Cases Of Hemifacial Spasm Research Articles

Two Cases of Hemifacial Spasm Completely Recovered after Repeated BTX-A Treatment

Hemifacial Spasm (HSF) refers to the intermittently involuntary clonic twitch or painless rigidity of one or two sides of facial muscles. Patients with hemifacial spasm generally have a decline in quality of life, accompanied by anxiety, depression and other emotional problems, which further aggravate hemifacial spasm symptoms. BTX-A injection is the first choice for treatment of HFS, which can not only relief the symptoms of HFS but also improve the mood problems. There have been no reported cases of HFS cured by drugs or BTX-A. Here we reported two HFS patients recovered after multiple BTX-A treatments without recurrence for 3-8 years, which might provide a clue for further exploration of the pathogenesis of HFS.

Spasmes hémifaciaux. Étiologies et conduite à tenir

Hemifacial spasm (HFS) is an involuntary contracture of the facial muscles innervated by the ipsilateral facial nerve. We studied the etiology of these HFS. This retrospective study included 233 patients with HFS who came to the ophthalmologist for quarterly botulinum neurotoxin A injection. Of these, we analyzed the 198 patients for whom MRI scans were performed. We recorded patient clinical data and clarified the etiology of their HFS. The 198 patients (62.6% women) had a mean age of 55.7±14years. An etiology was found in 52.5% of cases. In 34.5% of HFS, MRI revealed vascular compression where the facial nerve emerged from the brainstem. We specify the arteries involved. Brain tumors accounted for 1.5% of cases. MRI was normal in 64.5% of cases. In these secondary cases of HFS, we found 8.5% peripheral facial palsy, 4% post-traumatic HFS and 4% secondary to an eye injury. Stress was found in 17% of patients. This study illustrates the need for MRI with attention to the posterior fossa in the work-up of HFS in order to identify primary HFS associated with vascular compression of the facial nerve and to rule out a rare but serious posterior fossa tumor. The treatment of HFS is based on quarterly injections of botulinum neurotoxin/A (NTBo/A), the three brands of which have market approval. The injection pattern and frequency is customized according to the results. In cases of insufficient response to injections of NTBo/A, neurosurgical microvascular decompression may be considered for cases of primary HFS.

Microvascular decompression for hemifacial spasm: a review of twenty-one operated cases

BackgroundMicrovascular decompression of facial nerve provides definitive and long-term cure for hemifacial spasm. We review our experience of treating hemifacial spasm by microvascular decompression.ObjectivesTo evaluate the results of microvascular decompression of facial nerve for hemifacial spasm and to discuss the critical steps during surgery necessary to achieve a good result.Patients and methodsTwenty-one cases of hemifacial spasm operated by the author were analysed. All the patients underwent microvascular decompression of the facial nerve by the retromastoid approach. Preoperative and postoperative videos of the patients were made with their consent. Patient outcome and complications were analysed.ResultsTwenty patients had complete resolution of the spasm after surgery. The second operated patient had facial palsy with hearing loss in the immediate postoperative period and recurrence of the spasm after 6 months of surgery. Postoperative mild transient facial weakness in one patient, mild sensory-neural hearing loss in two, delayed facial palsy which resolved completely in two patients, transient facial twitching which responded to carbamazepine in one and paradoxical CSF rhinorrhea treated successfully by lumbar drainage in one patient were the complications noted.ConclusionHemifacial spasm is best treated by surgery, and our results compare favourably with those in the existing literature. Sensorineural hearing loss and facial nerve palsy are the main complications to be expected during the learning curve.

