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

A Case Report of Hemifacial Spasm Caused by Vestibular Schwannoma and Literature Review

BACKGROUND

Most cases of hemifacial spasm result from mechanical compression at the root exit zone of the facial nerve by vascular loops, and only a few cases are caused by vestibular schwannoma.

CASE PRESENTATION

We report a case of symptomatic hemifacial spasm induced by a small vestibular schwannoma that was totally resected. A 64-year-old man was admitted to our department with a 14-month history of symptomatic right-sided hemifacial spasm. During the process of microvascular decompression, no definite vessel was found to compress the facial nerve. By further exploration of regions other than root exit zone, a small vestibular schwannoma compressing the internal auditory canal portion of facial nerve from the ventral side was discovered. Resection of the tumor was then conducted. The symptoms of hemifacial spasm disappeared immediately after surgery.

CONCLUSIONS

We should be aware that magnetic resonance imaging is not always precise and perhaps misses some miniature lesions due to present image technique limitations. A small vestibular schwannoma might be the reason for HFS, although preoperative magnetic resonance tomography angiography showed possible vascular compression at the facial nerve root. More importantly, a full-length exploration of the facial nerve is in urgent need to find potential compression while performing microvascular decompression for HFS patients.

Surgical treatment of hemifacial spasm caused by fusiform vertebral artery aneurysm: case report and literature review

BACKGROUND

Root exit zone (REZ) compression by a fusiform vertebral artery (VA) aneurysm is a rare cause of hemifacial spasm (HFS). We report a case of successful microvascular decompression (MVD) for the treatment of HFS caused by a fusiform VA aneurysm. We also review the relevant literature and demonstrate the effectiveness of surgical treatment.

CASE DESCRIPTION

A 64-year-old man presented with a 2-year and 4-month history of progressive involuntary facial twitching on the right side. Radiological examination revealed a fusiform right VA aneurysm. The REZ that was compressed by the aneurysm and the underlying anterior inferior cerebellar artery (AICA) was surgically decompressed by transposing the VA and AICA and wrapping the aneurysm. Immediately post-operation, the patient's symptoms disappeared. For 7 years and 4 months postoperatively, there was no symptom recurrence or increase in aneurysm size.

CONCLUSION

MVD is an effective treatment for HFS caused by a fusiform VA aneurysm because symptoms are likely to improve immediately after treatment.

Treatment for Hemifacial Spasm Associated with a Dissecting Vertebral Artery Aneurysm Requiring Microvascular Decompression in Addition to Endovascular Trapping: A Case Report with Literature Review

BACKGROUND

 The treatment protocol for hemifacial spasm (HFS) associated with dissecting vertebral artery aneurysm (DVAA) has not been established.

CASE DESCRIPTION

 A-42-year-old man with left HFS underwent endovascular trapping for a DVAA that was identified on brain imaging. Although the dissecting segment was treated successfully, the HFS persisted for 3 months, and subsequently microvascular decompression (MVD) was needed. The posteroinferior cerebellar artery (PICA) was found to be interposed between the root exit zone of the facial nerve and DVAA during surgery. After pulling out the PICA, the HFS ceased immediately.

CONCLUSION

 HFS associated with DVAA should be considered carefully before formulating a treatment strategy. Moreover, the cause of pulsatile compression may not be visible on brain imaging, and MVD surgery may be indicated in such cases.

Hemifacial spasm caused by vertebral artery aneurysm treated by endovascular coil embolization

BACKGROUND

Hemifacial spasm (HFS) caused by vertebral artery (VA) aneurysms is rare. Several cases of HFS caused by VA aneurysms treated by endovascular parent artery occlusion (PAO) have been reported. Recently, we treated a rare case of HFS caused by a saccular VA aneurysm at the bifurcation of the posterior inferior cerebellar artery (PICA), which was successfully treated by endovascular coil embolization, preserving the parent artery, and PICA. We discuss endovascular treatment for HFS induced by VA aneurysms with a literature review.

