Left Facial Nerve Research Articles

Accelerated outgrowth in cross-facial nerve grafts wrapped with adipose-derived stem cell sheets.

In this study, we devised a novel cross-facial nerve grafting (CFNG) procedure using an autologous nerve graft wrapped in an adipose-derived stem cell (ADSC) sheet that was formed on a temperature-responsive dish and examined its therapeutic effect in a rat model of facial palsy. The rat model of facial paralysis was prepared by ligating and transecting the main trunk of the left facial nerve. The sciatic nerve was used for CFNG, connecting the marginal mandibular branch of the left facial nerve and the marginal mandibular branch of the right facial nerve. CFNG alone, CFNG coated with an ADSC suspension, and CFNG wrapped in an ADSC sheet were transplanted in eight rats each, designated the CFNG, suspension, and sheet group, respectively. Nerve regeneration was compared histologically and physiologically. The time to reinnervation, assessed by a facial palsy scoring system, was significantly shorter in the sheet group than in the other two groups. Evoked compound electromyography showed a significantly higher amplitude in the sheet group (4.2 ± 1.3 mV) than in the suspension (1.7 ± 1.2 mV) or CFNG group (1.6 ± 0.8 mV; p < .01). Toluidine blue staining showed that the number of myelinated fibers was significantly higher in the sheet group (2,450 ± 687) than in the suspension (1,645 ± 659) or CFNG group (1,049 ± 307; p < .05). CFNG in combination with ADSC sheets, prepared using temperature-responsive dishes, promoted axonal outgrowth in autologous nerve grafts and reduced the time to reinnervation.

Head Injury - Soccer

HISTORY: A 16 year-old male presented to an outpatient sports medicine clinic one month after a head-to-head collision during a soccer match with concern for concussion. There was no loss of consciousness, and he continued to play the rest of the game with a mild headache. He felt normal and asymptomatic that evening and was able to complete homework. The following morning he felt tired, but was able to perform adequately at school. Over the coming weeks, he noticed progressive worsening of his cognitive symptoms and tiredness. His athletic trainer became concerned for a concussion and held him from practice. One week prior to presentation he noted midline lower lip numbness, teeth pain while chewing, hearing his pulse in his left ear, and poor sleep due to sweatiness. He also felt progressive lethargy and difficulty concentrating and missed the last three days of school due to these symptoms. His medical history was significant only for a recently diagnosed inguinal hernia. PHYSICAL EXAMINATION: Mild cognitive deficits in attention and memory, impaired balance on BESS, normal motor strength. Cranial nerve exam showed ptosis of the left eye, mild left facial nerve palsy, decreased hearing in the left ear, and altered sensation to light touch over the middle lower lip. There was no focal tenderness or deformity of the skull or scalp. DIFFERENTIAL DIAGNOSIS: Mild traumatic brain injury Intracranial hemorrhage Cerebral mass Bell’s palsy TESTS AND RESULTS: MRI Brain with and without contrast: Asymmetric enhancement of the left 7th cranial nerve, asymmetric nodular enhancement along the left 5th nerve with enhancement of muscles of mastication, diffuse bilateral pachymeningeal enhancement. Complete Blood Count: WBC 19k, platelets 80, hematocrit 30.4 CT Chest, Abdomen, Pelvis: Large abdominal soft-tissue mass herniating through the inguinal canal, most consistent with a lymphoma CSF Cytology: Enlarged B-cells most consistent with Burkitt lymphoma. FINAL DIAGNOSIS: Stage IV Burkitt lymphoma, with primary lesion in abdomen, and perimeningeal spread, causing cranial nerve V and VII palsies. TREATMENT AND OUTCOMES: 1. Admitted for prompt initiation of chemotherapy. 2. Cranial nerve symptoms resolved with chemotherapy and steroids. 3. After multiple rounds of chemotherapy, there is no evidence of residual lymphoma.

