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.
http://www.chictr.org/ ChiCTR-TRC-11001504 Date of registration: 24 June, 2011.
The date the first patient was randomised: 30 September, 2011.
Hemifacial spasm; Microvascular decompression; Muscle relaxant; Succinylcholine; Vecuronium; Intraoperative monitoring; Lateral spread response
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.
Hemifacial spasm; Microvascular decompression; Delayed resolution
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
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.
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
Hemifacial spasm; Microvascular decompression; Root exit zone
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.
Abnormal muscle response; facial-motor evoked potential; hemifacial spasm; 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.
Hemifacial spasm; Microvascular decompression; Prognosis; Chronology
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.
facial nerve; hemifacial spasm; pulsed radiofrequency treatment
Microvascular decompression (MVD) for hemifacial spasm (HFS) is a safe and effective treatment with favorable outcomes. The purpose of this study was to evaluate the incidence of delayed cranirve ( VI, VII, and VIII ) palsy following MVD and its clinical courses.
Between January 1998 and December 2009, 1354 patients underwent MVD for HFS at our institution. Of them, 100 patients (7.4%) experienced delayed facial palsy (DFP), one developed sixth nerve palsy, and one patient had delayed hearing loss.
DFP occurred between postoperative day number 2 and 23 (average 11 days). Ninety-two patients (92%) completely recovered; however, House-Brackmann grade II facial weakness remained in eight other patients (8%). The time to recovery averaged 64 days (range, 16 days to 9 months). Delayed isolated sixth nerve palsy recovered spontaneously without any medical or surgical treatment after 8 weeks, while delayed hearing loss did not improve.
Delayed cranial nerve (VI, VII, and VIII) palsies can occur following uncomplicated MVD for HFS. DFP is not an unusual complication after MVD, and prognosis is fairly good. Delayed sixth nerve palsy and delayed hearing loss are extremely rare complications after MVD for HFS. We should consider the possibility of development of these complications during the follow up for MVD.
Delayed facial palsy; Microvascular decompression; Delayed cranial palsy; Delayed hearing loss; Delayed abducens palsy
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.
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.
Hemifacial spasm; Vertebrobasilar artery
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.
Pneumatocele; Posterior fossa surgery; Hemifaical spasm; Mastoid air cell
The present study was performed to determine whether the intraoperative monitoring of brainstem auditory evoked potentials (BAEPs) during microvascular decompression operations is effective in preventing profound hearing loss or deafness in the ipsilateral ear. The authors retrospectively compared the auditory morbidity of posterior fossa microvascular decompression surgery for the treatment of tic douloureux and hemifacial spasm before and after the introduction of routine intraoperative BAEP monitoring in 1984. Each patient underwent a similar procedure performed by the same surgeon. The two patient groups were comparable with regard to age, sex, and indications for surgery, Auditory morbidity did not decline with the increasing experience of the surgeon prior to 1984; 10 (6.6%) of 152 primary operations (151 patients) in which monitoring was not performed were followed by a profound ipsilateral hearing loss or deafness. In the monitored group, none of 109 operations (104 patients) caused profound hearing loss or deafness. This significant decline in auditory morbidity is attributed by the authors to the use of intraoperative BAEP monitoring, which allows the surgeon to alter the operation in response to degradations in the wave patterns. Based on our experience and that of others, we believe that intraoperative BAEP monitoring is of value in reducing the auditory morbidity of posterior fossa microvascular decompression surgery.
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.
Microvascular decompression; Hemifacial spasm; Elderly patients
Numerous medical and surgical therapies have been utilized to treat the symptoms of trigeminal neuralgia (TN). This retrospective study compares patients undergoing either microvascular decompression or balloon ablation of the trigeminal ganglion and determines which produces the best long-term outcomes.
A 10-year retrospective chart review was performed on patients who underwent microvascular decompression (MVD) or percutaneous balloon ablation (BA) surgery for TN. Demographic data, intraoperative variables, length of hospitalization and symptom improvement were assessed along with complications and recurrences of symptoms after surgery. Appropriate statistical comparisons were utilized to assess differences between the two surgical techniques.
MVD patients were younger but were otherwise similar to BA patients. Intraoperatively, twice as many BA patients developed bradycardia compared to MVD patients. 75% of BA patients with bradycardia had an improvement of symptoms. Hospital stay was shorter in BA patients but overall improvement of symptoms was better with MVD. Postoperative complication rates were similar (21% vs 26%) between the BA and MVD groups.
MVD produced better overall outcomes compared to BA and may be the procedure of choice for surgery to treat TN.
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.
