Complete Facial Paralysis Research Articles

Vestibulopathy in Patients Presenting With Ramsay Hunt Syndrome.

Ramsay Hunt syndrome (RHS) refers to a reactivation of the varicella-zoster virus in the distribution of the facial nerve, but it can involve other cranial nerves as well. In patients with polyneuropathy, the vestibulocochlear nerve is most involved after the facial nerve. The clinical manifestations and long-term vestibular outcomes in these patients remain unclear. This report aims to characterize the clinical course of this rare subset of RHS patients. This study is a retrospective case series. The study was conducted in a tertiary care institution. Patients with RHS polyneuropathy presenting with vestibular deficit were reviewed over a 30-year period. Case details including initial presentation, House-Brackmann grade, treatment regimen, vestibular examination and testing, MRI findings, and follow-up time were extracted. A total of 22 patients were identified. The mean age of diagnosis was 53 years and the average follow-up time was 23 months. Most patients demonstrated complete facial paralysis (88%) upon presentation. Nystagmus was rarely recorded during physical examination (18%, n = 4). For those patients who underwent MRI of the internal auditory canal (n = 17), 59% demonstrated enhancement of the facial nerve, with a notable absence of vestibulocochlear nerve abnormality. Of the patients who underwent vestibular testing, all demonstrated unilateral caloric weakness on videonystagmography (VNG; 66% ± 22%, n = 8). Patients with RHS polyneuropathy and vestibular complaints do not consistently demonstrate objective vestibular physical examination or imaging findings on presentation. However, VNG consistently demonstrates significant unilateral weakness on caloric stimulation. Most patients in our sample continued to have vestibular complaints at latest follow-up.

Efficacy of electrical stimulation of the zygomaticus muscle in complete facial paralysis: evidence from facial grading and automated image analysis.

Surface Functional Electrical Stimulation (FES) is a well-studied intervention for multiple muscular disorders. However, it is still controversially discussed as a complementary therapy for complete facial paralysis. The aim of this intervention is to test a daily home-based ES concept as a pilot study regarding safety, feasibility, and effects on facial functionality and symmetry. In a prospective single-centre pilot study, 10 patients (median 61 years, denervation 130 d) with complete peripheral facial paralysis performed home-based FES of the affected lateral mouth region Stimulation parameters, facial paralysis scores and standardised photographs were assessed in monthly follow-ups. No serious adverse events appeared. Stimulation parameters could be constantly increased indicating effective muscle training while subjectively perceived functionality of the face improved. Thus, smile angle of the paralysed side improved as well. FES is a safe therapy model for application in facial nerve paralysis patients. A feasible stimulation protocol could be applied, which improved the functionality and symmetry of the stimulated facial region. A future controlled, randomised and double-blind follow-up study is needed to investigate these initial results in a further evolved replicable setting.

Simultaneous Reconstruction of Voluntary and Spontaneous Smiles and Eyelid Closure With Triple Latissimus Dorsi Muscle Flaps.

Using the free latissimus dorsi muscle flap for dynamic reconstruction for established facial paralysis helps reconstruct various facial dysfunctions, depending on nerve and muscle arrangements. The authors divided the latissimus dorsi muscle into 3 flaps, 2 placed in the cheek area to reconstruct a "voluntary and spontaneous smile" and 1 fixed to the fascia implanted in the eyelid to treat lagophthalmos in a 1-stage procedure in a 61-year-old woman who underwent tumor resection for a left facial nerve schwannoma and developed complete facial paralysis. Fascia lata and free latissimus dorsi muscle grafting were performed. Spontaneous smile was reconstructed using the contralateral facial nerve as a motor source. Voluntary smile and eyelid closure were reconstructed using the ipsilateral masseter nerve, dividing the latissimus dorsi muscle flap into 3 muscle bodies. This procedure restored her smile and eyelid closure ability, with a nearly normal overall facial impression, making it a valuable technique for 1-term reconstruction of smiles and eyelid closure.

Long-term facial nerve outcome in surgically treated petrous bone cholesteatoma patients.