Head Injury - Soccer

HISTORY: A 16 year-old male presented to an outpatient sports medicine clinic one month after a head-to-head collision during a soccer match with concern for concussion. There was no loss of consciousness, and he continued to play the rest of the game with a mild headache. He felt normal and asymptomatic that evening and was able to complete homework. The following morning he felt tired, but was able to perform adequately at school. Over the coming weeks, he noticed progressive worsening of his cognitive symptoms and tiredness. His athletic trainer became concerned for a concussion and held him from practice. One week prior to presentation he noted midline lower lip numbness, teeth pain while chewing, hearing his pulse in his left ear, and poor sleep due to sweatiness. He also felt progressive lethargy and difficulty concentrating and missed the last three days of school due to these symptoms. His medical history was significant only for a recently diagnosed inguinal hernia. PHYSICAL EXAMINATION: Mild cognitive deficits in attention and memory, impaired balance on BESS, normal motor strength. Cranial nerve exam showed ptosis of the left eye, mild left facial nerve palsy, decreased hearing in the left ear, and altered sensation to light touch over the middle lower lip. There was no focal tenderness or deformity of the skull or scalp. DIFFERENTIAL DIAGNOSIS: Mild traumatic brain injury Intracranial hemorrhage Cerebral mass Bell’s palsy TESTS AND RESULTS: MRI Brain with and without contrast: Asymmetric enhancement of the left 7th cranial nerve, asymmetric nodular enhancement along the left 5th nerve with enhancement of muscles of mastication, diffuse bilateral pachymeningeal enhancement. Complete Blood Count: WBC 19k, platelets 80, hematocrit 30.4 CT Chest, Abdomen, Pelvis: Large abdominal soft-tissue mass herniating through the inguinal canal, most consistent with a lymphoma CSF Cytology: Enlarged B-cells most consistent with Burkitt lymphoma. FINAL DIAGNOSIS: Stage IV Burkitt lymphoma, with primary lesion in abdomen, and perimeningeal spread, causing cranial nerve V and VII palsies. TREATMENT AND OUTCOMES: 1. Admitted for prompt initiation of chemotherapy. 2. Cranial nerve symptoms resolved with chemotherapy and steroids. 3. After multiple rounds of chemotherapy, there is no evidence of residual lymphoma.

MON-262 A Case of the Suprasellar Atypical Teratoid Rhabdoid Tumor (ATRT) Presenting in an Adult Treated with Intrathecal Chemotherapy

Background: Atypical teratoid rhabdoid tumors (ATRTs) are highly malignant tumors that usually present as a posterior fossa mass in children less than 3 years old. Only 38 cases have been reported in adults. They are also typically located in the supratentorial region. In none of the reported cases of suprasellar ATRT in the adult, intrathecal chemotherapy (via ommaya) has been used. Clinical case: A 70-year-old woman presented with a severe headache and magnetic resonance imaging (MRI) revealed a suprasellar mass measuring 2.9 x 2.1 x 3.0 cm. Shortly after her presentation, she developed an acute 3rd nerve palsy, and repeat MRI found dramatic interval growth. A transsphenoidal approach for biopsy/resection was attempted, but the lesion was not accessible via this corridor. She then underwent a right frontotemporal craniotomy and subsequently developed panhypopituitarism, including diabetes insipidus. Pathology revealed poorly differentiated malignant cells. Immunohistochemistry was positive for synaptophysin, Epithelial Membrane Antigen (EMA), Tumor protein p53, and negative for integrase interactor 1 (INI-1 antibody) with loss of expression in tumor nuclei with positive internal control in endothelial cells. These findings confirmed the diagnosis of ATRT. The Ki-67 index was 60% consistent with a highly proliferative tumor. One month later, she developed acute mental status change. Repeat computed tomography, and MRI showed recurrence of the tumor at the same location with new leptomeningeal enhancement involving the left facial nerve. Multimodal treatment was instituted, consisting of intraventricular/intrathecal chemotherapy with etoposide and topotecan plus fractionated external beam cranial irradiation (30 Gy in 10 fractions). She continued to deteriorate, and following consultation with her family, she was transferred to hospice care and died six months following her initial surgery. Conclusion: This is the first case of adult suprasellar ATRT that has been treated with intrathecal chemotherapy. There is no consensus on the best combination of chemotherapy, and often the St. Jude’s protocol used in the treatment of pediatric ATRT is used. In line with the biological behavior reported for this tumor in children and adults in different locations, the tumor was very aggressive, resulting in the patient’s death only after 6 months from the diagnosis despite aggressive surgical and medical treatment. Reference: 1. Athale, U. H., J. Duckworth, I. Odame, and R. Barr. 2009. Childhood atypical teratoid rhabdoid tumor of the central nervous system: a meta‐analysis of observational studies. J. Pediatr. Hematol. Oncol. 31:651-663. 2. Shonka N, Armstrong T (2011) Atypical teratoid/rhabdoid tumors in adults: A case report and treatment-focused review. J Clin Med Res 3: 85-92.

