Hemifacial spasm due to cerebellopontine angle lipoma: case report

Evaluating the utility of a scoring system for lipomas of the cerebellopontine angle

BACKGROUND

Cerebellopontine angle (CPA) lipomas are rare, benign, slow-growing masses. Resections are considered in symptomatic patients who are refractory to targeted medical therapies, but at those stages the lipomas have often reached considerable sizes and encompass critical neurovascular structures. The objective of this study is to develop and to evaluate the utility of a scoring system for CPA lipomas. The hypothesis is that CPA lipomas with lower scores are probably best managed with early surgery.

METHODS

The PubMed database was searched using relevant terms. Data on patient and lipoma characteristics were extracted and used to design a scoring system. CPA lipomas were stratified by scores with corresponding managements and outcomes analyzed.

RESULTS

One hundred and seventeen patients with CPA lipomas were identified and 40 CPA lipomas were scored. The remaining CPA lipomas were deficient in data and not scored. No lipomas were scored as 1. Score 2 lipomas (n = 12; 30%) most often underwent serial surveillances (n = 5; 41.6%), with the majority of symptoms remaining unimproved (n = 2; 40%). Patients with score 2 CPA lipomas treated with medical therapies (n = 3; 25%) often experienced symptom resolution (n = 2; 66.6%) (p = 0.0499). Patients with score 2 CPA lipomas undergoing surgical resections (n = 3; 25%) all experienced symptom resolution (n = 3; 100%) (p = 0.0499). Score 3 was most common (n = 16; 40%) and these lipomas were often surgically resected (n = 10; 62.5%). The majority of patients with score 3 CPA lipomas having undergone surgical resections (n = 10; 62.5%) experienced symptom improvement (n = 1; 10%) or resolution (n = 4; 40%).

CONCLUSIONS

Score 2 CPA lipomas are smaller and would be deemed non-surgical in general practice. However, our data suggest that these lipomas may benefit from either medical therapies or early surgical resections. The advantages of early surgery are maximal resection, decreased surgical morbidity, and improved symptom relief.

Management of cerebellopontine angle lipomas: need for long-term radiologic surveillance?

OBJECTIVE

To date, only a very limited number of lipomas of the cerebellopontine angle (CPA) have been reported. Our objective was to examine clinical and radiologic features of CPA lipomas and determine the most appropriate management plan.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

Patients with CPA lipomas were identified through the skull base multidisciplinary meeting database.

INTERVENTIONS

Radiologic surveillance and clinical assessment.

MAIN OUTCOME MEASURES

Tumor growth, assessed through radiologic measurements on serial magnetic resonance imaging, demographics, presenting symptoms, and any correlation between weight gain and lipoma growth were among the examined factors.

RESULTS

Of the 15 patients with CPA lipomas, six were female and nine were male, with an average age at presentation of 50.2 years (range, 31.7-76.4 yr) and an average follow-up time of 51.7 months (range, 6-216 mo). The lipomas were unilateral in all cases, nine on the right (60%) and six on the left (40%) side. None of the lipomas increased in size. All patients were treated conservatively. Sensorineural hearing loss was the main presenting symptom (80%) followed by tinnitus (46.7%) and vertigo (20%). None of the patients suffered from facial nerve dysfunction. There was no correlation between weight gain and tumor growth.

CONCLUSION

CPA lipomas can be diagnosed accurately with appropriate magnetic resonance imaging techniques and be managed conservatively with safety. Cochleovestibular are the most common presenting symptoms, whereas facial nerve involvement is rare. CPA lipomas do not tend to grow and can be monitored on a less regular basis.