The term petrous bone cholesteatoma (PBC) represents a slow-growing epidermal lesion arising from the petrous part of the temporal bone. It is a rare incidence accounting for only 4-9% of all petrous bone lesions. PBC represents a real surgical challenge due to its complex relationship with critical neurovascular structures. To demonstrate our experience in using various options of facial nerve (FN) management during surgical treatment of PBC and analyze the long-term facial function outcomes. Retrospective medical record review in a quaternary skull-base center. Medical records of 298 PBC cases operated between the years 1983 and 2024 were thoroughly evaluated. Sanna's classification scheme was used to classify cases into the appropriate class and the House-Brackmann (HB) grading system of the FN was used to assess the facial function pre- and postoperatively. A total of 298 PBC cases were surgically treated at our center. Males constitute 68% (n = 203) of total operated PBC patients while the rest 32% (95) were females, making the male-to-female ratio 2.2:1. The age in this series ranged from 9 to 85. According to updated Sanna's PBC classification, 44% were supralabyrinthine, 33% were massive, 9% were infralabyrinthine-apical, 8% were infralabyrinthine, and 5% were apical. On preoperative FN function examination, 45% (n = 133) of patients had various degrees of paresis and complete paralysis whereas 55% (n = 165) had normal FN function. The commonest degree of paresis observed was HB-III (18.5%) followed by HB-IV (5.7%). A total of 40(13.4%) patients, however, had complete facial paralysis at the initial presentation. The facial function was compromised more frequently in supralabyrinthine and massive PBCs. Among the total patients who had an abnormal facial function at presentation, 52% had paresis/paralysis for less than a year whereas 48% had FN paresis/paralysis for greater than one year. The most commonly used surgical approaches at our center were transotic (TO), modified transcochlear type A (MTCA) with rerouting of the FN, and translabyrinthine (TLAB) with external auditory canal (EAC) closure. Intraoperatively an intact fallopian canal was found only in 33% (n = 99) cases whereas the rest 67% (n = 199) had erosion of the fallopian canal either with intact (n = 24) or infiltrated FN (n = 175). The FN was maintained in the bony fallopian canal in 35% (n = 104) cases. An active form of FN management, however, was required in 65% (n = 194) of cases either intraoperatively or as a second-stage procedure. Factors affecting postoperative FN function include age, preoperative FN function (HB), duration of paralysis, class of PBC, surgical approach, and method of active FN management. PBCs represent diagnostically and surgically challenging lesions of temporal bone which are usually frustrating to the treating surgeon. Preoperative anatomic classification of the lesion enables the physician to choose the appropriate surgical approach. Sanna's classification is the most widely accepted system used to classify PBC. This classification is based on the relation of the lesion to the labyrinthine block. Active FN management, including rerouting, end-to-end anastomosis, cable nerve grafting, and masseteric-to-FN anastomosis routinely come into play in the surgical management of PBCs, and the postoperative FN results after such interventions can be satisfactory in most cases.

Masseteric-facial anastomosis and hypoglossal-facial anastomosis after lateral skull base and middle ear surgery.