Mechanism underlying cranial nerve rhizopathy

The cranial nerve rhizophathy, commonly presented with trigeminal neuralgia (TN) or hemifacial spasm (HFS), is a sort of hyperexcitability disorders with higher incidence in senior Asian. In this paper, a novel hypothesis on the pathogenesis is proposed and with which some clinical phenomena are explained.In those with crowded cerebellopontine angle in anatomy, the cranial nerve root and surrounding vessel are getting closer and closer to each other with aging and finally the neurovascular conflict happens. As the interfacial friction associated with pulse, the nerve incurs demyelination. Since this pathological change develops to a certain degree, some transmembrane proteins emerge from the nerve due to a series of signaling pathway mediated by inflammatory cytokines. Among them, voltage-gated (Nav1.3) and mechanosensitive (Piezo2) ion channels may play the important role. With pulsatile compressions, the Piezo2 drives the resting potential toward depolarization forming a state of subthreshold membrane potential oscillation. Under this condition, just an appropriate pressure can make the membrane potential easy to reach threshold and activate the sodium channel, eventually generating conductible action potentials from the axon. When these ectopic action potentials propagate to the central nerve system, an illusion of sharp pain is perceived; while to the nerve-muscle junctions, an attack of irregular muscle constriction occurs.This hypothesis can well explain the symptomatic manifestation of paroxysmal attacks aroused by emotions. When we get nervous or excited, our heart rate and blood pressure alter correspondingly, which may give rise to “a just right pressure” – with specific frequency, amplitude and angle – impacting the suffered nerve to reach the threshold of impulse ignition. After a successful microvascular decompression surgery, the trigger is gone (there is no compression anymore) and the symptom is alleviated. While the postoperative recurrence could be attributable to Teflon granuloma development if had been placed improperly – for this nerve root has been susceptible no matter to arteries or to neoplasms. Besides, it may illustrate the clinical phenomenon that secondary TN or HFS cases are seldom caused by schwannoma: with a proliferative sheath, the nerve root is actually insulated. By contrast, not all neurovascular contacts can lead to the onset: it demands an exclusive extent of demyelination firstly.

Ptosis following botulinum toxin injection in hemifacial spasm

Hemifacial spasm (HFS) is characterized by irregular involuntary tonic or clonic contractions of muscles innervated by the seventh cranial nerve. Patients usually need long-term treatment, as spontaneous remission is infrequent. Repeated botulinum toxin injection has been shown as a safe and successful treatment for symptomatic relief in patients with HFS.1 Side effects are usually mild and transient. Ptosis has been reported in about 24% of patients with HFS probably due to diffusion of toxin to levator palpebrae superioris muscle.2 However, the frequency of ptosis in patients with HFS has not been addressed yet, due to causes other than botulinum toxin side effect. Herein, we present a case of HFS who presented to our clinic with complaint of complete ptosis and progressive pain early after botulinum toxin injection. Despite initial negative evaluations, further work up revealed a compressive lesion. A 75-year-old man presented with left severe ptosis since 3 weeks ago (Figure 1). He was known case of left HFS since 4 years ago, and botulinum toxin had been regularly injected for his symptom relief in orbicularis oculi, corrugator, and procerus muscles. Figure 1. Left Blepharoptosis one week after botulinum toxin injection The patient stated that this new ptosis had begun within a week after his last Dysport (Ipsen, Ltd., Slough, Berkshire, UK) injection while he had no ptosis in his previous injections. In past medical history, he had ischemic heart disease, hypertension, cataract extraction of both eyes, and glaucoma surgery on his right eye. He had been admitted to the neurology ward of a general hospital.

Consensus of the Iberoamerican Oculoplastic Society for diagnosis and management of facial dystonia

Abstract Objective To propose guidelines for the diagnosis and treatment of facial dystonia prepared by a group of experts in orbit and oculoplastics from the Iberoamerican Oculoplastic Society. Material and methods An interactive discussion between the expert panel and those attending the 6th Iberoamerican Society of Oculoplastics Congress, which took place at the Hospital Nuestra Senora de la Luz in Mexico City on 22 October 2018, providing their personal experience based on evidence for diagnosis and treatment of facial dystonia. Around 200 ophthalmologists specialized in oculoplastics from North, Central and South America, Spain, and Portugal were involved. Discussion was focused on the following themes: pathophysiology, diagnosis, medical management, and surgical management. Conclusions Facial dystonia diagnosis is clinical; therefore, image studies are rarely needed. The ophthalmologist is generally the first physician to be consulted, and is able to be the treating physician, with the exception of specific cases of hemifacial spasm where management with neurosurgery may be beneficial. Botulinum toxin is the treatment of choice. Treatment with oral neuroleptics and myectomy of the orbicularis oculi muscle are reserved for refractory cases, since these do not have an adequate clinical response as first choice treatments. Persistent use of botulinum toxin does not modify the natural course of the disease.