Hemifacial spasm due to a large distant ipsilateral posterior fossa meningioma

A rare case of hemifacial spasm due to an ipsilateral foramen magnum/clival meningioma is described. Magnetic resonance imaging demonstrated that the tumor was located distant to the cranial nerve VII/VIII complex. Resolution of the ipsilateral hemifacial spasm was noted after complete resection of the tumor. The mechanism of hemifacial spasm was likely due to displacement and distortion of the brain stem from the lesion distant to the cranial nerve VII/VIII complex. In our review of the literature this is the first reported case of an ipsilateral posterior fossa meningioma causing hemifacial spasm from indirect mass effect.

Cerebellopontine angle lipoma: a rare differential diagnosis

Intracranial lipomas in an infratentorial and extra-axial location are extremely rare. The presented case of an extensive lipoma of the cerebellopontine angle (CPA) represents 0.05% of all CPA tumors operated on in our department from 1978 to 1996. The lipoma constitutes an important differential diagnosis because the clinical management differs significantly from other CPA lesions. The clinical presentation and management of the presented case are analyzed in comparison to all previously described cases of CPA lipomas. The etiology and the radiological features of CPA lipomas are reviewed and discussed. CPA lipomas are maldevelopmental lesions that may cause slowly progressive symptoms. Neuroradiology enables a reliable preoperative diagnosis. Attempts of complete lipoma resection usually result in severe neurological deficits. Therefore, we recommend a conservative approach in managing these patients. Limited surgery is indicated if the patient has an associated vascular compression syndrome or suffers from disabling vertigo.

The many faces of hemifacial spasm: differential diagnosis of unilateral facial spasms

Hemifacial spasm is defined as unilateral, involuntary, irregular clonic or tonic movement of muscles innervated by the seventh cranial nerve. Most frequently attributed to vascular loop compression at the root exit zone of the facial nerve, there are many other etiologies of unilateral facial movements that must be considered in the differential diagnosis of hemifacial spasm. The primary purpose of this review is to draw attention to the marked heterogeneity of unilateral facial spasms and to focus on clinical characteristics of mimickers of hemifacial spasm and on atypical presentations of nonvascular cases. In addition to a comprehensive review of the literature on hemifacial spasm, medical records and videos of consecutive patients referred to the Movement Disorders Clinic at Baylor College of Medicine for hemifacial spasm between 2000 and 2010 were reviewed, and videos of illustrative cases were edited. Among 215 patients referred for evaluation of hemifacial spasm, 133 (62%) were classified as primary or idiopathic hemifacial spasm (presumably caused by vascular compression of the ipsilateral facial nerve), and 4 (2%) had hereditary hemifacial spasm. Secondary causes were found in 40 patients (19%) and included Bell's palsy (n=23, 11%), facial nerve injury (n=13, 6%), demyelination (n=2), and brain vascular insults (n=2). There were an additional 38 patients (18%) with hemifacial spasm mimickers classified as psychogenic, tics, dystonia, myoclonus, and hemimasticatory spasm. We concluded that although most cases of hemifacial spasm are idiopathic and probably caused by vascular compression of the facial nerve, other etiologies should be considered in the differential diagnosis, particularly if there are atypical features.

CEREBELLOPONTINE ANGLE ARACHNOID CYST: A CASE OF HEMIFACIAL SPASM CAUSED BY AN ORGANIC LESION OTHER THAN NEUROVASCULAR COMPRESSION

OBJECTIVE

A rare case of cerebellopontine angle arachnoid cyst manifesting as hemifacial spasm (HFS) is reported. The patient is a 42-year-old woman with 10-month history of left HFS. A preoperative magnetic resonance imaging scan showed a well-demarcated area, hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging, in the left cerebellopontine angle, without contrast enhancement, resembling an arachnoid cyst.

METHODS

The cyst was excised with microneurosurgical technique and the facial, vestibular, and acoustic nerves were completely decompressed from the arachnoid wall.

RESULTS

The postoperative course was uneventful, and the left HFS disappeared immediately. Histologically, the cyst wall was a typical arachnoidal membrane. Ten months after surgery, the patient is symptom free.