Lateral skull base (LSB) and middle ear pathologies often involve the facial nerve (FN), and their treatment may require FN sacrifice. Cases with unidentifiable proximal stump or intact FN with complete FN palsy, necessitate FN anastomosis with another motor nerve in order to restore innervation to the mimicking musculature. The results of hypoglossal-to-facial nerve anastomosis (HFA) and masseteric-facial nerve anastomosis in patients with facial paralysis after middle ear and LSB surgeries, are presented and compared. Adult patients with total definitive facial paralysis after middle ear or LSB surgery undergoing facial nerve reanimation through hypoglossal or masseteric transfer anastomosis were enrolled. The facial nerve function was graded according to the House Brackmann grading system (HB). The facial function results at 3months, 6months, 12months, 18months and at the last follow up (more than 18months) are compared. 153 cases of LSB and middle ear surgery presented postoperative facial palsy and underwent facial nerve reanimation surgery with HF in 85 patients (55.5%) and MF in 68 patients (44.5%). The duration of the FN palsy before reconstructive surgery was inversely associated to better FN results, in particular with having a grade III HB (p = 0.003). Both techniques had significantly lower HB scores when an interval between palsy onset and reanimation surgery was 6months or less (MF p = 0.0401; HF p = 0.0022). Patients who underwent a MF presented significant improvement of the FN function at 3months from surgery (p = 0.0078). At the last follow-up, 63.6% recovered to a grade III HB and 22.7% to a grade IV. On the other hand, the first significant results obtained in the HF group were at 6months from surgery (p < 0.0001). 67.8% of patients had a grade III HB after a HF at the last follow-up, 28.8% a grade IV. FN grading at 6months from surgery was significantly lower in the MF group compared to the HF (p = 0.0351). The two techniques had statistically similar results at later follow-up evaluations. MF was associated to initial superior results, presenting significant facial recovery at 3months, and significantly better functional outcomes at 6months from surgery compared to HF. Although later results were not significantly different in this study, earlier results have an important role in order to limit the duration of risk of corneal exposure.

Enhancing Lower Eyelid Suspension Outcomes Through Pre-surgical Facial Nerve Reanimation: A Comparative Study.

Lower eyelid suspension, a common therapeutic procedure for facial paralysis-induced eyelid retraction, faces challenges due to high recurrence in patients lacking facial muscle function and impedes wider adoption. This research aims to explore the potential effects of restoring orbicularis oculi muscle tension through facial nerve reanimation prior to lower eyelid suspension and to define the indications for lower eyelid suspension. The study encompassed 32 individuals with complete facial paralysis, segmented into group A (reanimation group) and group B (non-reanimation group), based on whether the orbicularis oculi muscle's tension was restored through facial nerve reconstruction prior to lower eyelid suspension. Subjective assessments of eyelid closure (the inter-eyelid gap upon gentle closure) and objective methods measures of scleral show (the distance from the pupil's center to the lower eyelid margin, MRD2) were used to provide a comprehensive analysis of long-term effectiveness. The group A exhibited significantly greater long-term improvement in lagophthalmos and lower eyelid ectropion. The alterations in MRD2 measured 2.66 ± 0.27mm in the group A versus 2.08 ± 0.53 mm in the group B, denoting a statistically significant variance (p < 0.001). Moreover, while the ratio of MRD2 preoperative 6 months postoperative revealed no significant difference between groups, a significant difference emerged in 12 months postoperative (group A: 1.02 ± 0.21; group B: 1.18 ± 0.24; p < 0.05), with the values in group A closer to 1, indicative of enhanced symmetry. Restoring the tension in the orbicularis oculi muscle through facial nerve reconstruction prior to palmaris longus tendon sling could effectively sustain long-term outcomes of lower eyelid retraction correction and reduce the recurrence rate. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Biopsy of the facial nerve in slow-onset facial palsy

IntroductionPrimary squamous cell carcinoma of the parotid gland typically presents as a palpable, often painless mass. Peripheral facial palsy as the only sign of malignant neoplasia is rare. In these cases, the diagnosis is regularly confirmed by radiological imaging followed by surgical exploration and biopsy. However, if there is no detection of malignant lesions and no evidence of a tumor, the reluctance to take a biopsy of an unremarkable nerve can lead to misdiagnoses.Case reportA 40-year-old female patient without medical history presented to our clinic with a complete right-sided peripheral facial palsy that had slowly progressed for 2.5 years. All other otorhinolaryngological examination findings were within normal limits. Magnetic resonance imaging examination of the head and neck and 18-fluorodeoxyglucose positron emission tomography showed unremarkable results. We proceeded with surgical exploration, which revealed no evidence of a tumor and an externally completely unremarkable facial nerve. A biopsy from the main trunk area of the nerve revealed an infiltration by a squamous cell carcinoma. Total parotidectomy with resection and reconstruction of the facial nerve and neck dissection was performed. Considering the absence of a primary tumor and other tumor formations the diagnosis of a completely regressive primary squamous cell carcinoma of the parotid gland was confirmed.ConclusionIn conclusion, in the case of slow-onset peripheral facial palsy that persists without signs of recovery, a gadolinium-enhanced MRI should be performed. If imaging is unremarkable and there is no primary tumor detection along the course of the facial nerve, a surgical exploration with biopsy of the facial nerve is necessary.