Ameliorating Effect of Microvascular Decompression on Patients with Coexistence of Hemifacial Spasm and Glossopharyngeal Neuralgia: A Retrospective Study

Microvascular decompression (MVD) has been widely accepted for treating hemifacial spasm (HFS) and glossopharyngeal neuralgia (GN); an effective surgical treatment of coexistent HFS and GN still remains to be determined, however. In this paper we discuss the operative strategy of MVD for patients with coexistent HFS and GN. This was a retrospective study. All cases of HFS with or without GN at China-Japan Friendship Hospital from January 2014 to June 2016 have been included. All patients underwent MVD and have been followed up for an average of 1.5 years. A total of 5375 cases of HFS were included, wherein 8 cases coexist with GN. Eight patients had same offending vessel(s) compressing the root entry zone of glossopharyngeal nerve and facial nerve. Posterior inferior cerebellar artery was identified as at least 1 of the offending arteries in all 8 patients. After MVD, spasm ceased in all 8 cases, with 7 cases ceasing immediately and 1 within 2 months. Pain disappeared also in all cases, with 7 cases immediately and 1 case after 4 days. No recurrence or complication was observed during the follow-ups. HFS combined with ipsilateral GN was rare. MVD could be performed to effectively relieve nerve root compression and associated symptoms for coexistent HFS and GN. Sufficient exposure of root entry zones of both nerves and fully decompression of offending blood vessels and exploratory sequences of different nerve roots are critical points for improving operative effect and reducing complications.

Wedge-technique for transposition of the vertebral artery in microvascular decompression for hemifacial spasm: technical nuances and surgical outcomes.

Transposition of the vertebral artery (VA) for microvascular decompression for hemifacial spasm (HFS) is often challenging. Various procedures have been proposed to transpose the immobile tortuous VA that cannot be decompressed satisfactorily in the usual manner. A Teflon piece that is cut into a wedge shape was used for transposition of the VA as an offending artery in HFS. One or more wedge-shaped Teflon pieces were simply inserted into a small space between the VA and the brainstem or cerebellar hemisphere without any contact with the entry into the root exit zone (REZ) of the facial nerve. A minimal space can be created by slight mobilization of the VA through rostral or caudal, or in between to the lower cranial nerves (LCNs). In cases of a hypertrophic VA that is hard to mobilize, two or more rigid wedge-shaped Teflon pieces that are coated by fibrin glue can be applied to obtain adequate mobilization of the VA. Moreover, a much harder Teflon bar, which is bent into a V shape, can be used in cases of an immobile VA. Once the VA is transposed to an appropriate position, the Teflon, VA, and contacted surface of the brainstem are fixed together by drops of fibrin glue. The offending arteries were VA-posterior inferior cerebellar artery (PICA) in eight cases, VA in four cases, PICA in four cases, VA-anterior inferior cerebellar artery (AICA) in one case, and AICA in one case. Eighteen cases of HFS were successfully treated using the "Wedge technique." Symptoms disappeared within 2weeks in all patients. Transient facial nerve palsy developed in one case, and transient hoarseness developed in one case. The wedge technique is a simple straight-line maneuver that facilitates sufficient transposition of the VA without any related complications. This technique is also useful for other large offending vessels, such as the anterior or posterior inferior cerebellar arteries, which are hard to mobilize due to the torque of the vessels.