CONCLUSION

It is well-known that in approximately 10% of cases, trigeminal neuralgia can be caused by a space-occupying mass. However, the fact that HFS can also be caused by organic lesions as well as neurovascular compression is less well-known. Although the occurrence of tumor compression causing HFS has been previously recognized, cerebellopontine angle cysts have very rarely been described. The observation of a patient with a cerebellopontine angle arachnoid cyst causing HFS prompted us to review the literature relative to HFS caused by an organic lesion rather than neurovascular compression.

MICROVASCULAR DECOMPRESSION IN HEMIFACIAL SPASM RESULTING FROM A CEREBELLOPONTINE ANGLE LIPOMA

OBJECTIVE

Hemifacial spasm caused by a cerebellopontine angle lipoma is extremely rare. We describe a patient with left-sided hemifacial spasm caused by vascular compression of the facial and vestibulocochlear cranial nerves by the anteroinferior cerebellar artery embedded within a cerebellopontine angle lipoma.

CLINICAL PRESENTATION

A 77-year-old man presented with a 10-year history of left-sided facial spasms that progressively worsened over time and significantly interfered with his ability to read, drive, and interact in social situations. Neurological examination showed obvious left hemifacial spasm, including orbicularis oculi and levator labii muscles. Magnetic resonance imaging revealed characteristic abnormal signal within the cerebellopontine angle cistern that was consistent with lipoma abutting the anteroinferior cerebellar artery.

INTERVENTION

Surgical exploration with standard retrosigmoid craniectomy and subarachnoid dissection of the cerebellopontine angle was performed. The offending anteroinferior cerebellar artery branch was dissected away from the VIIth and VIIIth cranial nerves. Teflon felt was interposed between the artery and nerves after the artery was dissected off the surface of the lipoma. Electrophysiological monitoring showed resolution of the abnormal hemifacial spasm response during the procedure. No attempt was made to resect the lipoma, given the risk to injury of the brainstem and perforating blood vessels. Postoperatively, the patient's symptoms were completely resolved.

CONCLUSION

This case demonstrates that relief of the vascular compression, when present, of the VIIth cranial nerve is sufficient for resolution of hemifacial spasm symptoms, even when associated with nearby, benign lesions.

Cerebellopontine Angle Lipomas: Report of Four Cases and Review of the Literature

OBJECTIVE:

To define the management of internal acoustic meatus and cerebellopontine angle (CPA) lipomas according to their clinical, histological, and surgical characteristics.

METHODS:

We report four new cases of CPA lipomas diagnosed in the Department of Otorhinolaryngology–Head and Neck Surgery of Hôpital Pitié-Salpêtrière and review 94 cases reported previously in the literature.

RESULTS:

Lipomas represented 0.14% of CPA and internal acoustic meatus tumors. Localization was on the left side in 59.9%, on the right side in 37%, and bilateral in 3.1% of the patients. The diagnosis was confirmed radiologically in 33 of 98 patients, surgically in 60 patients, and by autopsy in 5 patients. The most frequent associated symptoms were of cochleovestibular origin, such as hearing loss (62.2%), dizziness (43.3%), and unilateral tinnitus (42.2%). Other associated symptoms involved the facial nerve (9%) or the trigeminal nerve (14.4%). Complete resection was performed in only 32.8% of the patients with frequent cranial nerve involvement. Frequent cranial nerve involvement was seen in 95.4% of all patients. After surgery, patient symptomatology was unchanged in 9.2% of the patients, and 50% were improved; however, new postoperative deficits occurred in two-thirds of the patients. Overall, 72.2% of the patients experienced new postoperative deficits such as hearing loss (64.8%). Preservation of hearing was possible in only 26% of the patients. Only 18% of patients were improved after surgery without any new postoperative deficits.

CONCLUSION:

Preoperative diagnosis of internal acoustic meatus/CPA lipomas is based on magnetic resonance imaging. The aim of surgery in these cases is not tumor removal but cranial nerve decompression or vestibular transection, and surgery is performed only in patients with disabling and uncontrolled symptoms.