CASE DESCRIPTION

A 59-year-old man presented with the left HFS persisting for 2 months. Magnetic resonance imaging revealed a left saccular VA-PICA aneurysm and demonstrated that a left facial nerve was compressed by the aneurysm at the root exit zone. Angiography revealed that the PICA was branching from the aneurysm neck. Endovascular coil embolization was performed using the balloon remodeling technique to preserve the left VA and PICA. HFS disappeared after treatment.

CONCLUSION

Although microvascular decompression was commonly accepted for the standard treatment of HFS, coil embolization of aneurysms without PAO may be an effective treatment for HFS caused by VA aneurysms.

Coil Embolization of VA-PICA Aneurysm Presenting with Hemifacial Spasm with Assistance of Abnormal Muscle Response Monitoring

Objective

We report a rare case of symptomatic vertebral and posterior inferior cerebellar arteries (VA-PICA) aneurysm-caused ipsilateral hemifacial spasm (HFS) for which coil embolization of the aneurysm with the assistance of abnormal muscle response (AMR) monitoring was effective.

Case Presentation

A 62-year-old woman presented with left HFS. Magnetic resonance imaging showed a saccular aneurysm of the left VA-PICA which compressed the seventh cranial nerve at its root exit zone (REZ). Stent-assisted coil embolization resulted in intraoperative disappearance of AMR in the intraoperative electrophysiological study and HFS was relieved temporally. One month after endovascular surgery, HFS slightly occurred again with the re-appearance of the AMR, although there was no recurrence of aneurysm. Thereafter, the frequency of her HFS markedly decreased to once per several days 1 year after the coiling.

Conclusion

Although complete disappearance of symptoms was not obtained, it was suggested that coil embolization is one of the therapeutic options for HFS which is caused by aneurysmal compression of REZ and intraoperative AMR is useful for identification of responsible lesions and determination of therapeutic effects.

Hemifacial spasm due to contralateral aneurysmal compression of the facial nerve successfully treated with endovascular coil embolization: case report

BACKGROUND AND IMPORTANCE

Hemifacial spasm is usually caused by compression of the facial nerve at the root exit zone (REZ), whereas fusiform aneurysmal compression is extremely rare. The authors describe symptomatic hemifacial spasm caused by a contralateral fusiform aneurysm of the vertebral artery (VA) that was treated by endovascular coil embolization.

CLINICAL PRESENTATION

A 55-year-old woman developed left hemifacial spasm that had gradually worsened over a period of 2 years before admission to our hospital. Cerebral angiography showed an elongated right VA fusiform aneurysm near the VA union that inclined toward the left side. The cause of the facial spasm was considered to be compression of the left facial nerve REZ by the aneurysm. Endovascular parent artery embolization including the aneurysm was performed. The hemifacial spasm disappeared within 3 months.

CONCLUSION

Hemifacial spasm caused by contralateral VA fusiform aneurysm can be treated by intravascular parent artery occlusion with coil embolization.

Hemifacial spasm caused by fusiform aneurysm at vertebral artery-posterior inferior cerebellar artery junction

Hemifacial spasm induced by intracranial aneurysm is a rare clinical condition. A 45-year-old male patient presented with a 3-year history of progressive involuntary twitching movement on right face. On radiological study, a dilated vascular lesion compressing the brain stem was found at the junction of vertebral artery and posterior inferior cerebellar artery. On operative field, we found the posterior inferior cerebellar artery and the fusiform aneurysm compressing root exit zone of facial nerve. Microvascular decompression was performed and the facial symptom was relieved without complications.

Microvascular decompression for hemifacial spasm associated with vertebrobasilar artery

OBJECTIVE

Hemifacial spasm (HFS) is considered as a reversible pathophysiological condition mainly induced by continuous vascular compression of the facial nerve root exit zone (REZ) at the cerebellopontine angle. As an offending vessel, vertebrobasilar artery tends to compress much more heavily than others. The authors analyzed HFS caused by vertebrobasilar artery and described the relationships between microsurgical findings and clinical courses.

METHODS

Out of 1,798 cases treated with microvascular decompression (MVD) from Jan. 1980 to Dec. 2004, the causative vessels were either vertebral artery or basilar artery in 87 patients. Seventy-nine patients were enrolled in this study. Preoperatively, computed tomography (CT) or brain magnetic resonance (MR) imaging with 3-dimentional short range MR technique was performed and CT was checked immediately or 2-3 days after anesthetic recovery. The authors retrospectively analyzed the clinical features, the compression patterns of the vessels at the time of surgery and treatment outcomes.

