrospinal fluid leak occurred in one patient (3%). Delayed transient facial weakness occurred in one patient.
The TRZ and the CNS segment were more vulnerable area to the compression of vessels. We suggest that surgical avenue with the INIF approach provides early identification of this area.c
PMCID: PMC2773391  PMID: 19893723
Hemifacial spasm; Microvascular decompression; Root exit zone
18.  Prognostic Factors of Hemifacial Spasm after Microvascular Decompression 
The factors that influence the prognosis of patients with hemifacial spasm (HFS) treated by microvascular decompression (MVD) have not been definitely established. We report a prospective study evaluating the prognostic factors in patients undergoing MVD for HFS.
From January 2004 to September 2006, the authors prospectively studied a series of 293 patients who underwent MVD for HFS. We prospectively analyzed a number of variables in order to evaluate the predictive value of independent variables for the prognosis of patients undergoing MVD. The patients were followed-up at regular intervals and divided into as cured and unsatisfactory groups based on symptom relief. Uni- and multivariate analyses were performed using logistic regression models.
A total 273 of 293 (94.2%) patients achieved symptom relief within one year after the operation. Intraoperatively, the indentation of the root exit zone was observed in 259 (88.5%) patients. Uni- and multivariate analyses revealed that the symptoms at postoperative 3 months (p<0.001) and indentation of the root exit zone (p=0.036) were associated with good outcomes.
The intraoperative finding of root exit zone indentation will help physicians determine the prognosis in patients with HFS. To predict the prognosis of HFS, a regular follow-up period of at least 3 months following MVD should be required.
PMCID: PMC2711230  PMID: 19609416
Hemifacial spasm; Microvascular decompression; Prognosis; Chronology
19.  Outcome of microvascular decompression for trigeminal neuralgia using autologous muscle graft: A five-year prospective study 
Asian Journal of Neurosurgery  2012;7(3):125-130.
Trigeminal Neuralgia (TGN) is a syndrome characterized by Paroxysmal, shock like hemifacial pain. Among the various treatment options micro vascular decompression (MVD) has gained popularity in the recent years.
Materials and Methods:
182 patients underwent MVD, between 1995–2007 out of 530 patients treated for Trigeminal Neuralgia at our service. All were operated by retro auricular sub occipital craniectomy by a single surgeon using autologous muscle graft. They were assessed for pain relief, complications and the data was analysed.
Males were 84 (61.3%) females 53 (38%) with a ratio of 1.5=1. Age ranged from 25-75 years. Duration of symptoms ranging from 6 months to 25 years (average 4-6 years). Seventy seven (56.2% were affected on the right side whereas 60 (43.8%) had pain on the left side. Imaging demonstrated vascular compression in 84 (61%). At surgery superior cerebellar artery was the commonest cause of compression in 71.5%. More than one artery was found in relation to the nerve in 15.3%. There was no mortality, CSF leak 2.9% and transient facial palsy in 2.2% were the notable complications.
MVD is the procedure of choice for TGN if there is no contraindication for surgery. Adequate tissue respect, meticulous surgical steps and experience will reduce complications. Autologus muscle graft can give comparable and durable results possibly with lesser complications.
PMCID: PMC3532758  PMID: 23293667
Microvascular decompression; muscle graft; outcome; trigeminal neuralgia
20.  Facial nerve compression by the posterior inferior cerebellar artery causing facial pain and swelling: a case report 
We report an unusual case of facial pain and swelling caused by compression of the facial and vestibulocochlear cranial nerves due to the tortuous course of a branch of the posterior inferior cerebellar artery. Although anterior inferior cerebellar artery compression has been well documented in the literature, compression caused by the posterior inferior cerebellar artery is rare. This case provided a diagnostic dilemma, requiring expertise from a number of specialties, and proved to be a learning point to clinicians from a variety of backgrounds. We describe the case in detail and discuss the differential diagnoses.
Case presentation
A 57-year-old Caucasian woman with a background of mild connective tissue disease presented to our rheumatologist with intermittent left-sided facial pain and swelling, accompanied by hearing loss in her left ear. An autoimmune screen was negative and a Schirmer’s test was normal. Her erythrocyte sedimentation rate was 6mm/h (normal range: 1 to 20mm/h) and her immunoglobulin G and A levels were mildly elevated. A vascular loop protocol magnetic resonance imaging scan showed a loop of her posterior inferior cerebellar artery taking a long course around the seventh and eighth cranial nerves into the meatus and back, resulting in compression of her seventh and eighth cranial nerves. Our patient underwent microvascular decompression, after which her symptoms completely resolved.