[Cerebellopontine angle lipoma: clinical case]

Lipomas of the cerebellopontine angle are extremely rare. These tumors are probably maldevelopment lesions which can cause slowly progressive neurological symptoms. Including the present case, 90 lipomas in this localization have been described in the literature. The authors report a case of cerebellopontine angle lipoma in a 44-year-old male patient who suffered right hearing loss and tinnitus during seven months. The literature concerning this rare cerebellopontine angle tumor is review. The symptoms, radiological features and surgical management are discussed.

Transient hemifacial spasm associated with subarachnoid brainstem cysticercosis: a case report

The authors present the case of a 69 year old woman who developed bladder incontinence and confusion. A CT scan showed severe hydrocephalus and calcifications, prompting a ventriculoperitoneal shunt placement. On the day after operation the patient presented left hemifacial spasm. MR revealed a subarachnoid cysticercus rostral to the pons, and surgical excision was proposed. She refused surgery and was placed on prednisone. Brainstem auditory responses were absent on the left side 2 months after shunting and were still abnormal 53 months later. The hemifacial spasm disappeared 3 months after shunt placement and has not recurred in 5 years of follow-up.

Lipomas of the internal auditory canal and cerebellopontine angle

OBJECTIVE

To evaluate lipomas of the internal auditory canal (IAC) and cerebellopontine angle (CPA).

STUDY DESIGN

Retrospective review.

METHODS

Review of a multi-institutional series of 17 lipomas of the IAC/CPA, combined with a Medline review of the 67 cases reported in the world literature.

RESULTS

This series of 17 IAC/CPA lipomas is the largest reported series to date, bringing the total number of documented cases to 84. There appears to be a nearly 2:1 male to female predominance. Sixty percent were left-sided lesions, and three were bilateral. Hearing loss, dizziness, and tinnitus were the most common presenting symptoms. Surgical resection was performed in 52 (62%) of these lesions; however, total tumor removal was accomplished in only 17 (33%), which is most likely because of the fact that these tumors tend to have a poorly defined matrix and a dense adherence to neurovascular structures. Sixty-eight percent of patients experienced a new deficit postoperatively, 11% were unchanged, and only 19% improved with no new deficit. Only one documented case of tumor growth was identified; however, the reported follow-up was short (average, less than 3 years).

CONCLUSION

With the magnetic resonance imaging techniques now available, lipomas can be reliably differentiated from other masses within the CPA and IAC, so histopathologic diagnosis is rarely necessary. Because of the potential for significant morbidity with resection of these lesions, we believe that conservative follow-up is the best treatment option for patients with these rare lesions. Surgery is indicated only when significant progressive or disabling symptoms are present.

Hemifacial spasm due to posterior fossa tumors: the impact of tumor location on electrophysiological findings

Ephaptic transmission is one of the electrophysiological hallmarks of hemifacial spasm. It is generally accepted that in the majority of patients with idiopathic hemifacial spasm, microvascular compression of the facial nerve at the site where the nerve exits the brain stem is the underlying cause. Whether the actual site of the ephapse is at the site of the lesion or at a nuclear level due to hyperexcitability of the facial motor nucleus is still controversial. Rarely, hemifacial spasm may be due to space occupying lesions in the cerebellopontine angle or in the brain stem. We report the electrophysiological findings of four patients with hemifacial spasm due to extra-axial tumors in different locations of the posterior fossa. The location of the tumor was intrameatal in one patient, in the cerebellopontine angle in two patients and in the brain stem in another patient. Facial nerve motor neurographies including transcranial magnetic stimulation revealed abnormal findings in two patients. Selective stimulation of facial nerve branches demonstrated delayed (ephaptic) responses in all but one patient whose hemifacial spasm had disappeared after treatment with carbamazepine. The latencies of the delayed responses did not correlate with the tumor location. In sum, the site of ephaptic transmission cannot be reliably determined by latency measurements of the delayed response because of its variability which is probably caused by the different size and diameter of the axons participating in ephaptic transmission as well as by the extent of focal demyelination at the site of the lesion. A neuroradiological work up including MR imaging should be mandatory in all patients with hemifacial spasm because electrophysiological studies fail to differentiate between idiopathic and symptomatic hemifacial spasm.