Overlooked and Underestimated: New Insight on Communicating Branches of The Facial Nerve

The facial nerve demonstrates wide anatomical variation and significant clinical relevance. Branching patterns of the facial nerve have been extensively studied, but communicating branches have comparatively received far less attention. Communicating branches of the facial nerve are hypothesized as an important means of motor recovery to facial nerve injury, and therefore must be carefully considered by physicians working in the region of innervation. Indeed, damage to branches of the nerve is associated with significant ramifications to patients, and facial nerve injury is the most common complication of facial surgery. Knowledge of communicating branches may contribute to preservation of facial nerve function, and therefore are important to describe and document. This study aims to clarify the frequency and branching patterns of communicating branches of the facial nerve. Cadaver specimens from the Gift Body Program at Kansas City University College of Osteopathic Medicine revealed the anatomy. Cadaveric dissections were performed bilaterally to identify and document communicating branches across the facial nerve extending from the temporal to cervical branches. Frequency and location of communicating branches were assessed among 15 body donors bilaterally, yielding 30 facial nerves for analysis. Due to the variability of facial nerve branches observed bilaterally on specimens, this study utilized right and left facial nerves of each donor as individual specimens. We document and describe the presence of communicating branches across the temporal, zygomatic, buccal, marginal mandibular, and cervical branches. This characterization has more accurately established the generalizable area(s) in which communicating branches are located. A higher frequency of communicating branches between the marginal mandibular and cervical branches was observed than has been previously reported. The locations of these branches are described in relation to nearby landmarks for use in clinical and surgical settings. Branch variations were carefully outlined and overlaid to demonstrate areas of density to support surgical and procedural awareness

Iatrogenic injury and regeneration of the facial nerve after parotid gland tumour surgery: a pilot study with clinical and neurophysiological assessment

Introduction. Benign tumour surgery of the parotid gland may cause iatrogenic injury of the facial nerve, with results of postoperative treatment depending on the type of injury. The study aimed to clarify the mechanism of facial nerve injury after benign tumour surgery of parotid gland. Materials and Methods. The effectiveness was verified preoperatively and 1, 3, 6 and 17 months postoperatively. House-Brackmann scales, electroneurography, blink reflex study and needle electromyography were performed. Pharmacological treatment (Galantamine, Cocarboxylase, Dexamethasone, Triamcinolone) and supervised physiotherapeutic procedures (Facial-Oral-Tract-Therapy, Proprioceptive neuromuscular facilitation) were applied for six months. Results. Tumour removal led to the total paralysis of the left facial nerve, IV, III and III House-Brackmann grades were ascertained at the subsequent 3rd–5th periods of observation. In postoperative studies, electroneurography results showed full functional recovery of the frontal branch and incomplete regeneration in the marginal mandibular branch. Blink reflex examination showed proper parameters of evoked potentials only during preoperative and the last observation period. Residual voluntary activity of the frontal muscle and weak voluntary activity of orbicularis oris muscle were recorded in the needle electromyography examination. Contracture of mimic muscles at rest and improvement of their voluntary activity on the left side was observed six months after surgery compared to the early period of observation. Conclusion. Consecutive studies showed the predominant axonal type of injury in the marginal mandibular branch and neuropraxia effect of the facial nerve, allowing the creation of a rehabilitation programme optimal for the functional recovery of the nerve.