RESULTS

There were 47 were male and 32 female patients. HFS developed on the left side in 52 cases and on the right side in 27. The mean age of onset was 52.3 years (range 19-60) and the mean duration of symptoms was 10.7 years. Many patients (39 cases; 49.1%) had past history of hypertension. HFS caused only by the vertebral artery was 8 cases although most of the other cases were caused by vertebral artery (VA) in combination with its branching arteries. Most frequently, the VA and the posterior inferior cerebellar artery (PICA) were the simultaneous causative blood vessels comprising 32 cases (40.5%), and in 27 cases (34.2%) the VA and the anterior inferior cerebellar artery (AICA) were the offenders. Facial symptoms disappeared in 61 cases (77.2%) immediately after the operation and 68 cases (86.1%) showed good outcome after 6 months. Surgical outcome just after the operation was poor in whom the perforators arose from the offending vessels concurrently (p<0.05).

CONCLUSION

In case where the vertebral artery is a cause of HFS, commonly branching arteries associated with main arterial compression on facial REZ requires more definite treatment for proper decompression because of its relatively poor results compared to the condition caused by other vascular compressive origins.

Endovascular treatment of ruptured posterior circulation dissecting aneurysms

BACKGROUND

and aim: Dissecting aneurysms of the posterior circulation constitute a relatively uncommon subgroup of aneurysms. They account for 3-7% of cases of nontraumatic subarachnoid hemorrhage. Because of high risk, in most cases the patients require surgical or endovascular therapy. In this study we discuss the clinical efficacy of endovascular treatment with long-term follow-up in ruptured dissecting aneurysms of the posterior circulation.

MATERIALS AND METHODS

This retrospective study was conducted at our institution between January 1995 and June 2005. Eight patients (4 male; 4 females) ranging in age from 24 to 65 years (mean, 46.75 years), were included. All presented with SAH. Endovascular treatment was based on the configuration of the dissecting aneurysm. Attempt was made to occlude the dissecting aneurysm.

RESULT

A total of 8 ruptured dissecting aneurysms in the posterior circulation were treated. Out of them 5 were in the intradural vertebral artery, 2 in the basilar trunk and one in the proximal PCA. All the cases were technically successful. We have seen only two complications. The pre and post procedure (at the time of discharge) mean modified Rankin scores in the patients were 4.6 (SD 0.51) and 1.7 (SD 1.98). This improvement in Rankin score after endovascular treatment was statistically significant (Wilcoxon signed rank test, P=.017).

CONCLUSION

Endovascular management of these lesions is safe and effective mode of treatment and gives adequate protection from rebleed.

Resolution of Hemifacial Spasm after Surgical Obliteration of a Tentorial Arteriovenous Fistula: Case Report

OBJECTIVE AND IMPORTANCE:

We describe a patient with a tentorial dural arteriovenous fistula who presented with ipsilateral hemifacial spasm.

CLINICAL PRESENTATION:

A 50-year-old man sought treatment for left facial twitching that worsened over 6 months. Magnetic resonance imaging and catheter angiography demonstrated a left tentorial dural arteriovenous fistula.

INTERVENTION:

The patient underwent a retrosigmoid craniotomy and ligation of the draining vein at the site of the fistula. Intraoperative angiography showed complete obliteration of the fistula. The patient's hemifacial spasm improved significantly after the fistula was obliterated.

CONCLUSION:

Posterior fossa arteriovenous fistulas can present with a hemifacial spasm related to compression of the facial nerve by arterialized leptomeningeal veins. Microsurgical obliteration of the fistula can resolve the related symptoms.

Endovascular management of vertebrobasilar dissecting aneurysms

BACKGROUND AND PURPOSE

Several approaches to the treatment of dissecting aneurysms of the vertebrobasilar system have been used. We evaluated our endovascular experience, which includes trapping and proximal occlusion.

