[Surgical Techniques for Microvascular Decompression in Hemifacial Spasm].

This study discusses the key microvascular decompression(MVD)techniques for the treatment of hemifacial spasm(HFS). The author's experience is based on their institution's cases, highlighting three critical techniques. (1)Vertebral artery(VA)repositioning: Repositioning the VA is essential in challenging cases. This article focuses on the relocation of the proximal portion of the VA and the importance of careful dissection. (2)Relocating vessels compressing the peripheral branches of the facial nerve: HFS can result from nerve compression at various locations, including the cisternal portion. This study addressed cisternal compression and considered the nearby nerves. (3)Considering the perforating branches during repositioning, cases may involve complex branching of the perforating arteries. This paper describes an approach that carefully repositions the vessels without damaging the perforating branches. The results from 100 VA-involved cases showed excellent outcomes, with 91.2% of patients experiencing T0(excellent)results. This study emphasized the need to adapt the surgical approach to each unique case to ensure the safety and effectiveness of MVD. This study provides insights into the critical MVD techniques for HFS, emphasizing the importance of continuous experience and knowledge accumulation. These techniques can be learned by other neurosurgeons, thereby expanding the availability of safe and successful MVD procedures for HFS.

Extremely long posterior cerebral artery P1 segment.

PURPOSE: Excluding aplasia and hypoplasia of the P1 segment of the posterior cerebral artery (PCA), anatomical variations in the PCA are rare. To our best knowledge, there are few reports of an extremely long P1 segment of the PCA. METHODS: Herein, we report a rare case of an extremely long P1 segment of the PCA, which was diagnosed by 1.5-T magnetic resonance angiography (MRA). RESULTS: A 96-year-old woman was transferred by ambulance to our hospital with impaired consciousness. Her symptom improved, and magnetic resonance imaging showed no significant findings. MRA revealed an extremely long P1 segment of the left PCA. The length of the P1 segment of the left PCA was 27.3 mm. The left posterior communicating artery (PCoA) was 20.9 mm, which is not considered long. The left anterior choroidal artery branched from the internal carotid artery distal to the PCoA branching position. Basilar artery fenestration was also incidentally identified. CONCLUSION: Careful imaging assessment was important for identifying the extremely long P1 segment of the PCA in the present case. This rare anatomical variation can also be confirmed by 1.5-T MRA.

Correlation between Delayed Relief after Microvascular Decompression and Morphology of the Lateral Spread Response in Patients with Hemifacial Spasm-Further Examination with Compound Motor Action Potentials.

Although microvascular decompression (MVD) is a reliable treatment for hemifacial spasm (HFS), postoperative delayed relief is one of its main issues. We previously evaluated the morphology of the lateral spread response (LSR) and reported correlation between delayed relief after MVD and polyphasic morphology of the LSR. This study aimed to investigate the morphology of LSR and the course of recovery of the compound motor action potential (CMAP), to better understand the pathophysiology of delayed healing of HFS. Based on the pattern of the initial LSR morphology on temporal and marginal mandibular branches stimulation, patients were divided into two groups: the monophasic and polyphasic groups. The results of MVD surgery and sequential changes in the CMAP were evaluated 1 week, 1 month, 1 year, and final follow-up after the surgery. Significantly higher rates of persistent postoperative HFS were observed in patients with the polyphasic type of initial LSR at 1 week and 1 month after the surgery (P < 0.05, respectively). In the polyphasic group, the amplitude of the CMAP tended to gradually improve with time, while in the monophasic group, the amplitude of the CMAP decreased on the seventh postoperative day, followed by its gradual improvement. There is a significant correlation between delayed relief after MVD and polyphasic morphology of the initial LSR in patients with HFS. In the polyphasic group, CMAP recovered earlier and showed less reduction in amplitude, suggesting segmental demyelination, with less damage to peripheral nerves.

Significant Correlation between Structural Changes in the Net-like Appearance on Postoperative Cranial Magnetic Resonance Images and Hematoma Recurrence in Cases of Chronic Subdural Hematoma.

Organized hematoma, which exhibits a net-like appearance on imaging studies, is one of the predisposing factors for the recurrence of chronic subdural hematoma. Patients who are positive for the net-like appearance are often treated with only burr hole surgery. We investigated the relationship between postoperative structural changes in the net-like appearance and the recurrence rate of chronic subdural hematoma. Of the 949 patients with chronic subdural hematoma treated with primary burr hole surgery between January 2010 and April 2021 at our hospital, 268 who were considered positive for the net-like appearance on T2- and T2 star-weighted magnetic resonance images were extracted. We followed the structural changes in the net-like appearance postoperatively and subsequently classified the patients into three groups: decreasing type, shifting type, and no change and deterioration type. The relationship between each structural change and the recurrence rate in the three groups was investigated. Postoperative recurrence requiring surgery occurred in 3.5% of the subjects with decreasing type, 0% with shifting type, and 100% with deterioration type of the net-like appearance (P < 0.05), indicating differences in the recurrence rates according to postoperative structural changes in the magnetic resonance images (MRI) features of chronic subdural hematoma. Our results indicate that the risk of postoperative chronic subdural hematoma recurrence can be predicted by focusing on the structural changes in the postoperative net-like appearance on MRI.