HYPERDENSE BASILAR ARTERY – EARLY SIGN OF STROKE

Hyperdense artery sign is presumed to represent acute thrombus or clot, and is an early indicator of posterior circulation stroke. This sign if detected, in proper clinical scenario can help the clinician to detect the basilar occlusion and to intervene early. We are presenting a case of 30 yr. old female, normotensive, nondiabetic presented with sudden onset focal left sided seizure, central vertigo, diplopia and decreased vision in left eye to emergency department. On examination, ptosis and anisocoria, Left facial nerve palsy. Patient was advised NCCT Head, which showed hyperdense basilar artery , seen retrospectively after MRI.&#x0D; &#x0D;

A Mouse Model of Dysphagia After Facial Nerve Injury.

Dysphagia is common following facial nerve injury; however, research is sparse regarding swallowing-related outcomes and targeted treatments. Previous animal studies have used eye blink and vibrissae movement as measures of facial nerve impairment and recovery. The purpose of this study was to create a mouse model of facial nerve injury that results in dysphagia to enhance translational research outcomes. Prospective animal study. Twenty C57BL/6J mice underwent surgical transection of the main trunk (MT) (n = 10) or marginal mandibular branch (MMB) (n = 10) of the left facial nerve. Videofluoroscopic swallow study (VFSS) assays for drinking and eating were performed at baseline and 14 days postsurgery to quantify several deglutition-related outcome measures. VFSS analysis revealed that MT transection resulted in significantly slower lick and swallow rates during drinking (P ≤ .05) and significantly slower swallow rates and longer inter-swallow intervals during eating (P ≤ .05), congruent with oral and pharyngeal dysphagia. After MMB transection, these same VFSS metrics were not statistically significant (P > .05). The main finding of this study was that transection of the facial nerve MT leads to oral and pharyngeal stage dysphagia in mice; MMB transection does not. These results from mice provide novel insight into specific VFSS metrics that may be used to characterize dysphagia in humans following facial nerve injury. We are currently using this surgical mouse model to explore promising treatment modalities such as electrical stimulation to hasten recovery and improve outcomes following various iatrogenic and idiopathic conditions affecting the facial nerve. NA Laryngoscope, 131:17-24, 2021.

The efficiency of ozone therapy and low-level laser therapy in rat facial nerve injury

PurposeComparison of low-level laser therapy (LLLT) and ozone therapy (OT) methods for the treatment of facial nerve injury (FNI) in rats, evaluated by histomorphometric measurement analysis. Materials and methodsThirty rats were randomly divided into control (C), LLLT, and OT groups. The left facial nerves (FNs) of all rats (n = 30) were used in this study. These were held in a surgical clamp for 30 s to create neuropathic damage. The non-injured right FNs of the rats in the control group formed the fourth, sham (S) group in this study (n = 10). Therefore the total number of evaluated samples was 40. The injured FNs of rats in the control group were left to heal spontaneously, whereas LLLT was applied for 21 consecutive days (output 100 mW/cm2 and wavelength 850 nm) and OT (2 ml; 80 μm/ml) once every 2 days for 21 days. ResultsAfter histomorphological evaluation, the OT group revealed statistically significant outcomes following FNI compared with the OT and control groups in terms of branching of nerve fibers (p = 0.003), nerve fiber diameters (p = 0.0398), nerve fiber areas (p = 0.042), and axon numbers (p = 0.0327). Although the LLLT group revealed a better healing process than the control group, the outcome was not statistically significant in terms of branching of nerve fibers (p = 0.6804), nerve fiber diameters (p = 0.7424), nerve fiber areas (p = 0.7048), and axon numbers (p = 0.7588). ConclusionsOT resulted in statistically significant differences in outcome when compared with the LLLT and control groups, and provided a safe and effective treatment for FNI in rats. OT could therefore be considered as an alternative treatment of FNI. Clinical studies should now be performed to establish whether comparable results can be achieved in humans.