Hemifacial spasm associated with external carotid artery compression of the facial nerve

We report a unique case of hemifacial spasm due to compression of the facial nerve by the main trunk of the external carotid artery within the parotid space. Decompression of the facial nerve as well as partial section of the proximal trunk of the nerve, caused the hemifacial spasm to disappear. Our case gives support to the theory that hemifacial spasm can be caused by pressure on the facial nerve along all its course and not only in its intra-cranial portion.

Schwannoma arising from the intermediate nerve and manifesting as hemifacial spasm. Case report

This 35-year-old man presented with left facial spasm that had persisted for 10 months. Microvascular decompression was performed to relieve the symptom. No responsible vessel could be identified during surgery, but a small mass seeming to arise from the intermediate nerve and compressing the seventh cranial nerve was removed. The histological diagnosis was Antoni-B type schwannoma. This unique case of schwannoma arising from the intermediate nerve was recognized by means of an operative microscope, and supports the idea that portions of the seventh nerve schwannoma originate from the components of the intermediate nerve.

Hemifacial spasm resulting from cerebellopontine angle lipoma: case report

A case of hemifacial spasm associated with a cerebellopontine angle lipoma is described. Both the seventh and the eighth cranial nerves were incorporated and distorted within this tumor, which seemed to be the cause of hemifacial spasm and other cranial nerve dysfunctions, but obvious vascular elements were not included. To identify a cerebellopontine angle lesion as a lipoma is very important in surgical management. Magnetic resonance imaging is essential to the differential diagnosis of the cerebellopontine angle lesion.

Hemifacial spasm caused by contralateral cerebellopontine angle meningioma: case report

A large meningioma in the cerebellopontine angle manifested itself as a contralateral hemifacial spasm. On computed tomographic and magnetic resonance imaging scans, the brain stem was markedly displaced and distorted by the tumor. After total removal of the meningioma, the hemifacial spasm completely disappeared.

Efficacy and side effects of botulinum toxin treatment for blepharospasm and hemifacial spasm

PURPOSE

To analyse the effectiveness and rate of side effects of botulinum toxin treatment for blepharospasm and hemifacial spasm.

METHODS

In a prospective trial, 81 patients with blepharospasm and 70 with hemifacial spasm were treated with botulinum toxin A in the neuroophthalmology clinic at St Vincent's Hospital, Melbourne. Some 989 treatments were given and the mean follow-up time was 28.7 months.

RESULTS

The duration of action was longer for patients with hemifacial spasm than for those with blepharospasm (median 12.0 weeks compared with 7.0 weeks, P < 0.0001). There was no change in the duration of effect over time with repeated treatments of the same dose (F = 0.4, P > 0.05). Once an effective dosage was reached, increasing the dose further did not prolong the duration of effect. There were no systemic side effects, but there were a number of local transient side effects. The most significant side effect was ptosis, which occurred in 12% of treatments given to those patients with blepharospasm and hemifacial spasm.

CONCLUSION

Botulinum toxin is an effective treatment for blepharospasm and hemifacial spasm, but there are a number of side effects, the most significant being ptosis.

Facial myokymia due to acoustic neurinoma

The case of a 62-year-old female patient who presented with facial myokymia is reported. The patient had a 13-year history of progressive left-sided hearing loss. In further course, involuntary, wormlike, rippling movements of the left facial muscles developed. Computed tomography revealed a tumor located in the left cerebellopontine angle. Electrophysiologic examinations confirmed the diagnosis of facial myokymia. The tumor, which evolved from the eighth cranial nerve, was totally removed microsurgically. The tumor was histologically verified to be an acoustic neurinoma. Postoperatively, the patient had a facial nerve paralysis, and the facial myokymia was no longer present. The present case provides further evidence that facial myokymia may be triggered by alterations at one of various sites along the course of the motor axons of the facial nerve.