Microvascular Decompression for Concurrent Trigeminal Neuralgia and Hemi-Laryngopharyngeal Spasm: A Case Report.

BACKGROUND AND IMPORTANCE: Hemi-laryngopharyngeal spasm (HeLPS) may result from vascular compression of the vagus nerve and can be treated using microvascular decompression. We describe the clinical characteristics and surgical treatment in a case of concurrent trigeminal neuralgia (TN) and HeLPS. CLINICAL PRESENTATION: A 44-year-old man presented with a 12-month history of right TN and 8-month history of intermittent episodes of repeated throat contractions associated with a very distressing choking sensation. Preoperative 3-dimensional fusion imaging demonstrated compression of the trigeminal nerve by the superior cerebellar artery and petrosal vein and compression of the vagus nerve by the posterior inferior cerebellar artery and one of its branches. Microvascular decompression was performed by a right standard retrosigmoid approach with enlarged craniotomy. Initially, the compression of the trigeminal nerve was identified by visual inspection. All the offending vessels were wrapped in Teflon felt, transposed away from the trigeminal nerve, and adhered to the tentorial membrane and petrous bone using fibrin glue. Furthermore, observation of the caudal rootlets of the vagus nerve revealed that the posterior inferior cerebellar artery and its branch compressed the ventral side of the nerve. These vessels were displaced antero-caudally with Teflon felt and fibrin glue; no other vessels were found around the trigeminal and vagus nerves. Postoperatively, the patient had immediate and complete resolution of symptoms of TN and HeLPS without recurrence at the 18-month follow-up. CONCLUSION: HeLPS may occur with TN, and neurosurgeons should identify the symptoms suspicious of this disease preoperatively.

Objectively-captured Changes in Trigeminal Fibers before and after Microvascular Decompression Using 3D T2-SPACE MRI Might Relate to Eventual Residual Symptoms.

Although microvascular decompression (MVD) is a reliable treatment for trigeminal neuralgia (TN), neurosurgeons sometimes encounter patients whose symptoms do not improve postoperatively or who experience good treatment efficacy but develop other sensory disturbances. This study aims to objectively identify changes in nerve fibers before and after surgery by MRI and to clarify the relationship between the changes and residual postoperative symptoms. We retrospectively analyzed data from 36 consecutive patients who underwent MVD for classical TN at our hospital between November 2019 and November 2020. Cases that fulfilled the diagnostic criteria for multiple sclerosis were excluded. We confirmed the changes on the brainstem side of the trigeminal nerve preoperatively and at seven days postoperatively using 3D T2-SPACE MRI, in which the patients were divided into three groups: preoperative T2 high intensity positive (A), postoperative T2 high intensity positive (B), and no T2 high-intensity region (C). The primary outcome measures were therapeutic efficacy and frequency of postoperative numbness. The results of MVD surgery were evaluated one year postoperatively. The percentage of cases in which treatment outcomes were rated as excellent or good at one year: group A: 0 (0%), group B: 6 (100%), and group C: 25 (96.2%) (p < 0.05); the frequency of numbness: 2 (50%) in group A, 3 (50%) in group B, and 1 (3.8%) in group C, indicating significant differences between the three groups (p < 0.05). 3D T2-SPACE MRI sequences can be used to identify changes in trigeminal nerve fibers before and after MVD, which might correlate with eventual residual symptoms.

Intravenous Fosphenytoin Therapy as an Acute Rescue Treatment for Glossopharyngeal Neuralgia Crisis in Patients Awaiting Neurosurgical Procedures: A Case Series.

INTRODUCTION: Few treatments exist for acute attacks of glossopharyngeal neuralgia (GPN). We investigated the efficacy of intravenous fosphenytoin therapy (IFT) during GPN crisis. CASE PRESENTATION: We evaluated records of 4 consecutive patients with GPN awaiting microvascular decompression (MVD) who received IFT (total, 750 mg). Pain severity was evaluated using a Numerical Rating Scale (NRS). The score was 10 (maximum pain) before treatment. Case 1 (a 52-year-old woman, left GPN): for 12 hours after IFT, pain was eliminated (NRS 0/10); however, severe pain recurred 2 days later. She received MVD 9 days after IFT. Case 2 (a 72-year-old woman, right GPN): pain score reduced to 0/10 immediately after IFT and remained so for 2 days. Severe pain recurred, and she underwent MVD 4 days after IFT. Case 3 (a 69-year-old woman, right GPN): pain was reduced (NRS, 5/10) immediately after IFT and nearly eliminated (1/10) 1 hour later. After 6 hours, severe pain recurred; she received a second IFT 3 days later, and pain score dropped to 1/10. She was pain-free for 24 hours but intermediate pain recurred in 2 days. Microvascular decompression was performed 9 days after the second IFT. Case 4 (a 32-year-old woman, right GPN): Pain score reduced to 0/10 immediately after IFT and remained so for 4 days. She underwent MVD 4 days after IFT. No evidence of recurrence was found throughout the 24-, 22-, 20-, and 5-month follow-ups. CONCLUSIONS: These results provide new insights into the innovative therapeutic option of intravenous fosphenytoin and contribute to advancements in treating acute GPN crisis.