Surgical Treatment of Secondary Hemifacial Spasm: Long-Term Follow-Up

Hemifacial spasm (HFS) is generally caused by the root exit zone of the facial nerve compressed by an overlying arterial loop. HFS can also be caused by various types of tumor, aneurysm, or arteriovenous malformation. We retrospectively analyzed patients to evaluate possible differences in the demographic and clinical features between primary and secondary HFS. A retrospective study of 3140 cases of HFS treated in our department between January 2009 and June 2016. Among the 3140 total cases, 26 patients had secondary HFS. The 26 tumors of secondary HFS included 11 meningiomas, 8 epidermoid cysts, and 7 vestibular schwannomas. Compared to those with idiopathic HFS, those patients with tumor-induced HFS were significantly younger (P < 0.05). Secondary HFS tended to have responsible vessels, and were observed in 20 (76.92%) of these 26 patients. The long-term effective rate of operation was 84% in the secondary HFS group and was 96.45% in the primary HFS group (P < 0.05); the incidence rate of complication was 12% in the secondary HFS group and was 3.06% in the primary HFS group (P < 0.05). In cases of secondary HFS, facial nerves of most patients were compressed by blood vessels, so microvascular decompression after tumor resection plays an important role. We should examine the entire nerve root for possible vascular compression.

Hemifacial Spasm as Rare Clinical Presentation of Vestibular Schwannomas

Although classical hemifacial spasm (HFS) has been attributed to an atraumatic pulsatile vascular compression around the root exit zone (REZ) of the facial nerve, rare tumor-related HFS associated with meningiomas, epidermoid tumors, lipomas, and schwannomas in the cerebellopontine angle have been reported. The exact mechanism and the necessity of microvascular decompression for tumor-induced HFS is not clear, especially for vestibular schwannomas. We retrospectively analyzed 10 patients with vestibular schwannomas out of 5218 cases of hemifacial spasm between 2004 and2014. Hemifacial spasm occurred ipsilateral to the vestibular schwannoma in 9 patients and contralateral to the lesion in 1 patient. The mean follow-up period was 86 months (range, 22-140 months). All patients underwent surgery for resection of the vestibular schwannoma. Following the principle of neurovascular compression, offending vessels were found in 7 patients, no offending vessels in 2 patients, and a tumor with the displacement of brain stem contributing to contralateral facial nerve compression in 1 patient. HFS was relieved immediately postoperatively in 9 patients, whereas it improved gradually and then resolved after one month in one patient with a contralateral vestibular schwannoma. For HFS induced by vestibular schwannomas in our study, the majority of cases are caused by a combination of tumor and vascular co-compression at the REZ. Surgical intervention resulted in resolution of symptoms. For HFS with ipsilateral vestibular schwannoma, exploration of the facial nerve root for vascular compression should be performed routinely after tumor resection. It is critical to check that no vessel is contact with the entire nerve root.

Safety and effectiveness of microvascular decompression for treatment of hemifacial spasm through mini craniotomy

Abstract Background: The hemifacial spasm (HFS) defined as involuntary intermittent twitching of the muscles of the face (usually unilateral). The spasms characteristically begin around the eye and then extend to affect other muscles of the ipsilateral face. It is caused by vascular element compressing the facial nerve that may be either the anterior or the posterior inferior cerebellar arteries in most cases. Objective of our work: to describe the operative technique (pearls and common mistakes), the efficacy and morbidity of microvascular decompression technique for hemifacial spasm through mini craniotomy, determine the prognostic factors affecting success rate of the surgery. Material &amp; method: A retrospective study of 23 cases of hemifacial spasm treated by mini craniotomy retro sigmoid approach and microvascular decompression at neurosurgery dept., Mansoura University Hospital in last 10 years was investigated. This include Epidemiological, clinical and imaging details, selected treatment options and patients’ outcome. Results: complete resolving of symptoms was conducted in 19 cases 82.6% while reoperated in 2 cases with improvement in one case. Facial palsy appeared postoperative in 6 cases 4 of them improved in 3 months, transient hearing loss in 4 cases17.4% which improved later, cerebrospinal fluid leak appeared in 3 cases 13% which managed conservatively. Conclusions: MVD relieves symptoms of HFS in about 80% of patients while recurrence still in low percentage. The study reported low permanent Complications and generally transient.