Lipoma of the cerebellopontine angle. Case reports and literature review

Two patients with cerebellopontine angle (CPA) lipoma were studied. They were submitted to surgical treatment. Available literature was reviewed and 29 cases with same lesion were identified which had been treated by surgery. Clinical manifestations, possibility of diagnostic methods, surgical indications and treatment strategies are discussed. Attention is called to the peculiarities of CPA lipomas and the doubtful validity of attempting complete excision in all cases.

Parkinson-like disease by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) toxicity in Macaca fascicularis: synaptosomal metabolism and action of dihydroergocriptine

The maximal rates (Vmax) of some enzyme activities related to synaptosomal energy metabolism were studied in different types of synaptosomes from cerebellar cortex of Macaca Fascicularis (Cynomolgus monkey). Different synaptosomal populations, namely "large" and "small" synaptosomes, were isolated from the anterior lobule of the cerebellar cortex of monkeys treated p.o. with dihydroergocriptine at the dose of 12 mg/kg/day before and during the induction of a Parkinson's-like syndrome by MPTP administration (i.v., 0.3 mg/kg/day for 5 days). The enzymes were chosen according to their regulatory role and as markers of the following metabolic pathways: (a) glycolysis ((hexokinase, phosphofructokinase, lactate dehydrogenase), (b) Krebs' (TCA) cycle (citrate synthase, malate dehydrogenase), (c) amino acid, glutamate metabolism (glutamate dehydrogenase, glutamate-pyruvate- and glutamate-oxaloacetate-transaminases), (d) acetylcholine catabolism (acetylcholinesterase) and (e) ATPases, i.e. Na(+)-K(+)-ATPase, Mg(2+)-ATP synthetase, Mg(2+)-ATPase, Ca(2+)-Mg(2+)-ATPase and Ca(2+)-ATPase Low and High affinity for Ca2+. The MPTP administration modified the activities of citrate synthase, malate dehydrogenase, Na(+)-K(+)-ATPase, acetylcholinesterase and glutamate-oxaloacetate transaminase only on selected types of synaptosomes. Pharmacological treatment by dihydroergocriptine was able to recovery at the steady-state levels the activities of these enzymes, thus demonstrating a partial protective effect on these biochemical parameters.

Magnetic resonance tomographic angiography in the investigation of hemifacial spasm

Magnetic resonance angiography (MRA), combined with submillimeter magnetic resonance tomographic angiographic sections (MRTA) showed vascular compression of the 7th cranial nerve or its root exit zone (REZ) in the brain stem in 24 of 37 patients (64.86%) with hemifacial spasm. MRA alone was positive for REZ compression in only 19 (51.4%) cases, while conventional MRI was even less revealing, only 10 (27%) cases being positive.

Cerebellopontine angle lipoma

A case of a cerebellopontine angle lipoma is presented with a typical clinical, audiometric and radiological features of an acoustic neuroma. The correct pre-operative diagnosis was elusive even with the aid of magnetic resonance imaging.

Lipoma of the cerebral cortex: case report

The first clinically diagnosed and successfully operated case of a symptomatic lipoma involving the cerebral cortex is reported. The patient presented with severe headaches and recurring focal seizures with secondary generalization. Computer tomography scan and magnetic resonance imaging suggested a left frontoparietal lipoma. After undergoing a craniotomy and tumor excision, the patient has shown resolution of headaches and seizures at 1-year follow-up. Lipomas of the cerebral cortex should be excised if symptomatic and accessible.