Case Report: Contralateral Progression of a Vestibular Schwannoma After Resection in a Patient with Neurofibromatosis Type 2

BACKGROUND AND IMPORTANCE: Bilateral vestibular schwannomas (VS) are a distinctive feature of neurofibromatosis type 2 (NF2) that result in a serious reduction in the quality of life for patients. The growth rates of these schwannomas are variable, and the early detection of increased growth is fundamental for improving outcomes. CLINICAL PRESENTATION: A 17-year-old man with NF2 and bilateral VS presented with complete right facial paralysis and sudden right hearing loss less than 1 month after resection of a left VS. Imaging revealed rapid growth of the right VS with intratumoral hemorrhage, and the patient underwent urgent surgical resection with some improvement in symptoms. DISCUSSION: Existing literature indicates a similar phenomenon after a longer post-operative period; however, none have shown such rapid symptomatology. Multiple etiologies were explored for this presentation, including the sudden decompression from the primary resection, paracrine factors, and hypervascularity from prior radiation. CONCLUSION: VS resection in a patient with NF2 may be followed by rapid growth in the contralateral VS, leading to severe symptom presentation. Patients should be counseled regarding this risk to enable early detection and intervention.

Hypoglossal-facial nerve (XII-VII) anastomosis for complete facial nerve paralysis: case-series report, accumulated experience and outcome assessment

Hypoglossal-facial nerve (XII-VII) anastomosis for complete facial nerve paralysis: case-series report, accumulated experience and outcome assessment

Acute‐onset distal dominant neuropathy after severe acute respiratory syndrome coronavirus 2 vaccination in a male patient with recent dengue infection: A case report

AbstractObjectiveGuillain–Barré Syndrome (GBS) is an autoimmune degenerative disease commonly presenting with acute progressive sensorimotor paralysis, sometimes associated with dysautonomia, facial diplegia and severe respiratory distress. Gastroenteritis due to Campylobacter jejuni and respiratory infection secondary to Epstein–Barr virus usually precede GBS; however, vaccination or recent dengue infection as temporal causes are rarely reported.Case PresentationHere, we present a 20‐year‐old man, who complained of a 5‐day history of a progressively worsening tingling sensation isolated in the hands and feet, and unilateral Bell's palsy on the left side of his face, which occurred 2 weeks after his severe acute respiratory syndrome coronavirus 2 vaccination and 6 weeks from his recent hospitalization from Dengue fever. Except for the left complete unilateral facial paralysis, weakness in the intrinsic hands and feet muscles, and sensory ataxia, the rest of his physical examination was unremarkable. On work‐up, the findings of albuminocytological dissociation and distal sensorimotor demyelinating polyneuropathy in the nerve conduction study supported the diagnosis of GBS.ConclusionThe enhanced immune response from a recent dengue infection and severe acute respiratory syndrome coronavirus 2 vaccination might increase the risk of GBS. The predominantly distal GBS phenotype has rarely been reported in the literature, adding to the peculiarity of this case.

Comparison of Outcomes of Facial Reanimation Between the Use of Cross-facial Nerve Graft and the Masseteric Nerve as the Donor Nerve for Reinnervation of Gracilis Muscle Flap Transfer.