METHODS

Thirty-five patients with intradural vertebrobasilar dissecting aneurysms presented to our institution between 1992 and 2002. Twenty-six were treated by endovascular means and two with surgery. In the endovascular group, 14 were in a supra-posterior inferior cerebellar artery (PICA) location, and three of these extended to the vertebrobasilar junction on the initial angiogram. Ten were located in an infra-PICA location, or no antegrade flow was seen in the PICA or anterior spinal artery. Two were located at the PICA with antegrade flow preserved in the branch. Twelve lesions were treated with trapping; another 14 were initially treated with proximal occlusion techniques, two of which eventually required trapping procedures. Follow-up images were obtained within 1 year of initial treatment in 24 patients. Mean follow-up for these patients was 3.5 years.

RESULTS

Initial treatments were technically successful and without complication in all 26 patients. Follow-up examinations showed complete cure in 19 of 24 patients. One patient died of global ischemia after presenting as Hunt and Hess grade 5 with subarachanoid hemorrhage. Two recurrent hemorrhages occurred in patients in the proximal occlusion group; one died, and the other underwent a trapping procedure. One patient developed contralateral vertebral dissection 24 hours after occlusion of a dissecting aneurysm of the dominant vertebral artery and died of a brain stem infarct. Another died of probable vasospasm, and the last died of an unknown cause 1 month after treatment. Two patients had recanalization despite an initial trapping procedure, both underwent further treatment. Mortality rate was 20% in the treated group (including the two patients treated surgically), with four of five deaths occurring during the initial hospital course. Mortality rate was 50% in the six patients in the untreated group who were available for follow-up.

CONCLUSION

Dissecting aneurysms of the vertebrobasilar system remain high-risk lesions because of their natural history. They can be managed by endovascular methods according to aneurysm location, configuration, collateral circulation, and time of presentation. Trapping results in better prevention of rehemorrhage. Proximal occlusion can achieve occlusion without manipulation of the affected segment when more direct endovascular occlusion or stent placement cannot be performed.

Demonstration of neurovascular compression in trigeminal neuralgia and hemifacial spasm with magnetic resonance imaging: comparison with surgical findings in 60 consecutive cases

BACKGROUND

Until recently, it has been impossible to demonstrate vascular compression at the root entry or exit zone (REZ) of the trigeminal nerve and facial nerve in patients with trigeminal neuralgia (TN) and hemifacial spasm (HFS) preoperatively, although surgical findings have revealed apparent neurovascular compression and its correction has resulted in a good outcome in most cases. Revealing the anatomic correlation between nerves and vessels at the REZ preoperatively would be useful to predict operative findings.

METHODS

To assess whether the vascular contact of the nerve at the REZ could be demonstrated preoperatively, high-resolution magnetic resonance tomographic angiography (MRTA) was performed in 21 patients with TN and 39 with HFS. Neuroradiological findings were compared with the operative findings in all patients. Contralateral asymptomatic nerves were evaluated as a control.

RESULTS

MRTA correctly identified offending vessels in 14 (67%) of the 21 TN and 34 (87%) of the 39 HFS patients. Failure to identify neurovascular contact was noted in the cases with compression by veins or small arteries, thickened arachnoid, or distal compression. Neurovascular contact was also observed in 15% of the asymptomatic nerves. The deformity of the nerve seemed to be a more important factor for determining operative indication.

CONCLUSIONS

MRTA could demonstrate offending vessels in TN and HFS at a high rate and was useful to predict operative findings. MRTA gave supportive evidence of surgical indications in patients with TN and HFS, although attention should be paid to the fact that MRTA did not necessarily detect all of the offending vessels.

Treatment of dissecting vertebral aneurysm

SUMMARY

We report 17 patients with dissecting aneurysm of the vertebral artery (VA) who were treated by direct surgery (n=8) or interventional surgery (n=9). Eight patients presented with subarachnoid hemorrhage (SAH) and nine with ischemia. Ten patients were treated by trapping of the aneurysm that was occlusion of the VA on both sides of aneurysm (direct surgery, n=2; interventional surgery, n=8). The other seven patients were treated by ligation of the VA proximal to the aneurysm (direct surgery, n=6; interventional surgery, n=l). Two patients underwent transposition of the posterior inferior cerebellar artery (PICA). In 15 patients, there were no major complications. Two patients who had been treated by proximal occlusion of the VA developed rebleeding and ischemia due to persistent retrograde filling of the dissecting site. We suggest that angiographic evidence of retrograde filling of the dissecting site should have been considered as an indication for trapping. Trapping of VA dissecting aneurysms is easier and safer by interventional surgery than by direct surgery.

