Frequency and prognosis of delayed facial palsy after microvascular decompression for hemifacial spasm

Summary Background. Microvascular decompression (MVD) for hemifacial spasm (HFS) provides a long-term cure rate. Delayed facial palsy (DFP) is not an unusual complication, but it has only been sporadically described in the literature. The purpose of this report is to evaluate the incidence of delayed facial palsy after MVD and its clinical course and final results. Methods. From January, 1998 to April, 2004, 410 patients underwent microvascular decompression for hemifacial spasm at our Institute. During this time, 21 patients (5.4%) developed delayed facial weakness; eighteen of them were given steroid medication and they were followed up in the out-patient clinic. Findings. Twenty-one patients developed DFP after microvascular decompression an incidence of 5.4%. There were seventeen women (81.0%) among the 21 patients with DFP who were included in this study. In twenty of them, the symptoms of HFS improved completely after the operation, but the spasm remained with one of them. The onset of palsy occurred between postoperative day 7 and 23 (average: 12.1 days). The palsy was at least Grade II or worse on the House-Brackmann (HB) scale. The time to recovery averaged 5.7 weeks (range: 25 days–17 weeks); 20 patients improved to complete recovery and 1 patient remained with minimal weakness, as Grade II on the HB scale, at the follow-up examination. Conclusion. Our findings demonstrated that the incidence of DFP was not so low as has been reported the literature, and it did not have any striking predisposing factors. Even though the degree of facial palsy was variable, almost all patients exhibited a complete recovery without any further special treatment. The etiology of DFP and its association with herpes infection should be further clarified.     

Intraoperative facial electromyography and brainstem auditory evoked potential findings in microvascular decompression for hemifacial spasm: correlation with postoperative delayed facial palsy

Background: Delayed facial palsy (DFP) after microvascular decompression (MVD) in patients with hemifacial spasm (HFS) is not uncommon, but the cause remains unknown. Objectives: To assess whether intraoperative electromyography (EMG) and brainstem auditory evoked potential (BAEP) can predict DFP after MVD. Methods: Between September 2009 and February 2011 we examined 86 patients, 9 of whom (10.4%) developed DFP after MVD on the same side. All patients underwent MVD and were followed-up for a median period of 13 months (range 6-22). We retrospectively examined intraoperative facial EMG and BAEP findings using our MVD patients' registry. We excluded secondary HFS and immediate postoperative facial palsy after MVD in this study. We assessed the prevalence and clinical characteristics of DFP and compared EMG and BAEP findings between DFP and non-DFP groups. Results: All patients recovered completely, with a mean time to recovery of 37.8 days (range 22-57). There were no significant differences between DFP and non-DFP patients in terms of the amplitude and latency of intraoperative EMG and BAEP. Conclusion: The usefulness of intraoperative facial EMG and BAEP is limited and cannot predict DFP after MVD for HFS. We speculate that DFP after MVD is not associated with permanent nerve damage according to the EMG findings.     

面肌痉挛行微血管减压术并发远隔部位出血患者的护理

总结9例面肌痉挛行微血管减压术并发远隔部位出血患者的护理经验.护理要点包括:警惕远隔部位出血的高危人群,早期识别术后远隔部位出血的先兆,紧急处置不同类型的远隔部位出血患者,实施医护一体化的目标血压管理,做好硬膜下引流管的护理,落实个性化心理护理.本组患者经过积极处理,神经功能逐渐恢复,均好转出院.     

Microvascular decompression for hemifacial spasm: long-term outcome and prognostic factors, with emphasis on delayed cure

The postoperative course of microvascular decompression (MVD) for hemifacial spasm (HFS) is variable, and the optimal time for assessing the results is unclear. From April 1997 to October 2007, MVD for HFS was performed in 801 patients. Patients were divided into two groups (cured or failed) according to subjective patient assessments over a 3-year period. We analyzed patient characteristics and surgical findings to determine prognostic factors. Medical records were analyzed retrospectively over the 3-year follow-up period. Of the 801 patients who underwent surgery, 743 (92.8 %) appeared to be cured, 70 (8.7 %) had residual or recurrent spasms more than 1 year after surgery, 11 (1.3 %) had gradual improvement over 3 years, and 1 (0.1 %) had delayed improvement more than 3 years after surgery. Fifty-eight patients (7.2 %) had residual or recurrent spasms more than 3 years after surgery, of which 19 (2.4 %) had recurrence after initial relief. The mean time to spasm recurrence was 18.9 months. Intraoperative resolution of the lateral spread response (LSR) after decompression (p?=?0.048) and severe indentation (p?=?0.038) were significant predictors of good long-term outcome after MVD for HFS. In our series, 70 patients (8.7 %) had residual or recurrent spasms more than 1 year after surgery, of which 12 (17.1 %) improved gradually after 1 year. If the surgeon can confirm intraoperative resolution of the LSR and severe indentation, reoperation can be delayed until 3 years after MVD.     