Application of the supine position in microsurgery for lesions of the cerebellopontine angle

Objective: To validate the usefulness of the supine position in microsurgery for lesions of the cerebellopontine angle (CPA) by the retrosigmoid approach. Methods: Thirty-nine patients with lesions (22 cases of tumor, 11 cases of trigeminal neuralgia and 6 cases of hemifacial spasm) of the CPA underwent tumor resection surgery or microvascular decompression surgery (MVDS). The patients were operated on in the supine position by retrosigmoid approach with the head turned 50 to 60 degrees away from the lesion and with slight forward flexion of the neck. Results: In the supine position, the surgery spent less time in the preoperative preparation period, and had minimal cerebellar retraction, with no resection of the cerebellum. There was no pressure sore and the brachial plexus injury in these patients. Gross total resection was achieved in 18 of patients, and subtotal resection happened in 4 patients. The vascular structures were separated from the trigeminal nerve or the facial nerve in microvascular decompression and thus the preoperative symptoms alleviated. Conclusions: In the supine position, the retrosigmoid approach alleviates cerebellar retraction, increases the exposure and gives better access to the CPA lesions. The associated postoperative complications are negligible. The method is more suitable for elder, debilitated or obese patients.

Fully neuroendoscopic microvascular decompression for the treatment of trigeminal neuralgia and hemifacial spasm

Objective To explore the safety and efficacy of the treatment of trigeminal neuralgia and hemifacial spasm via fully neuroendoscopic microvascular decompression (MVD). Methods The clinical data of 32 patients underwent fully neuroendoscopic MVD during the period from November 2014 to June 2016 and were enrolled into this retrospective study. Among them, 11 cases were trigeminal neuralgia (TN) and 21 cases were hemifacial spasm (HFS). Results The offending vessels were identified under endoscope in all cases. Among them, arterial compression was found in 28 cases, venous compression in 1 case, and both arterial and venous compression in 3 cases. In all 11 cases of trigeminal neuralgia, the symptom disappeared in 10 cases and was relieved in 1 case post surgery. Facial numbness occurred in 2 cases. In all 21 cases of hemifacial spasm, 20 cases obtained complete symptomatic relief and 1 case gained partial relief postoperatively. There was 1 case of hearing impairment and 1 case of mild facial paralysis reported post operation. No severe complications or death occurred. All cases were followed up for 6-24 months with a median period of 10.0±2.3 months. During the follow-up periods, none of the cases reported recurrence or aggravation. Conclusion Fully neuroendoscopic MVD, applied to treatment of TN and HFS, could help facilitate clear exposure of small vessels, avoid missing the offending vessels and reduce retraction of the cerebellum. Fully endoscopic MVD seems to be a safe and effective procedure and warrants further study and exploration. Key words: Microvascular decompression surgery; Neuroendoscopy; Neurosurgical procedures; Trigeminal neuralgia; Hemifacial spasm

The Effects of Combined Intraoperative Monitoring of Abnormal Muscle Response and Z-L Response for Hemifacial Spasm.

Microvascular decompression (MVD) is the most effective treatment for hemifacial spasm (HFS). During MVD surgery, abnormal muscle response (AMR) is widely used. Z-L response (ZLR) is a new monitoring method for HFS. We compared the effectiveness of AMR plus ZLR and simple AMR. In a retrospective study of 1868 cases of HFS treated using intraoperative monitoring between January 2013 and December 2015, 896 patients underwent simple AMR monitoring and 972 underwent combined intraoperative monitoring of AMR and ZLR. AMR waveforms were observed in 837 (93.42%) patients in the AMR group and in 898 (92.39%) patients in the AMR plus ZLR group (P > 0.05). During MVD, AMR waveforms disappeared in 772 patients in the AMR group and 854 patients in the AMR plus ZLR group (P < 0.05). The efficacy rate of MVD in the AMR plus ZLR group was higher compared with the AMR group when AMR was not detected or disappeared during the operation (P < 0.05). When AMR persisted during the operation, there was no significant difference between the 2 groups in efficacy of the operation (P > 0.05). Regardless of whether the compression vessels of the facial nerve are simple or complicated, combined intraoperative monitoring of AMR plus ZLR monitoring provides more valuable neurosurgical guidance than simple AMR during MVD for HFS.

Microvascular decompression for hemifacial spasm associated with the vertebral artery.