Mitochondrial factors involved in Parkinson's disease by MPTP toxicity in Macaca fascicularis and drug effect

The maximal rates (Vmax) of some mitochondrial enzyme activities related to energy transduction (citrate synthase, succinate dehydrogenase, malate dehydrogenase, NADH-cytochrome c reductase, cytochrome oxidase) and amino acid metabolism (glutamate dehydrogenase, glutamate-pyruvate- and glutamate-oxaloacetate- transaminases) were evaluated in non-synaptic ("free") and intrasynaptic "light" and "heavy" mitochondria from hippocampus of Macaca fascicularis (Cynomolgus monkey). The different mitochondrial populations were isolated from the hippocampus of monkeys treated p.o. with dihydroergocryptine at a dose of 12 mg/kg/day before and during the induction of a Parkinson's-like syndrome by MPTP administration (i.v., 0.3 mg/kg/day for 5 days). The MPTP administration modified the activity of some enzymes related to the metabolism of glutamate and the activity of succinate dehydrogenase on selected types of mitochondria. Pharmacological treatment by dihydroergocryptine promoted return to the steady-state levels of most enzymes, demonstrating a protective effect on these biochemical parameters.

Hemifacial spasm due to tumor, aneurysm, or arteriovenous malformation

The authors report eight cases of so-called symptomatic hemifacial spasm. They had gross pathological lesions such as a tumor (one epidermoid, one neurinoma, and two meningiomas), vascular malformation (one medullary venous malformation and two arteriovenous malformations), and aneurysm. In all four cases with a tumor, no artery compressed the facial nerve at the root exit zone. In three of the four cases, the hemifacial spasm disappeared after removal of the tumor in contact with the facial nerve. Compression or encasement of the facial nerve by the tumor was the pathogenesis of the hemifacial spasm in these three cases. The remaining case with tumor (tentorial meningioma) did not have a mass or vessel that directly compressed the facial nerve at the root exit zone. However, the hemifacial spasm disappeared after the removal of the tumor. In a case with a medullary venous malformation with arterial component, an engorged draining vein compressed the root exit zone of the facial nerve. In the remaining three vascular cases--two cases of arteriovenous malformation and a case of saccular aneurysm--enlarged feeding arteries and an aneurysm directly compressed the root exit zone of the facial nerve. Not only arterial or venous but also mass compression can cause hemifacial spasm in some symptomatic cases. Surgical decompression of the facial nerve from the causative organic lesion is the primary choice of treatment.

Painful tic convulsif caused by a brain tumor: case report and review of the literature

Patient with painful tic convulsif caused by a brain tumor is presented. The patient was admitted with right trigeminal neuralgia and ipsilateral facial spasm, i.e., painful tic convulsif. Preoperative computed tomography scans showed no apparent abnormalities; however, surgery revealed that these symptoms were associated with a pearly tumor located in the cerebellopontine angle. Subtotal resection for the decompression of the right trigeminal and facial nerves was performed and resulted in complete relief of the symptoms. Histological examination demonstrated the tumor to be an epidermoid cyst.

Hemifacial spasm: a review

Hemifacial spasm can be diagnosed by observation and clinical history. It is thought to arise primarily from compression of the facial nerve at the pons, usually by an adjacent artery. Although many approaches to treatment have been tried, the most effective is microvascular decompression of the facial nerve at the pons. That operation has well-recognized risks, including ipsilateral deafness. The latter complication ordinarily can be avoided by the use of intraoperative monitoring of auditory evoked potentials.

Hemifacial spasm in an infant due to fourth ventricular ganglioglioma. Case report

The case of an infant is reported in which hemifacial spasm due to a ganglioglioma of the fourth ventricle was relieved by surgery. Previously described causes of hemifacial spasm are summarized, and the relevance of this case to theories on the pathogenesis of the condition is discussed.

