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Background: Hemifacial spasm (HFS) is characterized by involuntary, progressive, and intermittent spasms in the upper and lower facial muscles. Due to the high success rate, microvascular decompression (MVD) is the treatment of choice, and intraoperative neuromonitoring (INM) is considered useful for achieving safe surgery. Still, most centers do not have this technology. Methods: We analyzed 294 patients with HFS treated with MVD without INM. We only included patients with a neurovascular etiology while excluding other causes, such as tumors. As part of the postoperative evaluation, we assessed preoperative magnetic resonance imaging and pure-tone audiometry. Results: The main complication was peripheral facial paralysis in 50 patients, followed by hypoacusis in 22 patients and deafness in 17 patients, associated with a failed surgical outcome (P = 0.0002). The anterior inferior cerebellar artery (AICA) was an offending vessel, and the involvement of more than one vessel was significantly associated with the development of facial nerve palsy (P = 0.01). AICA was also associated with hearing impairment (P = 0.04). Over 90% of immediate complications improve in the follow-up (6 months), and one patient did not show a cure for initial HFS. Conclusion: MVD is the method with the highest long-term cure rates for treating HFS; however, we must inquire into the multiple factors of the patient and the surgeon to predict surgical outcomes. INM is not a must during MVD for HFS. We recommend its use depending on the availability and mainly on the surgeon's skills, for surgeons.
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INTRODUCTION: The term 'painful tic convulsive' is used to describe the syndrome involving concomitant hemifacial spasm and ipsilateral trigeminal neuralgia. Vascular compression of the fifth and seventh cranial nerves is the most common cause, involving the entry and exit zone of rootlets coming from the brainstem; nevertheless, different etiologies of this syndrome has been previously reported. Treatment for this disease is based on surgical microvascular decompression of the nerve rootlets, but still a topic of debate. CASE REPORT: A 63-year-old woman with history of 14 years presenting left trigeminal neuralgia, associated with ipsilateral hemifacial spasm for more than ten years. Medical treatment was installed without adequate symptom control. Patient was subjected to surgical treatment via a microasterional approach, with dissection of arachnoid fibrous tissue surrounding fifth and seventh nerves during the first surgery. A second surgery was performed with insertion of a teflon fragment aside of each exit nerve root (V and VII-VIII complex). Symptoms resolved immediately after the surgery and has persisted during the 1-year follow-up. Painful tic convulsive etiology could be multifactorial. CONCLUSION: This report is the first clinical case describing basal arachnoiditis as a primary cause of painful tic convulsive.
TITLE: Presentacion inusual de un tic convulsivo doloroso.Introduccion. La presentacion clinica de un espasmo hemifacial asociado a neuralgia trigeminal ipsilateral se conoce como tic convulsivo doloroso. La causa mas comun de esta patologia es la compresion vascular de los nervios craneales V y complejo VII-VIII en la zona de entrada y salida de las raices en el tronco del encefalo, pero existen informes de diversas etiologias. Su tratamiento, aunque aun esta en discusion, se basa en la descompresion microvascular quirurgica. Caso clinico. Mujer de 63 años, con un cuadro de evolucion de 14 años de neuralgia trigeminal, con predominio en distribucion de la rama maxilar (V2) izquierda, asociado durante mas de 10 años a espasmo hemifacial ipsilateral. Tras fallar el tratamiento medico, se sometio a cirugia por abordaje microasterional, y en un primer momento se realizo una diseccion de adherencias aracnoideas firmes rodeando complejos nerviosos. En un segundo tiempo quirurgico se insertaron fragmentos de teflon en los sitios de entrada de los nervios V y complejo VII-VIII, y se logro una resolucion completa de la sintomatologia durante mas de un año. Conclusion. La etiologia del tic convulsivo doloroso en esta paciente fue aracnoiditis basal, lo cual la convierte en el unico caso comunicado hasta el momento con dicha etiologia.
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Aracnoidite/complicações , Espasmo Hemifacial/etiologia , Neuralgia do Trigêmeo/etiologia , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
INTRODUCTION. Pharmacological treatment is the first therapeutic step towards controlling pain in trigeminal neuralgia, but 25-50% of patients become medication resistant. There are currently several surgical alternatives for treating these patients. AIM. To evaluate the effectiveness and safety of stereotactic radiosurgery for the treatment of patients with trigeminal neuralgia. PATIENTS AND METHODS. A follow-up study was conducted on 30 patients who underwent radiosurgery using a Novalis linear accelerator. Eighty per cent of the dosage was calculated at the isocentre, the entry zone of the root of the trigeminal nerve. The mean follow-up time was 27.5 months (range: 1-65 months). RESULTS. The mean age was 66 years (range: 36-87 years), with a time to progression of 7.1 years (range: 4-27 years). The distribution of the pain was from the right side (63.3%). Of the 30 patients, 27 experienced an improvement (90%) 1.6 months (range: 1 week-4 months) after the treatment; 10 patients (33.3%) scored grade I, and 17 patients (56.6%) obtained a score of grade II. During the follow-up, four patients (14.2%) suffered a relapse; two underwent re-irradiation. Time without recurrence was 62.7 months (range: 54.6-70.8 months). The rate of side effects was 76.7% and only three patients developed facial anaesthesia with loss of the corneal reflex. CONCLUSIONS. The use of the linear accelerator is an effective therapeutic option in the treatment of trigeminal neuralgia, since it provides adequate long-term control of the pain, reduces the use of medication and improves the quality of life.