Microvascular decompression; Hemifacial spasm; Vertebrobasilar dolichoectasia
Although the mechanism of hemifacial spasm (HFS) is not yet well established, vascular compression of the facial nerve root exit zone and hyperexcitability of the facial nucleus have been suggested. We report a case of HFS in the setting of coinciding intracranial hemorrhage (ICH) of the pons and proximal ligation of the contralateral vertebral artery (VA) for the treatment of a fusiform aneurysm of the distal VA and discuss the possible etiologies of HFS in this patient. A 51-year-old male with an ICH of the pons was admitted to our hospital. Neuroimaging studies revealed an incidental fusiform aneurysm of the right VA distal to the origin of the posterior inferior cerebellar artery. Eight months after proximal ligation of the VA the patient presented with intermittent spasm of the left side of his face. Pre- and post-ligation magnetic resonance angiography revealed an enlarged diameter of the VA. The spasm completely disappeared after microvascular decompression.
Hemifacial spasm; Vertebral artery; Ligation; Aneurysm; Decompression; Hemodynamics
Hemifacial spasm is an uncommon disorder manifesting as a unilateral, involuntary, sporadic contraction of the musculature innervated by the seventh cranial nerve. Although debated, the etiology of hemifacial spasm is generally accepted as compression of the facial nerve by vessels of the posterior circulation. Early surgical techniques were ineffective and fraught with morbidity. Over the past 25 years microvascular decompression surgery has allowed the safe and effective treatment of hemifacial spasm. Recent reports combining microsurgical and endoscopic techniques have documented the advantages of the endoscope in exposing the anatomy of this region. Enhanced visualization allows a less traumatic dissection and increases the surgeon's ability to locate nerve-vessel conflicts often difficult to identify through the limited view of the microscope. This article reviews the history of hemifacial spasm and describes the first three cases of fully endoscopic vascular decompression for hemifacial spasm, emphasizing the advantages of this novel surgical approach.
Endoscopy; hemifacial spasm; vascular decompression
We conducted a study to evaluate the follow-up characteristics of patients with trigeminal neuralgia (TN) and to evaluate the factors affecting long-term outcome of microvascular decompression (MVD) in TN. Between 1983 and 2003, 156 patients with TN treated with MVD by 4 neurosurgeons at University Medical Centre Groningen/the Netherlands were evaluated. Baseline data from operative outcome were evaluated using univariate and multivariate analysis. The group consisted of 156 patients with TN: 90 females and 66 males with a median follow-up period of 9.7 years. The average age of initial symptoms was 51 years. The average duration of symptoms was 58 months. Postoperative 22 patients had a facial hyperpathia or hyperesthesia. Postoperatively, 137 patients had immediate relief. Postoperatively 1 year, 140 patients still had a good outcome of the operation. Twenty-seven patients with good immediate postoperative results had recurrent pain. From the group of patients with typical TN, 82% had good long-term results after operation. Patients with typical TN and immediate postoperative remission, in univariate analysis, had significantly more often an excellent/good postoperative outcome. Immediate postoperative remission is an independent predictive factor for a good long-term outcome. The long-term results of MVD in majority of patients were good with no mortalities and no major morbidities. Patients with typical TN had better long-term outcomes and less recurrence.
Microvascular decompression; trigeminal neuralgia; typical trigeminal neuralgia; Jannetta; long-term follow-up
Vascular cross-compression of cranial nerves has been proposed as the cause of cranial neuropathies, including trigeminal neuralgia and hemifacial spasm. Over the last decade we have used microsurgical vascular decompression to treat these two disorders. Results in 50 patients treated for trigeminal neuralgia have been excellent in 42, good in 5 and poor in 2; and 1 patient was cured after a second operation. Results in 22 patients treated for hemifacial spasm have been excellent in 18, good in 2 and fair in 1. One patient died. There were no late recurrences of symptoms.
The pathophysiological mechanisms of trigeminal neuralgia and hemifacial spasm remain unknown.
The aim of this prospective study was to demonstrate the influence of some factors on the prognosis of microvascular decompression in 37 patients with trigeminal neuralgia.
The results of microvascular decompression (MVD) in 37 patients with trigeminal neuralgia were evaluated at 6 months after surgery and were compared with clinical and operative findings.
The sex of the patient, the patient's age at surgery, the side of the pain, and the duration of symptoms before surgery did not play any significant roles in prognosis. Also, the visual analogue scale (VAS) of the patient, the duration of each pain attack, and the frequency of pain over 24 hours did not play any significant roles in prognosis. In addition, intraoperative detection of the type of conflicting vessel, the degree of severity of conflict, and the location of the conflict around the circumference of the root did not play any roles in prognosis. The only factors affecting the prognosis in MVD surgery were intraoperative detection of the site of the conflict along the root and neuroradiological compression signs on preoperative magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA).
These findings demonstrated that if neurovascular compression is seen on preoperative MRI/MRA and/or compression is found intraoperative at the root entry zone, then the patient will most likely benefit from MVD surgery.
Cranial nerve vascular compression syndromes; Microvascular decompression; Prognosis; Trigeminal neuralgia
We report a rare case of a ruptured de novo dissecting aneurysm induced by ethyl 2-cyano-acrylate. A 39-year-old woman underwent microvascular decompression for left hemifacial spasm. The offending vessel was left posterior inferior cerebellar artery (PICA). Left vertebral artery (VA) was mobilized and affixed to the dura mater with cyanoacrylate to remove pressure of PICA to the root exit zone of the facial nerve. The left VA was found to be intact at the time of the operation.