Botulinum A toxin (Oculinum) in ophthalmology

Botulinum A toxin has been used to treat strabismus and a variety of spasmodic neuromuscular diseases. Botulinum toxin treatment of strabismus is not as definitive and stable as the traditional surgical approach, but it has been found most useful in postoperative overcorrection, small deviations, sensory deviations, and acute sixth nerve palsy. This toxin has been effective in the treatment of essential blepharospasm and hemifacial spasm, for which it produces temporary relief of symptoms. In addition, this treatment has been applied to lower lid entropion, myokymia, aberrant regeneration of the seventh nerve, lid retraction, corneal exposure, nystagmus, spasmodic torticollis, and adductor spastic dysphonia.

Hemifacial spasm caused by a spontaneous dissecting aneurysm of the vertebral artery. Case report

The authors describe the first reported case of dissecting aneurysm presenting with hemifacial spasm. The patient was a 58-year-old woman with left hemifacial spasm of 2 years' duration. Cranial nerve examination was otherwise normal and no other clinical symptoms were observed. Vertebral angiography revealed a fusiform enlargement of the left vertebral artery and contrast medium remaining in the intramural false lumen in the venous phase. Microvascular decompression of the facial nerve with wrapping of the aneurysm resulted in complete relief of the hemifacial spasm.

Cerebellopontine angle lipoma in a teenager

Lipomas of the cerebellopontine angle are very rare lesions. To date, 18 patients have been reported, 17 of whom were adults. A second child is described with cerebellopontine angle lipoma.

[Hemifacial spasm: results of microvascular decompression in 53 patients]

In a ten year period 53 patients with hemifacial spasm were submitted to 54 microvascular decompression procedures in the posterior fossa. The technique was the same developed by Jannetta and the initial surgical results were considered excellent in 91% of the cases. The follow-up ranges from 60 days to 7 years, with 40 patients followed for more than two years and 16 for more than five years. Only one patient presented late recurrence of the spasms. There was no death nor serious complications which were usually transient and related do the seventh and eight nerve. In four patients we found no compression of the nerve root. We concluded that no matter what the causes of hemifacial spasm or the mechanisms of action of the surgery are the results of microvascular decompression are excellent and superior to all other clinical and surgical methods of treatment.

Identification of epidural neoplasm. Radiography and bone scintigraphy in the symptomatic and asymptomatic spine

Early identification and treatment of epidural neoplasm, before the development of significant neurologic deficits, provides the best opportunity for a favorable outcome. Among the many patients with symptoms, signs, or scintigraphic or radiographic findings suggesting possible epidural disease, a small proportion will have the lesion. The selection of patients for definitive imaging of the epidural space should be based on a determination of the risk of this complication. In this study, the medical records, plain spinal radiographs, bone scintigraphs and myelograms of 43 patients were analyzed retrospectively to assess the risk of epidural disease associated with specific clinical, radiographic, and scintigraphic findings. Cervical, thoracic, and lumbosacral spinal segments were evaluated independently. Symptomatic segments (SS) (N = 41), defined by focal pain or neurologic dysfunction, were distinguished from asymptomatic segments (AS). At SS, epidural disease was found at 86% and 8% of abnormal and normal spinal radiographs, respectively (P less than 0.001), and at 69% and 0% of abnormal and normal scintigrams, respectively (P less than 0.001), whereas at AS epidural disease occurred in 43% and 3% of abnormal and normal spinal radiographs, respectively (P less than 0.001), and 14% and 7% of abnormal and normal scintigrams, respectively (P = NS). Vertebral collapse was highly predictive of an epidural lesion. Epidural disease occurred in 12% of SS and 0% of AS with an abnormal scintigram and normal radiograph, 86% of SS and 45% of AS with abnormalities on both scintigram and radiograph, and at two AS when both were normal. Decision analysis applied to these data yielded a specific conditional probability of epidural disease for each combination of clinical, scintigraphic, and radiographic findings. These data provide a basis for the selection of patients for additional evaluation of the epidural space before neurologic deficits develop.