Decompression Surgery in Elderly Patients with Hemifacial Spasm Refractory to Botulinum Toxin

BACKGROUND

Botulinum toxin is an effective treatment for hemifacial spasm in elderly patients. However, some patients do not tolerate the side effects and frequency of botulinum toxin treatments.

OBJECTIVES

The purpose of this study was to evaluate the characteristics and outcomes of a cohort of elderly patients referred by neurologists for surgical decompression of the facial nerve following botulinum toxin treatment.

METHODS

In a prospective cohort study, logistic regression was used to detect potential predictors of spasm-freedom after surgical decompression of the facial nerve in elderly patients that received ≤8 and >8 botulinum toxin treatments for hemifacial spasm before surgery. Age, sex, side, preoperative symptom duration, and preoperative botulinum toxin treatment were assessed as potential predictors of spasm-freedom at last follow-up.

RESULTS

Of 76 elderly patients with hemifacial spasm treated with botulinum toxin and microvascular decompression, with at least 2-years of follow-up (median, 44.5 months), 84.2% were spasm-free at last follow-up. Age (P = 0.38), sex (P = 0.59), side (P = 0.15), preoperative symptom duration (P = 0.7), and number of preoperative botulinum toxin treatments (P = 0.3) were not predictors of long-term spasm-freedom. Permanent ipsilateral hearing loss was the most frequent complication (3.9%).

CONCLUSION

This study provides evidence that elderly patients can undergo botulinum toxin treatment for hemifacial spasm without compromising their likelihood of achieving spasm-freedom with future surgical decompression. Therefore, surgical decompression of the facial nerve is an effective therapy for elderly patients with hemifacial spasm refractory to botulinum toxin.

A Rare Combined Trigeminal Neuralgia with Hemifacial Spasm in a 78-year-old Male Patient

This case reported a 78-year-old male patient presented with combined trigeminal neuralgia and hemifacial spasm, which is a rare finding and seldom addressed. Magnetic resonance imaging examination showed compression of right N.V by the right superior cerebellar artery (SCA) but did not prove any compression on the right N.VII. This patient is treated with microvascular decompression, and we found out compression of right N.V by right SCA and N.VII from the right anterior inferior cerebellar artery. Postoperatively, the symptoms were resolved with transient hypoesthesia and no recurrence after 1-year follow-up.

Prospective, Multicenter Clinical Study of Microvascular Decompression for Hemifacial Spasm

BACKGROUND

Microvascular decompression (MVD) is the most effective procedure for hemifacial spasm (HFS). MVD results from nonspecialized or low-volume institutes are not always reliable. Most studies on MVD for HFS are retrospective and single centered; to the best of our knowledge, no prospective, multicenter studies exist.

OBJECTIVE

To evaluate short- and long-term outcomes and complications in patients who underwent MVD for HFS in specialized Japanese institutions, in this multicenter, prospective, cohort study.

METHODS

Included patients had undergone MVD for HFS in study centers between April 2012 and March 2015. Patients' postoperative grade of involuntary movements and complications were recorded postoperatively at 7 d (short-term) and at 1 (mid-term) and 3 (long-term) yr.

RESULTS

A total of 486 patients (150 men, 336 women; mean age 53.9 yr with 181 patients over 60 yr) were enrolled during the study period. Neuromonitoring was used in 96.3% of the cases. The complete cure rate of symptom relief, mortality rate, and complication rate at short-term follow-up were 70.6%, 0%, and 15%, respectively. The long-term follow-up was completed by 463 patients (95.3%); the complete cure rate of symptom relief and complication rate were 87.1% and 3.0%, respectively.

CONCLUSION

Our study revealed that under expert guidance and intraoperative neuromonitoring, the long-term curative effect rate of MVD for HFS is high, while complications are uncommon and usually transient. Our results indicate that MVD is an effective and safe treatment for patients with HFS, including elderly patients.

Hearing Outcomes after Microvascular Decompression for Hemifacial Spasm: An Institutional Experience

Introduction

Hearing loss following microvascular decompression (MVD) for hemifacial spasm is one of the most dreaded complications. Several factors such as stretching of VIII cranial nerve, vasospasm of labyrinthine artery, and acoustic trauma due to drill noise may be considered in its causation. We evaluated the incidence and severity of hearing loss following MVD in hemifacial spasm and the factors which might be responsible for this complication.

Methods

A retrospective analysis of 30 patients operated for hemifacial spasm between January 1, 2014, and December 31, 2018, with at least 3 months of follow-up were included in the study. Retromastoid craniotomy was made, and Teflon was placed between involved vessel and VII nerve.

Results

Freedom from hemifacial spasm was noted in 27 of 30 patients. Moderate spasm persisted in one patient, which was controlled with medications. The recurrence was noted in 3 patients at 6 months follow-up. Postoperatively, hearing loss was found in one female patient. The offending vessel was both anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA) loop, which was transpositioned during surgery, and the patient was spasm free postoperatively.

Conclusion

The incidence of hearing loss following MVD can be minimized using proper surgical techniques and various intraoperative adjuncts such as brainstem auditory evoked responses monitoring, use of endoscope, and indocyanine green or dual-image video angiography.