The aim of this study was to discuss the baseline characteristics of hemifacial spasm (HFS) associated with the vertebral artery (VA) and evaluate microvascular decompression (MVD) as a surgical treatment of the associated HFS. From February 2010 to February 2015, 118 consecutive patients with HFS underwent MVD. Of these, 29 cases of HFS were associated with VA, this series was compared with the remaining non-VA-associated HFS. Of the 29 cases of VA-associated HFS, the VA was directly compressing the root exit zone (REZ) in eight cases. In the other 21 cases, the VA contacted REZ indirectly via its branches. The symptoms were completely relieved in 26 cases (89.7%) and partially relieved in another two cases (6.9%). Between the VA-associated group and non-VA-associated group, no statistically significant difference existed in the surgical results. VA-associated HFS is not a rare condition. For all cases of VA-associated HFS, indirect compression due to VA was more common. MVD for VA-associated HFS still can achieve good results.

The Effects of Dual Abnormal Muscle Response Monitoring on Microvascular Decompression in Patients with Hemifacial Spasm.

Microvascular decompression (MVD) is the most useful treatment for hemifacial spasm (HFS). During MVD surgery, traditional abnormal muscle response (tAMR) is widely used to monitor success in decompressing the facial nerve. Dual AMR (dAMR) is a new monitoring method used during MVD for HFS. We compared the sensitivities and reliabilities of tAMR and dAMR. We performed a retrospective study of 1301 cases of HFS treated using MVD between January 2014 and March 2016. Among the 1301 cases, 587 patients underwent tAMR monitoring and 714 underwent dAMR monitoring. Typical abnormal muscle response (AMR) waveforms were observed in 484 patients (82.5%) in the tAMR group and in 688 patients (96.4%) in the dAMR group (P < 0.05). AMR waveforms disappeared in 459 patients in the tAMR group and in 655 patients in the dAMR group during MVD. One day, 7 days, 1 month, and 3 months after MVD surgeries with AMR disappearance, the effective rate of MVD was 95.0%, 94.3%, 94.5%, and 95.0%, respectively, in the tAMR group. The corresponding rates were 97.7%, 96.9%, 97.3%, and 98.0% in the dAMR group (P < 0.05). One day, 7 days, 1 month, and 3 months after MVD surgeries with AMR persistence, the effective rate of MVD was 68.0%, 64.0%, 64.0%, and 64.0%, respectively, in the tAMR group. The corresponding rates were 90.9%, 87.9%, 87.9%, and 90.9% in the dAMR group (P < 0.05). AMR monitoring provides valuable neurosurgical guidance during MVD for HFS. dAMR monitoring has better sensitivity and reliability than tAMR monitoring.

Hemifacial Spasm From Lyme Disease: Antibiotic Treatment Points to the Cause.

A wide range of etiologies can cause hemifacial spasm (HFS), including infection. In this case report, a 44-year-old woman developed HFS and was explored surgically 7 years later. No abnormalities were found. Afterward, treatment of a surgical wound infection with an oral cephalosporin resulted in a temporary HFS remission that had never occurred previously. This antibiotic experience prompted further workup for an underlying infection, which ultimately led to diagnosis of Lyme disease. Presentation of HFS due to Lyme disease has not been reported. Because its diagnosis can be occult and antibiotic therapy can be both diagnostic and therapeutic, Lyme disease should be a consideration for cases of HFS.

Teflon Might Be a Factor Accounting for a Failed Microvascular Decompression in Hemifacial Spasm: A Technical Note

Background: Although Teflon is widely adopted for microvascular decompression (MVD) surgery, it has never been addressed for failure analysis. This study analyzed the reasons for failed MVDs with emphasis on the Teflon sponge. Methods: Among the 685 hemifacial spasm cases between 2010 and 2014, 31 were reoperated on within a week because of unsatisfactory outcome, which was focused on in this study. Intraoperative findings regarding Teflon inserts of these repeat MVDs were reviewed. Results: Among the 38 without satisfactory outcomes, 31 underwent repeat MVDs, and they were all spasm free afterwards. Eventually, the final cure rate was 99.2%. It was found in the repeat MVDs that the failure was attributable to the Teflon insert in most of the cases (74.2%) directly or indirectly. It was caused by improper placement (47.8%), inappropriate size (34.8%) and unsuitable shape (17.4%) of the Teflon sponge. Conclusion: Although it is not difficult for an experienced neurosurgeon to discover a neurovascular conflict during the MVD process, the size, shape and location of the Teflon sponge should not be ignored. Basically, the Teflon insert is used to keep the offending artery away from the facial nerve root rather than to isolate it. Therefore, the ideal Teflon sponge should be just small enough to produce a neurovascular separation.