A case of refractory generalized atonic seizure and hemifacial spasm with the possible causative pontocerebellar lesion

The patient was a 35-year-old woman. At the age of 1, she had undergone resection and radiation therapy for neoplastic lesions in the pons. She had a history of gelastic seizures when she was in elementary school, and brief lapses of the neck and truncal muscular tone and convulsions on the left face occurred at the age of 23. After a generalized sharp wave in the ictal electroencephalogram and electromyogram recording, left orbicularis oris muscle contraction was observed followed by sudden cervical extensor atonia. Seizure propagation was noted in the cerebral cortex, left facial nerve nucleus, and brainstem reticular formation. In a simultaneous electroencephalography with functional MRI, the blood oxygen level-dependent effect related to generalized sharp waves was observed in the vicinity of brainstem lesions in addition to a decrease in bilateral frontal and parietal lobes signals, as detected in generalized seizures. These findings suggest that the lesion could be a part of the epilepsy network. Although most epileptic seizures are derived from the cerebral cortex, it is important to note that brainstem lesions are involved in seizures in the patient presented in this study.

Bell’s palsy due to congenital cholesteatoma of petrous apex: a case report

Congenital cholesteatoma (CC) is a rare disease, it accounts for 2-5% of all cholesteatomas [2] most common site being middle ear. Case report: We reported a case of 23-year-old female presented with progressive left sided facial asymmetry for 4 years and progressive hearing loss in the left ear for 2 years. She had normal left tympanic membrane and complete left lower motor neuron facial nerve palsy. High resolution computed tomography with contrast temporal bone showed extensive bony destruction, petrous apex and soft tissue lesion. Patient then proceed with transmastoid translabyrinthine approach. Diagnosis of cholesteatoma confirmed by histopathological examination (HPE). Congenital cholesteatoma of petrous apex is a rare case. It is a challenge to diagnose congenital cholesteatoma pre-operatively without specific radiological sign. This is because the disease is generally difficult to differentiate with mucocele and cholesterol granuloma on CT scan. Therefore, intraoperative diagnosis more accurate rather than the preoperative diagnosis.&#x0D; Bangladesh Med J. 2018 Jan; 47 (1): 41-43

Osteopetrosis craniopathy: a rare cause of bilateral compressive optic neuropathy and facial nerve palsy

A 10-year-old girl with underlying osteopetrosis presented with left-sided lagophthalmos (inability to close the eyelids completely) associated with painless blurring of vision for many months. She denied any previous ocular...

Meatal Anterior Inferior Cerebellar Artery Aneurysm with AICA-PICA Complex: Endovascular Coiling and Parent Artery Preservation

AbstractSecondary stroke prevention requires early initiation of antiplatelet; therefore, stroke mimics need to be ruled out particularly in circumstances when antiplatelet therapy can be of disastrous consequences. A 54-year-old female patient presented to the emergency department with symptoms of sudden-onset deviation of angle of mouth to the right side, left eye ptosis, and occipital headache for past 4-hour duration. Neurologic examination revealed right-sided gaze-dependent torsional nystagmus and left lower motor neuron facial weakness. An embolic posterior circulation stroke secondary to vertebral artery dissection was suspected. Diffusion-weighted imaging (DWI) did not show any acute infarcts, and careful review of susceptibility-weighted imaging (SWI) scans showed hemorrhage in the fourth ventricle. Subsequent digital subtraction angiography (DSA) was done, which showed left anterior inferior cerebellar artery (AICA) aneurysm involving its intrameatal segment with AICA-posterior inferior cerebellar artery (PICA) complex. Retrospective review of computed tomographic (CT) angiography images showed small aneurysm in the internal auditory meatus, which is difficult to discern secondary to adjacent bony structure and smaller size of the aneurysm. The patient underwent endovascular coiling of the aneurysm with preservation of the parent artery. Our experience concluded that these clinical features suggest remote subarachnoid hemorrhage secondary to the ruptured of AICA intrameatal segment aneurysm with left facial nerve paralysis and peripheral cochlear vestibular changes secondary to either compression (mechanical or pulsations of the aneurysm sac) or ischemia of vestibular apparatus. The neurointerventionist should consider the possibility of aneurysmal rupture, especially in cases of atypical location of hemorrhage and no signs of infarct on neuroimaging of posterior circulation stroke.