In patients with facial paralysis, the free functional gracilis muscle transfer is preferred for facial reanimation. The choice of an adequate motor nerve to innervate the transplanted gracilis muscle is one of the procedure's key components. We present a comparative study between cross-facial nerve graft (CFNG) and masseteric nerve as donor nerves for reinnervated gracilis flap transfer in patients with complete facial paralysis. Retrospective analysis was performed on all patients with complete facial paralysis who had a free functional gracilis muscle transfer for facial reanimation between January 2014 and December 2021. Only those who received gracilis transfer reinnervated by either CFNG or masseteric nerve were included in this study. The smile excursion and lip angle were measured for evaluating the outcomes postoperatively. The inclusion criteria were met by a total of 21 free functional gracilis muscle transfers, of which 11 were innervated by CFNG and 10 by the masseteric nerve. Both surgical procedures resulted in a highly considerable smile excursion of the reanimated side and postoperative improvement of static or dynamic lip angle. Masseteric nerve coaptation led to greater smile excursion and more significant improvement of dynamic lip angle than CFNG. For patients who have complete facial paralysis, face reanimation can be successfully accomplished by free gracilis transfer reinnervated by the CFNG or the masseteric nerve. In particular, the masseteric nerve is a reliable choice for dynamic smile reanimation.

Simultaneous Reconstruction of Smiling Eye Using V-Shaped Long Latissimus Dorsi Muscle Transfer in Patients with Flaccid Facial Paralysis.

Various neurovascular free muscle transfers for smile reconstruction in patients with facial paralysis have been reported. However, these methods focused on perioral smiling rather than eye smiling. Although the lower eyelid does not contribute significantly to eyelid closure, dynamic reanimation of the upward movement of the lower eyelid with bulging of the malar region during smiling is important in smile reconstruction. The authors present a novel procedure for smiling eye and perioral smiling. The V-shaped latissimus dorsi muscle flap containing the descending branch (DB) of the thoracodorsal nerve (TDN) was used. Muscle A (15 to 17 cm), which is located along the main trunk of the DB, is much longer than muscle B (10 to 12 cm), which is along the branch of DB. A distal stump of the TDN involved in muscle B was prepared. The true trunk and distal stump of the TDN were sutured to the contralateral facial and ipsilateral masseteric nerves, respectively. The central region of muscle A was positioned at the lateral part of the lower eyelid; the distal end of long muscle A was affixed to the temporal region, which enabled periocular movements and narrowing of the palpebral fissures alongside perioral smiling when muscle A contracted. Nine patients with complete flaccid facial paralysis were treated. All patients attained muscle contraction induced by the ipsilateral masseteric and contralateral facial nerves. The smiling eye appearance was observed in 7 of 9 patients. This procedure simultaneously improves paralytic ectropion at rest and aids eyelid closure and enables early voluntary smile and a later spontaneous smile.

Functional Outcome of Dual Reinnervation with Cross-Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis.

The combination of cross-facial nerve graft (CFNG) and masseteric nerve transfer (MNT) for reinnervation of facial paralysis may provide advantages of both neural sources. However, quantitative functional outcome reports with a larger number of patients are lacking in the literature. Here, the authors describe their 8-year experience with this surgical technique. Twenty patients who presented with complete facial paralysis (duration, <12 months) received dual reinnervation with CFNG and MNT. The functional outcome of the procedure was evaluated with the physician-graded outcome metric eFACE scale. The objective artificial intelligence-driven software Emotrics and FaceReader were used for oral commissure measurements and emotional expression assessment, respectively. The mean follow-up was 31.75 ± 23.32 months. In the eFACE score, the nasolabial fold depth and oral commissure at rest improved significantly ( P < 0.05) toward a more balanced state after surgery. Postoperatively, there was a significant decrease in oral commissure asymmetry while smiling (from 19.22 ± 6.1 mm to 12.19 ± 7.52 mm). For emotional expression, the median intensity score of happiness, as measured by the FaceReader software, increased significantly while smiling (0.28; interquartile range, 0.13 to 0.64). In five patients (25%), a secondary static midface suspension with fascia lata strip had to be performed because of unsatisfactory resting symmetry. Older patients and patients with greater preoperative resting asymmetry were more likely to receive static midface suspension. The authors' results suggest that the combination of MNT and CFNG for reinnervation of facial paralysis provides good voluntary motion and may lessen the use of static midface suspension in the majority of patients. Therapeutic, IV.

Case report: Bilateral facial palsy in pediatric acute lymphoblastic leukemia with central nervous system relapse.