Hemifacial spasm is characterized by unilateral clonic twitching, although our patient presented with more unusual symptoms of pain and swelling. Onset of symptoms is mostly in middle age and women are more commonly affected. Differential diagnoses include trigeminal neuralgia, temporomandibular joint dysfunction, salivary gland pathology and migrainous headache. Botulinum toxin injection is recognized as an effective treatment option for primary hemifacial spasm. Microvascular decompression is a relatively safe procedure with a high success rate. Although a rare pathology, posterior inferior cerebellar artery compression causing facial pain, swelling and hearing loss should be considered as a differential diagnosis in similar cases.
PMCID: PMC4018959  PMID: 24661509
Facial pain; Hemifacial spasm; Facial pain; Vascular compression; Posterior inferior cerebellar artery; Vascular compression
21.  Closed-Suction Drainage and Cerebrospinal Fluid Leakage Following Microvascular Decompression : A Retrospective Comparison Study 
We performed this study to investigate whether the use of closed-suction drainage following microvascular decompression (MVD) causes cerebrospinal fluid (CSF) leakage.
Between 2004 and 2011, a total of 157 patients with neurovascular compression were treated with MVD. MVD was performed for hemifacial spasm in 150 (95.5%) cases and for trigeminal neuralgia in 7 (4.5%) cases. The mean age of the patients was 49.8±9.6 years (range, 20-69). Dural substitutes were used in 44 (28.0%) patients. Ninety-two patients (58.6%) were underwent a 4-5 cm craniotomy using drainage (drainage group), and 65 (41.4%) did a small 2-2.5 cm retromastoid craniectomy without closed-suction drainage (no-drainage group).
Eleven (7.0%) patients experienced CSF leakage following MVD based on the criteria of this study; all of these patients were in the drainage group. In the unadjusted analyses, the incidence of CSF leakage was significantly related with the use of closed-suction drainage following MVD (12.0% in the drainage group vs. 0% in the no-drainage group, respectively; p=0.003; Fisher's exact test). Those who received dural substitutes and the elderly (cut-off value=60 years) exhibited a tendency to develop CSF leakage (p=0.075 and p=0.090, respectively; Fisher's exact test). In the multivariate analysis, only the use of closed-suction drainage was significantly and independently associated with the development of CSF leakage following MVD (odds ratio=9.900; 95% confidence interval, 1.418 to infinity; p=0.017).
The use of closed-suction drainage following MVD appears to be related to the development of CSF leakage.
PMCID: PMC3809436  PMID: 24175025
Microvascular decompression; Cerebrospinal fluid leakage; Closed-suction drainage; Hemifacial spasm; Trigeminal neuralgia
22.  Unusual recurrence of trigeminal neuralgia after microvascular decompression by muscle interposal 
Patients with trigeminal neuralgia (TN) and persistent or recurrent facial pain after microvascular decompression (MVD) typically undergo less invasive procedures in the hope of providing pain relief. However, re-operation should be considered in selected patients.
Case Report
A 48-year-old woman presented with recurrent trigeminal neuralgia (TN) 3 years following microvascular decompression (MVD). The patient underwent brain magnetic resonance angiography (MRA), which did not reveal neurovascular compression; therefore surgical re-exploration was carried out. During the operation, the fifth cranial nerve was seen without impingement from any blood vessels; however, a very firm tissue was observed and identified as the muscle fragment from the previous MVD procedure. The fifth cranial nerve was carefully separated from the muscle. Thereafter, the right SCA was dissected out from the muscle and suspended by a periosteum tape sutured to the nearby dura.
Our findings, along with similar cases reported in the literature, support the development of new inert materials and alternative surgical strategies that can limit TN recurrence.
PMCID: PMC3539511  PMID: 21455112
trigeminal neuralgia; microvascular decompression; recurrence
23.  Technical Modifications of Suboccipital Craniectomy for Prevention of Postoperative Headache 
Skull Base  2004;14(2):77-84.
A retrospective review of 53 consecutive patients who underwent a retrosigmoid vestibular nerve section (VNS) or microvascular decompression (MVD) through a modified suboccipital craniectomy with a minimum follow-up of 2 years was performed. Technical modifications to the suboccipital craniectomy included a skin incision designed to avoid the lesser and greater occipital nerves; a small, 2-cm diameter craniectomy with no intradural drilling of bone; and a simplified closure to prevent muscle adhesion to dura without the need for cranioplasty. The presence, duration, and severity of postoperative headache were the primary outcome measures. Craniectomy-related complications, operative time, and length of hospital stay were also reviewed. The incidence of postoperative headache after suboccipital craniectomy was 7.5% at 3 months (4/53), 3.8% at 1 year (2/53), and 3.8% at 2 years (2/53). Complications related to craniectomy included cerebrospinal fluid leakage (5.7%), aseptic meningitis (1.9%), and superficial wound infection (1.9%). The mean operative time was 145 and 98 minutes for VNS and MVD, respectively. The mean hospital stay was 2.2 and 3.6 days for VNS and MVD, respectively. Technical modifications of suboccipital craniectomy during retrosigmoid VNS and MVD lowered the incidence of postoperative headache and craniectomy-related complications and had no adverse effect on operative time or length of hospital stay.