Differences in functional brain alterations driven by right or left facial nerve efferent dysfunction: Evidence from early Bell's palsy.

Bell's palsy is defined as idiopathic unilateral facial nerve palsy. Early Bell's palsy is characterized by emerging asymmetric motor conduction of the facial nerve and obvious imbalance of facial muscle movement, which can result in a substantial psychological impact on patients and trigger brain cortical functional reorganization. However, the differences between the brain functional alterations were driven by right or left facial nerve efferent dysfunction in patients with early Bell's palsy are not fully understood. The neuroimage study in patients with different-sided Bell's palsy in the early stage will help to understand the different mechanisms involved in functional integration driven by unilateral facial efferent nerve dysfunction and to provide the theoretical foundation for the choice of suitable treatment strategy. Sixty-seven patients and 37 age- and sex-matched healthy controls were recruited to undergo resting-state functional magnetic resonance imaging (R-fMRI). Regional brain activity was analyzed by comparing the fractional amplitude of low-frequency fluctuations (fALFF) between right palsy and healthy control, left palsy and healthy control, and right and left palsy groups. The altered brain regions were further selected as seeds in subsequent functional connectivity (FC) analysis, and the correlations between the Toronto Facial Grading System (TFGS) scores and the connectivity alterations were also analyzed. The right and left Bell's palsy groups showed fALFF alterations compared with the healthy control group, and several brain regions with different fALFF values between the right and left palsy groups were identified. In the right palsy group, overall inter-regional FC increased in the right supramarginal gyrus (SMG), bilateral superior frontal gyrus (SFG), and left precentral gyrus (PreCG), compared with the left palsy group. Furthermore, the brain region pairs with higher FC in the right palsy group were left temporal pole of the superior temporal gyrus (TPOsup) and right SMG, left TPOsup and middle cingulate cortex (MCC), left TPOsup and left PreCG, right SMG and SFG, MCC and left PreCG, left and right SFG, and right SFG and left PreCG. In the right palsy group, the left TPOsup and PreCG showed a negative correlation with the TFGS score, while the right SFG and left PreCG showed a positive correlation with the TFGS scores. In the left palsy group, the left TPOsup and right SMG, and the right SMG and SFG region pairs showed a negative correlation with the TFGS score. The fALFF and FC analyses revealed the remodeling of different brain functional networks driven by right or left facial nerve efferent dysfunction in patients with early Bell's palsy. The reintegration mechanisms differed between patients with right and left Bell's palsy. Additionally, the severity of the disease showed different associations with altered FC.