Objective: To report the youngest case of a bilateral facial palsy secondary to a central nervous system relapse from acute lymphoblastic leukemia in a female young patient that was treated with intrathecal chemotherapy, systemic corticosteroids, and physical therapy with successful outcomes. Design: A case report of a 9-years old female patient with bilateral facial palsy. Results: A 9-years old patient with acute lymphoblastic leukemia presented with a complete right facial nerve palsy that progresses 10 days later to a simultaneous grade IV House-Brackmann left facial nerve palsy. Neuroimaging showed basal pachymeningeal and bilateral facial nerve enhancement, predominantly in the right side. Central nervous system metastasis was confirmed with cerebrospinal fluid cytometry and medical therapy was initiated with intrathecal chemotherapy, systemic corticosteroids, and physical therapy. Three weeks after the onset of treatment, both facial palsies ameliorated to a grade IV and III, left and right facial palsy, respectively. Conclusion: Central nervous system metastasis must be considered as a differential diagnosis of simultaneous bilateral facial palsy is presented. Early treatment with intrathecal chemotherapy, systemic corticosteroids and physical therapy may improve patients’ outcomes.

Patient Perception of Education, Care Coordination, and Psychological Distress After Developing Facial Paralysis

The management of vestibular schwannoma may include observation, microsurgical resection, or radiation of a tumor near the facial nerve. Injury to the facial nerve can result in facial paralysis with major functional, social, and psychological sequelae, and the experiences of patients after paralysis are not well studied. To (1) identify patient preparedness for developing facial paralysis and how well their care is coordinated following its development and (2) present in their own words outcomes of facial paralysis in terms of physical health, emotional health, self-perception, and social interactions. A qualitative observational study was performed using semistructured interviews at a tertiary care academic medical center. Semistructured interviews were conducted between January 1, 2018, and June 30, 2019, with adults aged 25 to 70 years who developed facial paralysis after treatment for vestibular schwannoma. Data were analyzed from July 2019 to June 2020. Perceptions of the educational and emotional experiences of individuals who developed complete facial paralysis after surgical treatment of vestibular schwannoma. Overall, 12 participants were interviewed (median age, 54 years [range, 25-70 years]; 11 were female). Saturation was achieved after 12 interviews, indicating that no further information could be elicited from additional interviews. Four major themes were identified: (1) lack of sufficient patient education about the diagnosis of facial paralysis; (2) lack of appropriate care coordination related to facial paralysis; (3) changes in physical and emotional health following facial paralysis; and (4) changes in social interactions and external support following facial paralysis. It is well-known that patients with facial paralysis have reduced quality of life, severe psychological and emotional sequelae. However, little is currently done to help prepare patients for this undesirable outcome. In this qualitative study of facial paralysis, patients express, in their own words, their feeling that the education and management of facial paralysis by their clinicians was inadequate. Before patients undergo surgery, and certainly after injury to the facial nerve, clinicians should consider the patient's goals, preferences, and values to ensure that a comprehensive educational program and psychosocial support system are implemented. Facial reanimation research has not adequately captured these key patient factors associated with the quality of communication.

Periocular management in recent facial palsy patients treated with triple innervation technique: A retrospective case series

Facial paralysis decreases eye protection mechanisms leading to ocular problems up to corneal ulceration, and blindness. This study aimed to evaluate the outcomes of periocular procedures for recent facial paralysis.Medical records of patients with unilateral recent complete facial palsy who did periocular procedures at the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) between April 2018 and November 2021 were retrospectively reviewed. 26 patients were included. All patients were evaluated 4 months after surgery. The first group included 9 patients who underwent upper eye lid lipofilling and midface suspension with fascia lata graft; they had no ocular dryness symptoms and no need for eye protection measures in 33.3% of cases, significant reduction of ocular symptoms and need for eye protection measures in 66.6% of patient, 0–2 mm lagophthalmos in 66.6% and 3–4 mm lagophthalmos in 33.3%.The second group of 17 patients who underwent upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy, had no ocular dryness symptoms and no need for eye protection measures in 17.6% of patient, significant reduction of ocular symptoms and need for eye protection measures in 76.4% of patient, 0–2 mm lagophthalmos in 70.5%, 3–4 mm lagophthalmos in 23.5% and one patient 5,8%had 8 mm lagophthalmos and persistent symptoms. No ocular complication, cosmetic complain or donner site morbidity were reported.Upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy decrease ocular dryness symptoms and need for eye protection measures and improve lagophthalmos: the association of the reinnervation with these complementary techniques is therefore highly recommended in order to immediately protect the eye.