Fusiform aneurysm of the vertebral artery presenting hemifacial spasm treated by intravascular embolization: case report

BACKGROUND

A rare case of fusiform vertebral artery aneurysm causing hemifacial spasm was successfully treated by intravascular embolization.

CASE DESCRIPTION

A 53-year-old man presented with left hemifacial spasm persisting for 2 years. No other clinical symptoms were observed. Vertebral angiography revealed a fusiform aneurysm of the left vertebral artery, and thin-slice spoiled gradient-recalled acquisition magnetic resonance imaging demonstrated the aneurysm compressing the root exit zone of the left facial nerve. The parent artery was occluded together with the aneurysm by intravascular embolization with Guglielmi detachable coils (GDCs). The patient is free of left hemifacial spasm without any complication.

CONCLUSION

Hemifacial spasm caused by aneurysms, especially fusiform aneurysms, is quite rare but can be treated by parent artery occlusion and coiling the aneurysm with GDCs.

Remission of hemifacial spasm after proximal occlusion of vertebrobasilar dissecting aneurysm with coils: case report

Intracranial aneurysm is a rare cause of hemifacial spasm and most of the previously reported cases are treated with surgical microvascular decompression. Authors report a case of hemifacial spasm caused by a dissecting aneurysm located at the vertebrobasilar junction which improved after endovascular obliteration of the affected vertebral artery with coils. The patient was a 69-year-old man with 20 months' history of left hemifacial spasm. A vertebral angiogram showed an irregular dilatation of the right vertebral artery associated with aneurysmal dilatation at the vertebrobasilar junction. Endovascular obliteration of the abnormally dilated right vertebral artery proximal to the vertebrobasilar junction was performed. The hemifacial spasm gradually improved after the embolisation and disappeared 6 months later. Endovascular proximal obliteration of the vertebral artery may have changed the hemodynamic force inside the aneurysm and eliminated the vascular compression at the root exit zone of the facial nerve.

Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation

STUDY DESIGN

Potential precipitating events and risk factors for vertebrobasilar artery dissection were reviewed in an analysis of the English language literature published before 1993.

OBJECTIVES

To assess the literature pertaining to precipitating neck movements and risk factors for vertebrobasilar artery dissection in an attempt to determine whether the incidence of these complications can be minimized.

SUMMARY OF BACKGROUND DATA

Vertebrobasilar artery dissection and occlusion leading to brain stem and cerebellar ischemia and infarction are rare but often devastating complications of cervical, manipulation and neck trauma. Although various investigators have suggested potential risk factors and precipitating events, the basis for these suggestions remains unclear.

METHODS

A detailed search of the literature using three computerized bibliographic databases was performed to identify English language articles from 1966 to 1993. Literature before 1966 was identified through a hand search of Index Medicus. References of articles obtained by database search were reviewed to identify additional relevant articles. Data presented in all articles meeting the inclusion criteria were summarized.

RESULTS

The 367 case reports included in this study describe 160 cases of spontaneous onset, 115 cases of onset after spinal manipulation, 58 cases associated with trivial trauma, and 37 cases caused by major trauma (3 cases were classified in two categories). The nature of the precipitating trauma, neck movement, or type of manipulation that was performed was poorly defined in the literature, and it was not possible to identify a specific neck movement or trauma that would be considered the offending activity in the majority of cases. There were 208 (57%) men and 158 (43%) women (gender data not reported in one case) with an average age of 39.3 +/- 12.9 years. There was an overall prevalence of 13.4% hypertension, 6.5% migraines, 18% use of oral contraception (percent of female patients), and 4.9% smoking. In only isolated cases was specific vascular disease such as fibromuscular hyperplasia noted.