Aneurysmal bone cyst: а case report

The study objective is to describe a clinical case of intracranial aneurysmal bone cyst in a 9-year-old patient with peripheral facial nerve paresis on the left.Materials and methods. In a 9-year-old patient with facial asymmetry and pain syndrome on the results of magnetic resonance imaging of the brain with contrast in the upper edge of the left temporal bone pyramid revealed inhomogeneous encapsulated lesion with the level of media separation in the structure, high-intensity zones on T1and T2-weighted images, additional intracranial lesion in the left temporal region. Multispiral computer tomography of the brain revealed a cystic-solid lesion with clear contours, causing destruction of the pyramid of the left temporal bone. Lesion spreads to the middle cranial fossa with compression of the basal parts of the left temporal lobe. The diagnosis was made: neoplasm of the left temporal bone (possibly primary cholesteatoma) with destruction of the pyramid and petrosal part of the temporal bone and clivus with suppuration and formation of abscess of the left temporal lobe. Left facial nerve paresis. Osteo-plastic trepanation of the skull in the left temporal region, microsurgical removal of the tumor of the base of the middle cranial fossa on the left and plastic of the skull base defect with abdominal fat were performed.Results. The postoperative period was uneventful. The patient complained of moderate headaches in the area of operative access. The wound healed by primary tension. Positive dynamics in neurological status in the form of regression of left facial nerve paresis was noted. Based on the data of morphological and immunohistochemical studies, an aneurysmal bone cyst was diagnosed.Conclusion. The method of choice in the treatment of an aneurysmal bone cyst of the skull base is the en block removal. In case of impossibility of carrying out radical operation radiotherapy and embolization of the vessels feeding a cyst can be used, however convincing researches about their efficiency in such cases are not published. Aneurysmal bone cyst is uncommon, and to differentiate it from chondroblastoma, teleangiectatic osteosarcoma and giant cell tumors is rather difficult, therefore, it is necessary to increase the level of knowledge about this nosology.

Carotid body paragangliomas – clinical variety and management (RCD code: I-O)

Paragangliomas (PGLs) are a group of rare, slow-growing tumours which are found between the base of the skull and the pelvis. The tumour may be asymptomatic, although a lump on the neck, cranial nerve palsy, or neck pain may be present. The treatment of choice is surgical resection. We present the cases of 7 patients (6 females) diagnosed with 9 PGLs of the carotid body (carotid body tumours – CBTs). These include: one case with known genetic burden, one of an advanced bilateral and recurrent tumour, and one with a malignant tumour. All presented CBTs were surgically removed. The size of a tumour correlates with postoperative complications. Resection of the largest lesion was associated with persistent left recurrent laryngeal, hypoglossal, and partial facial nerve paralysis. Other complications included single cranial nerve palsy and temporary Horner syndrome. JRCD 2018; 4 (1): 9-14.

Microvascular Decompression of Facial Nerve and Pexy of the Left Vertebral Artery for Left Hemifacial Spasm: 3-Dimensional Operative Video.

A 73-yr-old man presented with intractable left hemifacial spasm of 4 yr duration. Brain magnetic resonance imaging showed significant compression of left facial nerve by the left vertebral artery (VA) and anterior inferior cerebellar artery (AICA).The patient underwent a left retrosigmoid craniotomy and a microvascular decompression of the cranial nerve (CN) VII. Intraoperatively, we found that the distal AICA had a protracted subarcuate extradural course.1 This was relieved by intra/extradural dissection. The left VA and the AICA loop were compressing the root exit zone of CN VII. The VA was mobilized, and pexy into the petrosal dura was done with 8-0 nylon sutures (Ethilon Nylon Suture, Ethicon Inc, a subsidiary of Johnson & Johnson, Somerville, New Jersey). Once this was done, the lateral spread disappeared.2 The AICA loop was decompressed with 2 pieces of Teflon felt (Bard PTFE felt, Bard peripheral Vascular Inc, a subsidiary of CR Bard Inc, Temp, Arizona). After this, wave V of the brainstem auditory evoked potential (BAEP) disappeared completely, with no recovery despite the application of the nicardipine on the internal auditory artery (IAA). The IAA appeared to be stretched by the microvascular decompression. Arachnoidal dissection was done to release the CN VIII and an additional felt piece was placed to elevate the AICA loop; the BAEP recovered completely. The patient had a complete disappearance of the hemifacial spasm postoperatively, and hearing was unchanged.This 3-D video shows the technical nuances of performing a vertebropexy, release of the AICA from its extradural subarcuate course, and the surgical maneuvers in the event of an unexpected change in neuromonitoring response. The suture technique of vertebropexy is preferred to a loop technique, to avoid kinking of the VA.3Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Retrosigmoid Craniotomy for the Removal of Left Sided Tentorial and Posterior Fossa Meningioma Combined with Microvascular Decompression for Hemifacial Spasm.