PMCID: PMC1151675  PMID: 16145588
Suboccipital craniectomy; vestibular nerve; microvascular decompression; headache
24.  Microvascular Decompression for Hemifacial Spasm Associated with Vertebrobasilar Artery 
Hemifacial spasm (HFS) is considered as a reversible pathophysiological condition mainly induced by continuous vascular compression of the facial nerve root exit zone (REZ) at the cerebellopontine angle. As an offending vessel, vertebrobasilar artery tends to compress much more heavily than others. The authors analyzed HFS caused by vertebrobasilar artery and described the relationships between microsurgical findings and clinical courses.
Out of 1,798 cases treated with microvascular decompression (MVD) from Jan. 1980 to Dec. 2004, the causative vessels were either vertebral artery or basilar artery in 87 patients. Seventy-nine patients were enrolled in this study. Preoperatively, computed tomography (CT) or brain magnetic resonance (MR) imaging with 3-dimentional short range MR technique was performed and CT was checked immediately or 2-3 days after anesthetic recovery. The authors retrospectively analyzed the clinical features, the compression patterns of the vessels at the time of surgery and treatment outcomes.
There were 47 were male and 32 female patients. HFS developed on the left side in 52 cases and on the right side in 27. The mean age of onset was 52.3 years (range 19-60) and the mean duration of symptoms was 10.7 years. Many patients (39 cases; 49.1%) had past history of hypertension. HFS caused only by the vertebral artery was 8 cases although most of the other cases were caused by vertebral artery (VA) in combination with its branching arteries. Most frequently, the VA and the posterior inferior cerebellar artery (PICA) were the simultaneous causative blood vessels comprising 32 cases (40.5%), and in 27 cases (34.2%) the VA and the anterior inferior cerebellar artery (AICA) were the offenders. Facial symptoms disappeared in 61 cases (77.2%) immediately after the operation and 68 cases (86.1%) showed good outcome after 6 months. Surgical outcome just after the operation was poor in whom the perforators arose from the offending vessels concurrently (p<0.05).
In case where the vertebral artery is a cause of HFS, commonly branching arteries associated with main arterial compression on facial REZ requires more definite treatment for proper decompression because of its relatively poor results compared to the condition caused by other vascular compressive origins.
PMCID: PMC2588300  PMID: 19096662
Hemifacial spasm; Vertebrobasilar artery
25.  Facial and Lower Cranial Neuropathies after Preoperative Embolization of Jugular Foramen Lesions with Ethylene Vinyl Alcohol 
To report three unique cases of cranial neuropathy after super-selective arterial embolization of jugular foramen vascular tumors with ethylene vinyl alcohol.
Study Design
Clinical capsule report
Three tertiary academic referral hospitals
Three patients who underwent superselective arterial embolization (SSE) of head and neck paragangliomas with ethylene vinyl alcohol are described. One individual was treated with primary SSE, while the remaining tumors were treated with preoperative SSE followed by surgical extirpation within 72 hours. All patients were found to have new cranial nerve deficits following SSE.
One patient with isolated complete cranial nerve VII palsy demonstrated no return of function. One individual experienced cranial nerve VII, X, and XII palsies and demonstrated partial recovery of function of the involved facial nerve after 19 months. One subject experienced ipsilateral cranial nerve X and XI palsies after SSE and recovered full function of the spinal accessory nerve within one week, but failed to demonstrate mobility of the ipsilateral true vocal fold.
We present the first report documenting facial and lower cranial neuropathies after super-selective embolization of head and neck paragangliomas with EVA. Although it is difficult to draw conclusions from this small number of cases, it is plausible that use of ethylene vinyl alcohol during SSE may result in a higher risk of permanent cranial neuropathy than the use of other well-established and more temporary agents. Knowledge of the arterial supply to the cranial nerves can help the clinician to choose the embolization agent that will provide maximal occlusion while minimizing the risk of complications.
PMCID: PMC3581607  PMID: 22801041

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