Re-operation for persistent hemifacial spasm after microvascular decompression with the aid of intraoperative monitoring of abnormal muscle response

Background and objectives

Microvascular decompression (MVD) is the only solution that can effectively control hemifacial spasm (HFS). Regarding treatment of the patients who failed the first operation, it is still controversial. We tried to evaluate the safety and efficiency of the early re-exploration for such kinds of patients.

Methods

Thirteen patients failed the first MVD and received a second MVD procedure. The spasm was not resolved at all or became even more severe after the first MVD. Abnormal muscle response (AMR) persisted during the first MVD operation or disappeared once but emerged again. The patient had a strong will to do the re-operation and was aware of the high risks of operative complications.

Results

All the 13 patients got good or excellent spasm resolution immediately after the re-operation, which involved whole-range exploration and intraoperative AMR monitoring; however, there were two cases (15.4%) of permanent facial weakness and three cases (23.0%) of transient facial weakness.

Conclusions

Our experience on early repeat MVD is whole-range exploration and intraoperative AMR monitoring; in other words, re-operation cannot rely too much on experience.     

Abnormal muscle response monitoring during microvascular decompression for hemifacial spasm and long term results

OBJECTIVE: There is some debate over the reliability of intraoperative abnormal muscle response (AMR) monitoring as an indicator of postoperative long-term outcome in patients with hemifacial spasm (HFS). We investigated whether AMR findings obtained during microvascular decompression reflect postoperative long-term outcome. MATERIAS AND METHODS: Subjects were 51 HFS patients who underwent AMR monitoring during surgery. AMR recordings were obtained from the mentalis muscle by electrical stimulation of the temporal branch of the facial nerve and from the orbicularis oculi muscles by stimulation of the marginal mandibular branch. Postoperative follow-up was more than 5 years (range 61-118 months, mean 87 months). RESULTS: In 37 patients, AMR disappeared after vascular decompression. Among those patients, only one presented with spasm at the final follow-up examination. In 6 of 7 patients with AMR that disappeared early before the completion of decompression, hemifacial spasm resolved completely. Five of six patients in whom AMR still remained but with decreased amplitude at the end of surgery experienced complete resolution. CONCLUSIONS: Our findings suggest that intraoperative cessation including prior to decompression or decreased amplitude of AMR at the end of surgery indicates a high likelihood of postoperative long-term relief of HFS. We believe that intraoperative AMR monitoring is useful in MVD surgery for HFS.     

Delayed facial palsy after microvascular decompression for hemifacial spasm due to reactivation of varicella-zoster virus

We report a patient suffering from delayed facial palsy after microvascular decompression (MVD) for hemifacial spasm, in whom the pathogenesis was proved. A 56-year-old man with a left hemifacial spasm was admitted to our hospital. Preoperative MR imaging showed that the left anterior inferior cerebellar artery (AICA) was compressing the left facial nerve. The causative vessel was defined as AICA during surgery, and MVD was performed successfully. Seven days later, the patient showed severe left facial palsy. Serum antibody of varicella-zoster virus (VZV) was increased, and Gd enhanced MR imaging demonstrated an enhancement of a geniculate ganglion of the left facial nerve, indicating inflammation. These findings suggested that delayed facial palsy after MVD was caused by a re-activation of VZV. The facial palsy disappeared completely over a period of nine months.     

Teflon granuloma after microvascular decompression for hemifacial spasm: a case report and literature review

Teflon has been commonly used as a surgical material. In particular, Teflon has been considered suitable for microvascular decompression of cranial nerves, as it is a stable, inert substance that does not resorb or migrate. Giant cell foreign body reactions after microvascular decompression (MVD) have been reported, but this rare complication has not been well recognized. Here, we report one case of Teflon granuloma that occurred 4 years after MVD for hemifacial spasm. We discuss the cause, histopathological analysis, particular MVD surgical methods, and management of Teflon granuloma.     

Emprical factors associated with Brainstem auditory evoked potential monitoring during microvascular decompression for hemifacial spasm and its correlation to hearing loss

Background

Cranial nerve VIII is at risk during microvascular decompression (MVD) for hemifacial spasm (HFS). The primary aim of this study is to evaluate the empirical factors associated with brainstem auditory evoked potential monitoring and its correlation to post operative hearing loss (HL) after MVD for HFS.