CONCLUSIONS

The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.

Hemifacial spasm: clinical findings and treatment

Hemifacial spasm (HFS) is a peripherally induced movement disorder characterized by involuntary, unilateral, intermittent, irregular, tonic or clonic contractions of muscles innervated by the ipsilateral facial nerve. We reviewed the clinical features and response to different treatments in 158 patients (61% women) with HFS evaluated at our Movement Disorders Clinic. The mean age at onset was 48.5+/-14.1 years (range: 15-87) and the mean duration of symptoms was 11.4+/-8.5 (range: 0.5-53) years. The left side was affected in 56% instances; 5 patients had bilateral HFS. The lower lid was the most common site of the initial involvement followed by cheek and perioral region. Involuntary eye closure which interfered with vision and social embarrassment were the most common complaints. HFS was associated with trigeminal neuralgia in 5.1% of the cases and 5.7% had prior history of Bell's palsy. Although vascular abnormalities, facial nerve injury, and intracranial tumor were responsible for symptoms in some patients, most patients had no apparent etiology. Botulinum toxin type A (BTX-A) injections, used in 110 patients, provided marked to moderate improvement in 95% of patients. Seven of the 25 (28%) patients who had microvascular decompression reported permanent complications and the HFS recurred in 5 (20%). Although occasionally troublesome, HFS is generally a benign disorder that can be treated effectively with either BTX-A or microvascular decompression.

Proximal balloon occlusion for dissecting vertebral aneurysms accompanied by subarachnoid hemorrhage

Five patients with spontaneous dissecting vertebral aneurysms presenting with subarachnoid hemorrhage were treated with endovascular proximal balloon occlusion after a successful balloon Matas' test. Occlusion was performed in the extracranial portion of the vertebral artery after the potentially dangerous period of cerebral vasospasm. Two patients rebled preoperatively during the waiting period. Although angiograms demonstrated residual aneurysmal dilatation for four of the five patients, postoperative hemorrhages or progression of the dissection were not observed during the 19- to 48-month follow-up period. Only one patient experienced transient postoperative ischemic complication. Although the timing of the procedure and the site of occlusion remain controversial, proximal balloon occlusion of the vertebral artery appears to be a safe and effective therapy for patients with dissecting vertebral aneurysms presenting with subarachnoid hemorrhages. This method provides an important, less invasive alternative for this condition.

Endovascular treatment of vertebral artery dissections and pseudoaneurysms

Sixteen patients with dissecting aneurysms or pseudoaneurysms of the vertebral artery, 12 involving the intradural vertebral artery and four occurring in the extradural segment, were treated by endovascular occlusion of the dissection site. Patients with vertebral fistulas were excluded from this study. The dissection was caused by trauma in three patients (two iatrogenic) and in the remaining 13 no obvious etiology was disclosed. Nine patients presented with subarachnoid hemorrhage (SAH), two of whom had severe cardiac disturbances secondary to the bleed. The nontraumatic dissections occurred in seven women and six men, with a mean age on discovery of 48 years. Fifteen patients were treated with endovascular occlusion of the parent artery at or just proximal to the dissection site. One patient had occlusion of a traumatic pseudoaneurysm with preservation of the parent artery. Four patients required transluminal angioplasty because of severe vasospasm produced by the presenting hemorrhage, and all benefited from this procedure with improved arterial flow documented by transcranial Doppler ultrasonography and arteriography. In 15 patients angiography disclosed complete cure of the dissection. One patient with a long dissection of extracranial origin extending intracranially had proximal occlusion of the dissection site. Follow-up angiography demonstrated healing of the vertebral artery dissection but persistent filling of the artery above the balloons, which underscores the need for embolic occlusion near the dissection site. No hemorrhages recurred. One patient had a second SAH at the time of therapy which was immediately controlled with balloons and coils. This patient and one other had minor neurological worsening resulting from the procedure (mild Wallenberg syndrome in one and minor ataxia in the second). Symptomatic vertebral artery dissections involving the intradural and extradural segments can be effectively managed by endovascular techniques. Balloon test occlusion and transluminal angioplasty can be useful adjuncts in the management of this disease.