One year later, the patient sufferd subarachnoid haemorrhage (SAH) caused by rupture of a newly-developed dissecting aneurysm of the left VA. Endovascular occlusion of the dissecting site was performed using Guglielmi detachable coils. We suppose mechanical injury and chemical reaction of ethyl 2-cyanoacrylate induced dissecting aneurysm.
cyanoacrylate, microvascular decompression, cerebral aneurysm
Trigeminal neuralgia is most commonly caused by vascular compression at the trigeminal nerve (TN) root entry zone. Microvascular decompression (MVD) has been established as a useful treatment. Outcome depends on the correct identification of the compression site and its adequate decompression at surgery. Preoperative identification of neurovascular compression might predict which patients will benefit from MVD. Management of persistent or recurrent trigeminal neuralgia after an MVD is a baffling problem for neurosurgeons. An accurate neuroradiological evaluation of the TN padding following a failed MVD might help identify the underlying cause and plan further treatment.
A 68-year-old female presented with a right-sided trigeminal neuralgia (V3) refractory to medical therapy. A high-resolution three-dimensional magnetic resonance imaging (3D MRI) study included fast imaging employing steady-state acquisition (FIESTA) and time of flight multiple overlapping thin slab acquisition (TOF MOTSA) sequences to evaluate the neurovascular anatomy in the cerebellopontine angle. An unambiguous compression of the right TN at the rostral-medial site by the superior cerebellar artery (SCA) was identified. The SCA loop compressing the TN was identical in location and configuration to that predicted in the preoperative study. After the MVD, the patient was relieved from her pain and a postoperative high-resolution 3D MRI study confirmed the appropriate placement of the Teflon implant between the TN and SCA.
To our knowledge, this is the first report that characterizes the proper TN padding by high-resolution 3D MRI after trigeminal MVD. The present case also emphasizes the importance of performing a 3D MRI in patients with trigeminal neuralgia to anticipate the surgeon's view and predict the outcome after MVD.
Fast imaging employing steady-state acquisition; three-dimensional magnetic resonance angiography; three-dimensional magnetic resonance imaging; time of flight multiple overlapping thin slab acquisition; trigeminal neuralgia
To determine if the involuntary contractions of eyelids may have any effects on the development of corneal astigmatism, we performed this prospective study which includes 19 patients with either essential blepharospasm or hemifacial spasm. In hemifacial spasm, the degree of corneal astigmatism was evaluated between two eyes. Then the topographic changes were checked using vector analysis technique before and after passively opening the eyelids. They were also measured before and at 1 and 6 months after the injection of Botulinum toxin. Resultantly, 20 eyes had the with-the-rule (group1) and 9 eyes against-the-rule (group2) astigmatism. In hemifacial spasm, significantly more astigmatism was found at spastic eyes. The corneal topographic changes after passively opening the eyelids showed 10 eyes with the astigmatic shift to the with-the-rule, while the remaining 19 to the against-the-rule. At 1 month after injection of Botulinum toxin, group 1 showed reduced average corneal astigmatism, whereas group 2 showed increased astigmatism. The astigmatic change vector showed significantly more against-the-rule. In the contrary, 6 months after treatment, corneal astigmatism again increased in group 1 and decreased in group 2. So they took on the appearance of pretreatment astigmatic status eventually. Conclusively eyelids may play an important role in corneal curvature.
Astigmatism; Blepharospasm; Botulinum Toxin Type A; Corneal Topography; Eyelids
Although the rhomboid lip is a well-known structure constructing the foramen of Luschka, less attention has been directed to the structure for posterior fossa microsurgeries. The authors report two cases of the hemifacial spasm (HFS) with a large rhomboid lip, focusing on the importance of the structure during microvascular decompression.
A 59-year-old female presenting with left HFS was admitted to our hospital. A preoperative magnetic resonance image demonstrated an offending artery at the root exit zone of the VII nerve. The patient underwent microvascular decompression through the lateral suboccipital approach. The intraoperative findings showed that a large rhomboid lip adhered to the IX and X cranial nerves and prevented the exposure of the root exit zone of the VII cranial nerve. The rhomboid lip was meticulously separated from the cranial nerves so that the choroid plexus of the foramen of Luschka and the rhomboid lip could be safely lifted with a spatula, and the offending artery was successfully detached from the root exit zone. In another case of a 60-year-old male, the rhomboid lip was so large that it needed to be incised before separating it from the lower cranial nerves. In each case, the HFS was resolved following surgery without any new deficits.
The large rhomboid lip adhering to the cranial nerves should be given more attention in the posterior fossa surgeries and should be managed based on the microsurgical anatomy for preventing unexpected lower cranial nerve deficit.
Hemifacial spasm; infrafloccular approach; microvascular decompression; rhomboid lip