Neurotologic Complications Following Microvascular Decompression: A Retrospective Study

Objective  The main purpose of this article is to determine the frequency of neurotologic complications after posterior fossa microvascular decompression (MVD) surgery. Design  Retrospective case review. Setting  Tertiary care referral center. Participants  A total of 215 consecutive MVD operations by a single surgeon between March 1996 and May 2016 were reviewed with 192 surgeries on 183 patients meeting inclusion criteria. Main Outcome Measures  Neurotologic complications secondary to MVD. Results  The 52 males and 131 females had a mean age of 58.52 years (range, 28-92 years). Indications for MVD were trigeminal neuralgia ( n  = 162), hemifacial spasm ( n  = 23), glossopharyngeal neuralgia ( n  = 13), vagal palsy ( n  = 1), and tinnitus ( n  = 1). The outcomes examined were postoperative hearing loss, tinnitus, vertigo, and hemifacial paresis. At least one of these complications was present in 17.7% of patients. There were 4.17% with permanent hearing loss, 6.77% with transient hearing loss, 5.21% with tinnitus, 5.73% with vertigo, and 0.52% with hemifacial paresis. There was no significant difference in complication rates based on surgical indication. Conclusions  Neurotologic complications are a significant risk when performing MVD. It is important for otolaryngologists as well as neurosurgeons to be aware of such complications. We recommend perioperative audiometry in all patients undergoing MVD and believe there is utility in routine otolaryngologist involvement.

Veins of the Cerebellopontine Angle and Specific Complications of Sacrifice, with Special Emphasis on Microvascular Decompression Surgery. A Review

Good knowledge of the anatomy of veins is of crucial importance for the functional surgery of cranial nerve (CN) disorders, especially microvascular decompression for trigeminal neuralgia (TN), hemifacial spasm (HFS), and vagoglossopharyngeal neuralgia (VGPN). Although controversial, veins may be involved in neurovascular conflicts and may constitute dangerous obstacles to access to the CNs. With the aim of estimating the implications of veins in those diseases and evaluating the linked surgical difficulties, we carried out a review of the literature from 2000 to the end of February 2018. For this review, articles found on PubMed that gave enough precision about veins were retained (39 articles on TN, 38 on HFS, 8 on VGPN, and 26 on complications related to venous sacrifices). Before this review, we described a simplified anatomic classification of veins, amenable to easing the surgical approach to CNs. Access to the trigeminal nerve, via the infratentorial-supracerebellar route, is almost always affected by the superficial superior petrosal venous system, whereas access to the facial and cochleovestibular complex as well as to the lower CNs, through the infrafloccular trajectory, is almost always exempt of important venous obstacles. Respective incidences of venous compression at the origin of hyperactive CN syndromes are given. The percentages of a venous conflict alone were calculated at 10.8% for TN, 0.1% for HFS, and 2.9% for VGPN. We review the complications considered in relation with venous sacrifices. Precautions to minimize these complications are given.

Severe Hemifacial Spasm is a Predictor of Severe Indentation and Facial Palsy after Microdecompression Surgery

Background and Purpose

Hemifacial spasm (HFS) is mostly caused by the compression of the facial nerve by cerebral vessels, but the significance of spasm severity remains unclear. We investigated the clinical significance of spasm severity in patients with HFS who underwent microvascular decompression (MVD).

Methods

We enrolled 636 patients with HFS who underwent MVD between May 2010 and December 2013 at Samsung Medical Center (SMC), Seoul, Korea. Subjects were divided into two groups based on spasm severity: severe (SMC grade 3 or 4) and mild (SMC grade 1 or 2). We compared demographic, clinical, and surgical data between these two groups.

Results

The severe-spasm group was older and had a longer disease duration at the time of MVD compared to the mild-spasm group. Additionally, hypertension and diabetes mellitus were more common in the severe-spasm group than in the mild-spasm group. Regarding surgical findings, there were more patients with multiple offending vessels and more-severe indentations in the severe-spasm group than in the mild-spasm group. Even though the surgical outcomes did not differ, the incidence of delayed facial palsy after MVD was higher in the severe-spasm group than in the mild-spasm group. Logistic regression analysis showed that severe-spasm was correlated with longer disease duration, hypertension, severe indentation, multiple offending vessels, and delayed facial palsy after MVD.

Conclusions

Spasm severity does not predict surgical outcomes, but it can be used as a marker of pathologic compression in MVD for HFS, and be considered as a predictor of delayed facial palsy after MVD.

Combined Hyperactive Dysfunction Syndrome of the Cranial Nerves: A Retrospective Systematic Study of Clinical Characteristics in 44 Patients

BACKGROUND

Combined hyperactive dysfunction syndrome (HDS) is defined as the combination symptoms arising from overactivity in cranial nerves, specifically, trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN), without an obvious explanatory structural lesion. This study retrospectively analyzes the clinical characteristics of combined HDS treated with microvascular decompression (MVD) in a single institution.

METHODS

A total of 1450 patients with HDS were treated with MVD in our department during a 10-year period, among which 44 cases of combined HDS were identified. Clinical records and follow-ups were reviewed.

RESULTS

Combined HDS comprised 3.03% (44/1450) of all HDS in our series, with female predominance compared with single HDS (P = 0.002), including combined TN-HFS (14 cases), combined TN-GPN (26 cases), bilateral TN (2 cases), and combined TN-HFS-GPN (2 cases). The average age at diagnosis of patients with combined HDS (60.9 years) was significantly older than that of patients with single HDS (53.5 years) (P = 0.035). Hypertension was closely associated with the prevalence of combined HDS compared with single HDS (P = 0.009). The curative rate was 97.7% (43/44) after MVD, and the recurrence rate was 3.33%. The incidence rates of postoperative cardiac, pulmonary, thromboembolic, and delirium complications were higher in combined HDS than in single HDS (P < 0.05).

CONCLUSIONS

Combined HDS is a rarely occurring syndrome usually observed in older females, and the most common types are combined TN-GPN and combined TN-HFS. Age and gender seemed to be causes for developing combined HDS, and MVD shows potential as a favorable treatment choice.