Abstract Number ‐ 40: Unique presentation of Dural AV fistula with brainstem stroke and extensive edema

Introduction Intracranial dural arteriovenous fistulae (dAVFs) are typified by pathological anastomoses between meningeal arteries and dural venous sinuses or cortical veins. DAVFs can mimic other neurologic disorders and produce a broad spectrum of signs and symptoms, including headache, tinnitus, vertigo, Parkinsonism, and visual field and gait disturbances. We present a case report of extensive dural AV Fistula which lead to brainstem ischemic stroke from compression of brainstem flow void. Methods Case Report Results 64 year old man with past medical History of Rheumatoid arthritis, presented with sudden onset of right facial weakness. On arrival patient was noted to be hypertensive to 200/105 and on exam noted to have right complete facial nerve palsy. Patient also revealed a significant history of severe, throbbing, posterior headaches in the last 1–2 months. Patient had CT head which was negative for bleed. CT angiography showed Abnormal hyperattenuating tubular vessel extending along the right cerebellar hemisphere and posterolateral pons extending towards the venous confluence at Galen. Over the course of 5 hours, the patient reported difficulty swallowing and intense headaches. MRI brain showed acute to early subacute infarct involving the right dorsolateral medulla and abnormal T2 prolongation involving essentially the entire cross‐section of the upper medulla and inferior pons representing edema. The patient was taken for Diagnostic catheter angiogram which showed dural AV fistula extending along the right cerebellar hemisphere. Onyx embolization was performed on the Right Middle meningeal artery and right Superior cerebellar artery with complete obliteration of dAVF. Conclusions The spectrum of signs and symptoms associated with DAVFs has been attributed to any one or combination of 6 pathophysiologic factors: the arteriovenous shunt, cerebral hypoxia and ischemia, increased venous pressure, retrograde drainage and secondary engorgement of basal sinuses, sinus obstruction, and subarachnoid hemorrhage secondary to involvement of the pial venous system. Prompt evaluation and management is necessary for patients presenting with neurological symptoms with headache.

Abstract Number ‐ 226: Pontine Stroke Presenting as 1.5 Syndrome Evolving to 9 Syndrome over 72 Hours.

Introduction A 75 year old woman with a past medical history of hypertension developed sudden‐onset vertigo, nausea and vomiting. She did not immediately seek medical care, thinking she was suffering from food poisoning. The following day her symptoms improved however she developed new right sided weakness and gait imbalance, prompting her presentation to the ED. Her neurologic exam noted complete loss of adduction of the right eye and loss of horizontal extraocular movements of the left eye. She also displayed right upper extremity paresis, right upper extremity dysmetria and mild dysarthria. MRI of the brain disclosed acute pontine infarcts in the ventral and dorsal left paramedian regions. Over the next three days, her horizontal gaze palsy improved with some return of adduction of the right eye and horizontal movements of the left eye. However right sided paresis worsened, and in addition, progressed to include complete left facial palsy (lower motor neuron lesion). She was able to be discharged to rehab, placed on Aspirin 81 mg daily and Ezetimibe (due to elevated liver function enzymes) and 30 day Cardiac Event Monitor follow up. Methods Case report and review of literature. Results Due to the combination of multiple cranial nuclei and white matter tracts in the brainstem, ischemia can lead to several clinical manifestations. There are various presenting clinical syndromes, named numerically by structures involved and/or the clinical deficit. One‐and‐a‐half (1.5) syndrome, first reported by Fischer in 1967, is an uncommon entity caused by a lesion (most commonly infarction) in the pontine tegmentum [1]. It consists of complete ipsilateral horizontal gaze palsy (due to involvement of ipsilateral Paramedian Pontine Reticular Formation/Abducens Nucleus and Medial Longitudinal Fasciculus) and loss of adduction of the contralateral eye (due to involvement of the contralateral Medial Longitudinal Fasciculus). Extension of the lesion to the facial nucleus can produce ipsilateral lower motor neuron type facial palsy, leading to an even more uncommon 8.5 syndrome (7 + 1.5), described by Eggenberger in 1998 [2]. When the lesion involves the corticospinal tracts and/or the medial lemniscus, it can lead to contralateral hemiparesis and/or hemisensory deficits; the so called “9 syndrome” first proposed by Rosini et al in 2013 [3]. This rare entity has been reported in only a handful of cases. Conclusions The awareness of complex brainstem neuroanatomy enables precise localization of the clinical deficits. The noted slow progression of the clinical syndrome from 1.5 to 8.5 and finally 9 syndrome over 72 hours in this case highlights the complexity of small vessel brainstem ischemia.