Methods

Pre-operative and post-operative audiogram data and BAEP from ninety-four patients who underwent MVD for HFS were analyzed. Pure tone audiometry (PTA) and Speech Discrimination Score (SDS) were performed on all patients before and after surgery. Intraoperative neurophysiological data were reviewed independently. HL was assessed using the AAO-HNS classification system for non-serviceable hearing loss (Class C/D), defined as PTA >50 dB and/or SDS <50 % within the speech range of frequencies.

Results

Patients with HL had higher rates of loss in the amplitude of wave V and prolongation in the interpeak latency of peak I-V latency during MVD. Gender, age, side, and MVD duration did not increase the risk of HL. There was no correlation between successive number of BAEP changes (reflective of the number of surgical attempts) and HL. There was no association between the speed of recovery of BAEPs and HL.

Conclusions

Patients with new post-operative HL have a faster rate of change in the amplitude of wave V and the interpeak I-V latency during intraoperative BAEP monitoring for HFS. Our alarm criteria to inform the surgeon about impending nerve injury might have to be modified and prospectively tested to prevent rapid change in BAEPs.     

A case of hemifacial spasm in a juglar foramen tumor patient treated by microvascular decompression

Hemifacial spasm is a movement disorder characterized by involuntary paroxysmal chronic contractions of the facial musculature. The usual cause is simple vascular compression of the facial nerve, at its root exit zone of the brain stem. Previously only a case of hemifacial spasm associated with a juglar foramen tumor has been reported in the literature. In this article, we report a case in which hemifacial spasm accompanied an ipsilateral juglar foramen tumor in a 62-year-old woman. The sole use of arterial decompression of the facial nerve at the root exit zone resulted in complete resolution of the patient's symptoms.     

An analysis of failed microvascular decompression in patients with hemifacial spasm: focused on the early reoperative findings

Background  

Although the microvascular decompression (MVD) has become a definitive treatment for the primary hemifacial spasm (HFS), there still are some failed cases. To obtain a satisfactory postoperative outcome, those failure cases of MVD need to be analyzed.     

The value of lateral spread response monitoring in predicting the clinical outcome after microvascular decompression in hemifacial spasm: a prospective study on 100 patients

Microvascular decompression represents an effective treatment for hemifacial spasm. The use of lateral spread response (LSR) monitoring remains a useful intraoperative tool to ensure adequate decompression of the facial nerve. The aim of this study was to assess the value of LSRs intraoperative monitoring as a prognostic indicator for the outcome of microvascular decompression in hemifacial spasm. Our study included 100 patients prospectively. The patients were classified into four groups whether LSRs were totally, partially, not relieved, or not detected from the start. According to clinical outcome, the patients were classified into four groups depending on the clinical course after surgery and the residual symptoms if any. Then, correlations were made between LSR events and treatment outcome to detect its reliability as a prognostic indicator. LSRs were relieved totally in 56 % of the patients, partially relieved in 14 %, not relieved in 10 %, and were not detected in 20 % of the patients from the start. HFS was relieved directly after operation in 62 % with clinical improvement of 90–100 %. Thirty-one percent described 50–90 % improvement over the next 3 months after surgery. Almost all of these 31 % (28 out of 31 patients) reported further clinical improvement of 90–100 % within 1 year after surgery. Three percent suffered from a relapse after a HFS-free period, and 4 % reported minimal or no improvement describing 0–50 % of the preoperative state. The percentage of the satisfied patients with the clinical outcome who reported after 1 year a clinical improvement of 90–100 % was 90 %. Statistical analysis did not find a significant correlation between the relief of LSRs and clinical outcome. LSRs may only represent an intraoperative tool to guide for an adequate decompression but failed to represent a reliable prognostic indicator for treatment outcome.     

Long-term results of microvascular decompression for trigeminal neuralgia and hemifacial spasms according to preoperative symptomatology

Background

Microvascular decompression (MVD) is currently used in several centres for the treatment of trigeminal neuralgia (TN) and hemifacial spasms (HFS). How long-term results relate to the preoperative symptoms still needs to be documented. The primary aim of this study was to assess long-term results of MVD for TN and HFS, as related to the types of preoperative symptoms.

Methods

We performed a retrospective study including all first-time MVDs for TN and HFS done during the 11-year period (1999–2009) in the Department of Neurosurgery, The National Hospital (Rikshospitalet), Oslo. The patients were categorized depending on the pre-operative symptomatology.