TITLE: Radiocirugia estereotactica con acelerador lineal para el tratamiento de la neuralgia trigeminal. Experiencia de nueve años en una sola institucion.Introduccion. El tratamiento farmacologico constituye el primer escalon terapeutico para el control del dolor en la neuralgia del trigemino, pero entre el 25-50% de los pacientes se hace farmacorresistente. Actualmente existen varias alternativas quirurgicas para tratar a estos pacientes. Objetivo. Evaluar la efectividad y seguridad de la radiocirugia estereotactica para el tratamiento de pacientes con neuralgia del trigemino. Pacientes y metodos. Se dio seguimiento a 30 pacientes que se sometieron a radiocirugia con acelerador lineal Novalis. Se calculo el 80% de la dosis en el isocentro, la zona de raiz de entrada del nervio trigemino. El tiempo medio de seguimiento fue de 27,5 meses (rango: 1-65 meses). Resultados. La edad media fue de 66 años (rango: 36-87 años), con un tiempo de evolucion de 7,1 años (rango: 4-27 años). La distribucion del dolor fue del lado derecho (63,3%). De los 30 pacientes, 27 tuvieron mejoria (90%) 1,6 meses (rango: 1 semana-4 meses) despues del tratamiento; 10 pacientes (33,3%) tuvieron una valoracion de grado I y 17 pacientes (56,6%) una valoracion de grado II. Durante el seguimiento, cuatro pacientes (14,2%) tuvieron recidiva; dos se sometieron a reirradiacion. El tiempo sin recurrencia fue de 62,7 meses (rango: 54,6-70,8 meses). La tasa de efectos secundarios fue del 76,7%, y solo tres pacientes desarrollaron anestesia facial con perdida del reflejo corneal. Conclusiones. El uso del acelerador lineal es una opcion terapeutica efectiva en el tratamiento de la neuralgia del trigemino, proporciona a largo plazo adecuado control del dolor, reduce el uso de medicamentos y mejora la calidad de vida.
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Aceleradores de Partículas , Radiocirurgia/instrumentação , Neuralgia do Trigêmeo/cirurgia , Academias e Institutos/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Piscadela/efeitos da radiação , Feminino , Seguimentos , Humanos , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Qualidade de Vida , Lesões por Radiação/etiologia , Radiocirurgia/efeitos adversos , Radiocirurgia/estatística & dados numéricos , Recidiva , Reflexo Anormal , Estudos Retrospectivos , Transtornos de Sensação/etiologia , Zumbido/etiologia , Resultado do Tratamento , Neuralgia do Trigêmeo/epidemiologia , Neuralgia do Trigêmeo/psicologiaRESUMO
BACKGROUND: There are few data describing the microanatomy of the anterior-ventral spinal (AVSA) and anterior spinal arteries (ASA) and discussing their clinical and surgical implications. We describe the anatomical features of this arterial complex, and highlight their use when planning and performing surgical approaches to lesions involving the ventral aspect of the medulla and the foramen magnum. METHOD: The microsurgical anatomy and branching pattern of the AVSA and the ASA from fifty human cadaver brain stems is described using a surgical microscope. RESULTS: We found one anterior-ventral spinal artery at each side in 30 of the brain stems (60%). The ASA was a direct branch emerging from the left vertebral artery (VA) in 15 (30%), from the right VA in 4 (8%), and from the basilar artery (BA) in one brain stem (2%). The previously described as "typical pattern" of the junction of the AVS arteries from both sides, was observed only in 9 brain stems (18%). The anterior communicating spinal artery (ACoSA) was observed in 15 brain stems (30%). Also multiple ACoS arteries were described in one brain stem. Both, the AVSA and the ASA were observed to send long circumferential branches that supplied irrigation to the olive in 42 (84%) brain stems. CONCLUSIONS: This anatomical study gives important information for a better understanding of the clinical picture of ischemic lesions of the brain stem, such as the medial medullary syndrome, and highlights the remarkable role of the AVSA and ASA as anatomical landmarks during the surgical approaches to lesions involving the ventral aspect of the medulla and the foramen magnum.
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Bulbo/irrigação sanguínea , Medula Espinal/irrigação sanguínea , Artéria Vertebral/anormalidades , Artéria Basilar/anormalidades , Artéria Basilar/patologia , Artéria Basilar/cirurgia , Fossa Craniana Posterior/anatomia & histologia , Fossa Craniana Posterior/cirurgia , Forame Magno/anatomia & histologia , Forame Magno/cirurgia , Lateralidade Funcional/fisiologia , Humanos , Bulbo/fisiopatologia , Bulbo/cirurgia , Microcirurgia/métodos , Osso Occipital/anatomia & histologia , Osso Occipital/cirurgia , Base do Crânio/anatomia & histologia , Base do Crânio/cirurgia , Medula Espinal/cirurgia , Artéria Vertebral/patologia , Artéria Vertebral/cirurgiaRESUMO
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.