Comparison of static and dynamic symmetry between masseter-innervated and dual-innervated free multivector serratus anterior muscle transfer for complete facial paralysis

In this study, facial symmetry was compared between the masseter-innervated and dual-innervated free multivector serratus anterior muscle transfer (FMSAMT) methods. Eighteen patients with unilateral complete facial paralysis underwent facial reanimation surgery between April 2006 and July 2019. The masseter-innervated FMSAMT group (Group M, n=8) underwent end-to-end coaptation with the ipsilateral masseter nerve in one stage. The dual-innervated FMSAMT group (Group D, n=10) underwent end-to-end coaptation with the masseter nerve and end-to-side coaptation with the contralateral facial nerve via cross-face nerve graft. They were further divided into the one-stage (Group D1, n=5) and two-stage (Group D2, n=5) subgroups. The durations of periods until the first visible muscle contraction with clenching, first spontaneous smile, and the completion of resting tone were evaluated. The possibility of a spontaneous smile and symmetry of the midline and horizontal deviation at rest and during voluntary smiling were compared between each group. Groups M and D differed significantly in the possibility of a spontaneous smile and improvement rate of midline deviation and horizontal deviation at rest (p<0.001, p<0.001, and p=0.001, respectively) but not in the improvement rate of midline and horizontal deviation during voluntary smiling. The duration of the period until the completion of resting tone was significantly shorter in Group D1 than in Group D2 (p=0.048); however, the possibility of a spontaneous smile and the improvement rate of midline and horizontal deviation were not significantly different. Dual-innervated FMSAMT was effective in guaranteeing a symmetrical resting tone, voluntary smiling, and reproducing a spontaneous smile.

Surgical and nonsurgical treatment outcomes in traumatic facial nerve palsy.

Facial nerve decompression surgery is performed on patients with immediate, complete traumatic facial palsy. However, the clinical advantage of the surgical treatment has weak evidence because of lack of control groups in previous studies. Therefore, this study compared facial function outcomes between the patients who underwent surgery and those who did not. Furthermore, in cases of bilateral traumatic facial palsy, the outcomes of the surgical and nonsurgical sides were also discussed. A retrospective medical chart review of immediate and severe (House-Brackman [HB] grade V and VI) traumatic facial palsy was conducted. Twenty-five ears from the surgical group and eight ears from the conservative treatment group were enrolled. Among the patients, three with immediate and severe bilateral facial palsy underwent unilateral surgery. The average HB grade after 1-year follow-up was 1.7 in the surgical group and 1.5 in the nonsurgical group. Four patients who have definite facial canal disruption in the imaging study have recovered to HB grades I-III without surgical intervention. In patients with bilateral facial palsy, the nonsurgical side showed the same or better facial functions than the surgical side. Compared with nonsurgical conservative treatment, facial nerve decompression surgery did not show superior outcomes in immediate HB grade V-VI traumatic facial palsy. The clinical advantage of facial nerve decompression is questionable and should be re-evaluated in a prospectively designed study.