Results

The study population includes 303 first-time procedures performed by the senior author (PKE), 243 TN patients (65 % TN without constant pain and 35 % TN with constant pain) and 60 HFS patients (95 % typical HFS and 5 % atypical HFS). The patients were followed for a mean 71 months (range, 14–147). In both the TN and HFS patients, MVD caused lasting symptom relief in a high proportion of patients, including patients with atypical symptoms.

Conclusion

After MVD for TN and HFS, regardless of preoperative symptoms, lasting relief is observed in a high proportion of patients, with a favorable complication profile.     

不同剂量舒芬太尼术后镇痛方案对面肌痉挛微血管减压术后恶心呕吐的影响

目的:观察面肌痉挛微血管减压术后应用不同剂量舒芬太尼镇痛方案对术后恶心呕吐不良反应的影响。方法:回顾性纳入行微血管减压术的面肌痉挛女性患者183例,在相同麻醉方法的基础上根据术后是否使用舒芬太尼镇痛泵及其不同剂量将患者分为舒芬太尼2 μg/kg组（A组,60例）、舒芬太尼1 μg/kg组（B组,60例）和未使用镇痛泵组...     

A proposal for standardized analysis of the results of microvascular decompression for trigeminal neuralgia and hemifacial spasm

Background

The purpose of this study was to evaluate and analyze overall postoperative results from microvascular decompression (MVD) by combining the cure rate of symptoms with the complication rate. A new scoring system for obtaining objective surgical results from MVD for trigeminal neuralgia (TN) and hemifacial spasm (HFS) is proposed to document treatment results using consistent criteria in a standardized manner.

Method

Surgical results combining complications , if any, were obtained from a questionnaire sent to patients who had undergone surgery for TN or HFS in recent years and had been followed-up for more than 1?year after surgery (TN patients, n?=?54; HFS patients, n?=?81) When surgical outcome is complete resolution of symptoms, the efficacy of surgery (E) is designated E-0, but when moderate symptoms are still persist postoperatively, the score is designated E-2. When no complications are seen after surgery, the complication score (C) is C-0, while the score is C-2 if troublesome complications remain. In addition, total evaluation of the results (T) is judged by combining the E and C scores. For example, when E is 0, and C is C-2, the total evaluation is scored as T-2, which is diagnosed as fair.

Findings

The response rate of the questionnaire was 80.7% (109/135). Overall surgical data were evaluated and analyzed using our new scoring system. Analysis of the collected data revealed an outcome of T-0 was 70% (35/50 patients) and T-1 was 24% (12/50) and T-2 was 6% (3/50) in TN, whereas in HFS, T-0 was 61% (36/59) and T-1 was 27.1% (16/59) and T-2 was 6.8% (4/59) and T-3 was 5.1% (3/59).

Conclusion

The total results of MVD should be evaluated and analyzed by combining the cure rate of symptoms together with the complication rate. This new scoring system could allow much more objective analysis of the results of following MVD. Adopting this scoring system to objectively judge treatment results for TN and HFS, individual surgeons can compare their own overall surgical results with those of other institutes. Comparative results of MVD can also be provided to patients considering therapy to allow informed decision-making on the basis of good quality evidence.     

Microvascular decompression in patients with coexistent trigeminal neuralgia,hemifacial spasm and glossopharyngeal neuralgia

Background

Trigeminal neuralgia(TN), hemifacial spasm (HFS) and glossopharyngeal neuralgia (GPN) were referred to hyperactive dysfunction syndromes (HDSs) of the cranial nerves. These symptoms may occur synchronously or metachronously, but the combination of three diseases is extremely rare.

Methods

From 2007 through 2013, six patients with coexistent GPN-HFS-TN were treated in our department. The combined symptoms occurred on the same side in three and on both sides in three. These patients underwent nine microvascular decompression (MVD) procedures in total. The clinical data including operative findings were respectively analyzed, and the etiological factors as well as treatment strategies were discussed.

Results

Intraoperatively, in all the cases a small posterior fossa was found, which was crowded with cranial nerve roots and cerbellar vesels. Postoperatively, spasm was stopped immediately in four and within 3 months in two; the symptom of TN disappeared immediately in four and within 2 weeks in two; the symptom of GPN was relieved immediately in four and improved with medication in two. During the up to 77 months’ follow-up, no changes, recurrence or any dysfunctions of cranial nerves were observed in any of the patients.

Conclusions

The combination of HFS-TN-GPN is extremely rare and is often associated with a looped VBA and a smaller posterior fossa. However, MVD is still a good choice for treatment. To achieve a safe and effective outcome, dissection of the caudal cranial nerves and proximal transposition of the vertebral artery before decompression of the affected nerve roots are strongly recommended.