This 68-year-old woman presented with repeated episodes of bilateral hemifacial spasm with headache for 5 years and with recent progression of left sided symptoms. Preoperative imaging showed a left sided tentorial meningioma with brain stem and cerebellar compression. Left facial nerve was compressed by the vertebral artery (VA) and the right facial nerve by the anterior inferior cerebellar artery (AICA). This patient underwent left side retrosigmoid craniotomy and mastoidectomy. The cisterna magna was drained to relax the brain. The tumor was very firm, attached to the tentorium and had medial and lateral lobules. The superior cerebellar artery was adherent to the lateral lobule of the tumor and dissected away. The tumor was detached from its tentorial base; we first removed the lateral lobule. Following this, the medial lobule was also completely dissected and removed. The root exit zone of cranial nerve (CN) VII was dissected and exposed. The compression was caused both by a prominent VA and AICA. Initially, the several pieces of Teflon felt were placed for the decompression. Then vertebropexy was performed by using 8–0 nylon suture placed through the VA media to the clival dura. A further piece of Teflon felt was placed between cerebellopontine angle region and AICA. Her hemifacial spasm resolved postoperatively, and she discharged home 1 week later. Postoperative imaging showed complete tumor removal and decompression of left CN VII. This video shows the complex surgery of microsurgical resection of a large tentorial meningioma and microvascular decompression with a vertebropexy procedure. The link to the video can be found at: https://youtu.be/N5aHN9CRJeM .

Levamisol-induced leukoencephalopathy: clinical case

This is a description of a clinical case of levamisole-induced leukoencephalopathy. A few hours after the single intake of the immunomodulator levamisole (150 mg), the patient developed following cerebral symptoms: febrile fever, dizziness, frequent urination, impaired color vision, divergent strabismus, unsteady gait, severe weakness, increased drowsiness, retardation, delusions. The symptoms progressed towards a full clinical picture for about 2 months. The course of the disease was of a wavy nature: left-sided hemiparesis and the left facial nerve palsy were present at the beginning, with later inversion of symptoms represented by the right-sided hemiparesis and the right facial nerve palsy combined with dysarthria. Magnetic resonance imaging (MRI) revealed multiple foci of demyelination in both hemispheres of the brain that regressed after corticosteroid therapy administration. No abnormalities of the cerebrospinal fluid were detected. No pathology of the fundus was evident. The evoked potentials of the brainstem (auditory and visual) and somatosensory evoked potentials from the hands and feet were within normal limits. Plasmapheresis (3 procedures, each 2 liter, with intravenous administration of 1 g of solu-medrol after each session) was performed in the acute phase, which benefited the decrease in severity of the neurological symptoms. Vascular and metabolic therapy was performed afterwards, with the regression of the neurologic symptoms. No specific therapy was administered after the woman was discharged from the hospital. For a 10-year survey after the acute demyelinating process outbreak there’s a complete regression of neurologic symptoms and positive dynamics of the patient’s MRI. The woman is fully adapted physically, emotionally and socially.

Neglected left intraparotid facial nerve schwannoma causing complete facial nerve palsy: A case report

Extracranial schwannomas in the head and neck region are relatively rare neoplasms. The tumours are slow growing and often unnoticeable. The nerve of origin is unable to be determined until the time of surgery. Proper preoperative assessment of the disease can be done by imaging studies such as magnetic resonance imaging. The treatment for these tumours is surgical resection with preservation of the neural pathway. We report a case of left intraparotid facial nerve schwannoma in a middle-aged lady causing complete facial nerve paralysis. The clinical features, diagnostic possibilities and management are discussedBangladesh Journal of Medical Science Vol.17(4) 2018 p.680-682