Long-term surgical results in microvascular decompression for hemifacial spasm: efficacy, morbidity and quality of life.

SUMMARYHemifacial spasm is a condition that may severely reduce patients' quality of life. Microvascular decompression is the neurosurgical treatment of choice. The objective of this work was to describe the efficacy and morbidity of microvascular decompression for hemifacial spasm, evaluate the long-term efficacy on the quality of life and investigate prognostic factors for failure of the procedure. A retrospective study of 446 cases of hemifacial spasm treated by 511 retrosigmoid microvascular decompression over 22 years was conducted. Epidemiological, clinical and imaging findings, treatment modalities and outcomes of patients with pre- and postoperative HSF-8 quality of life questionnaire were studied. Success rate was 82% after first surgery and 91.6% after revision surgery. A low rate of perioperative morbidity was found. Facial palsy was mostly transient (5.5% transient and 0.2% permanent) and cochleovestibular deficit was seen in 4.8% of patients. Revision surgery increased nervous lesions (10.6% to 20.7%). Mean quality of life scores were significantly improved from 18 to 2 over 32, evaluated 7.3 years after surgery. Predictive factors of surgical failure were single conflicts (p = 0.041), atypical vasculo-nervous conflicts involving other vessel than postero-inferior cerebellar artery (p = 0.036), such as vein (p = 0.045), and other compression sites than root exit zone (p = 0.027). Retrosigmoid microvascular decompression is a safe and effective treatment of hemifacial spasm. Revision surgery is not to be excluded in case of failure, but does place patients at risk for more complications. Quality of life is improved in the long-term, indicating objective and subjective satisfaction.

Trigeminal neuralgia and hemifacial spasm associated with vertebrobasilar artery tortuosity

The tortuous vertebrobasilar artery (TVBA) often causes neurovascular conflicts in patients with trigeminal neuralgia (TN) and hemifacial spasm (HFS). Implementation of microvascular decompression (MVD) in these circumstances is hindered due to stiffness of the enlarged and dilated arteries and is often accompanied by poor outcomes. The surgical strategy in cases of trigeminal neuralgia and hemifacial spasm associated with the TVBA should be clarified in order to achieve good outcomes. MVD was performed in 268 TN patients and 71 HFS patients. The TVBA as a compressing vessel was identified in 30 cases (11 cases of TN, 18 cases of HFS, and 1 patient with painful tic convulsif). All patients underwent MVD and a retrospective analysis of clinical outcomes. Compression caused by the vertebral artery was found in all HFS patients and 4 TN patients, and compression caused by the basilar artery was observed in 7 TN cases. Additional compression of the cranial nerve root entry/exit zone by cerebellar vessels was observed in 21 cases. The TVBA was mobilized by dissection of arachnoid adhesions between the vessel and the brainstem and retracted laterally. Then, the TVBA was retracted from the brainstem to the caudorostral direction. These manipulations resulted is "spontaneous" decompression of the cranial nerves without placing prostheses between the artery and the nerve root entry/exit zone. In all cases (except two), the displaced TVBA was fixed between the enlarged artery and brainstem using pieces of the patient's muscle and adipose tissues, followed by application of fibrin glue. A cylindrical silicone prosthesis was used in 1 case. In another case, the TVBA was retracted using a fascial loop fixed to the dura mater of the petrous pyramid by means of a suture. After application of MVD, TN and HFS symptoms completely regressed. There were several transient complications and 2 cases of permanent hearing loss. No clinical symptom recurrence was observed. MVD is the most effective surgical treatment of TN and HFS caused by the TVBA. The TVBA should be retracted from the brainstem without placing prostheses in the nerve root entry/exit zone.