Significant Correlation between Delayed Relief after Microvascular Decompression and Morphology of the Abnormal Muscle Response in Patients with Hemifacial Spasm.

Although microvascular decompression (MVD) is a reliable treatment for hemifacial spasm (HFS), postoperative delayed relief of persistent HFS is one of the main issues. In patients with hemifacial spasm, stimulation of a branch of the affected facial nerve elicits an abnormal response in the muscles innervated by another branch. Several specific types of waves were found in the abnormal muscle response (AMR). This study aimed to confirm the relationship between the initial morphology of the AMR wave and delayed relief of persistent HFS after MVD. We retrospectively analyzed and compared the data from 47 of 155 consecutive patients who underwent MVD for HFS at our hospital between January 2015 and March 2020. Based on the pattern of the initial AMR morphology on orbicularis oculi and mentalis muscle stimulation, patients were divided into two groups, namely, the monophasic and polyphasic groups. The results of MVD surgery for HFS were evaluated 1 week, 1 month, and 1 year postoperatively, by evaluating whether or not the symptoms of HFS persisted at the time of each follow-up. There were significantly higher rates of persistent postoperative HFS in patients with the polyphasic type of initial AMR at 1 week and 1 month after the surgery (p < 0.05, respectively), as assessed using Yates chi-squared test and Fisher's exact test. A significant correlation was observed between delayed relief after MVD and polyphasic morphology of the AMR in electromyographic analysis in patients with hemifacial spasm.

Separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage.

Agenesis of the left common carotid artery with separate origins of the left internal and external carotid arteries from the aorta is an extremely rare anomaly. This anomaly is typically asymptomatic unless associated with other conditions. We report a case of separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage. A 42-year-old man was transferred to our hospital by ambulance because of left hemiparesis. Computed tomography scan revealed right putaminal hemorrhage. Computed tomography angiography and digital subtraction angiography demonstrated independent origins of the left internal carotid artery and external carotid artery from the aortic arch. Right internal carotid angiography revealed blood supply to the left anterior cerebral artery and middle cerebral artery via the anterior communicating artery. The separate origins of the left internal and external carotid arteries from the aorta may cause hemodynamic stress to the contralateral side, leading to right intracerebral hemorrhage.

Lateral Supracerebellar Infratentorial Approach for Superior Oblique Myokymia: A Case Series.

BACKGROUND: Few reports have shown that superior oblique myokymia (SOM) may result from vascular compression of the trochlear nerve and may be curable using microvascular decompression (MVD). OBJECTIVE: To report the clinical characteristics and surgical treatment of 2 cases of SOM and provide a review of the related literature. METHODS: Two patients with SOM were treated using MVD with the lateral supracerebellar infratentorial approach. The patients underwent diagnostic magnetic resonance imaging and three-dimensional fusion imaging preoperatively. A lateral suboccipital craniotomy was performed in the park-bench position. The trochlear nerve and branches of the superior cerebellar artery were confirmed after opening the cerebellomesencephalic fissure over the tentorial surface of the cerebellum. The vessel, which compressed the root exit zone of the trochlear nerve, was transposed far from the nerve and attached to the surface of the midbrain using Teflon felt and fibrin glue. RESULTS: The first case showed compression on both the ventral and rostral sides of the trochlear nerve root exit zone, and the second showed compression only on the ventral side. Large bridging veins on the tentorial surface of the cerebellum complicated the approach in the second case. Postoperatively, both patients had immediate and complete resolution of symptoms without recurrence at the 24-mo and 17-mo follow-ups, respectively. Five previous reports described the complete resolution of SOM after MVD. CONCLUSION: A presentation of an intermittent fluttering ocular sensation should prompt magnetic resonance imaging for ipsilateral trochlear nerve compression. The lateral supracerebellar infratentorial approach allows safe and efficacious MVD for SOM.

Analysis of clinicopathological features and NAB2-STAT6 fusion variants of meningeal solitary fibrous tumor with ectopic salivary gland components in the cerebellopontine angle.

Solitary fibrous tumors (SFTs) are rare mesenchymal tumors that can occur at any location. Since the identification of specific NAB2-STAT6 fusion in SFTs, the fusion gene variants, NAB2 exon 4-STAT6 exon 2/3 and NAB2 exon 5/6/7-STAT6 exon 16/17/18, have been reported to be associated with clinicopathological features, and the latter variant is predominant in meningeal SFTs. SFTs developing in the salivary glands are rare, and more rarely, those involving ectopic salivary glands (ESGs) have been reported in the cerebellopontine angle (CPA); however, their characteristics remain not well understood. In this study, we performed a clinicopathological and molecular analysis of 3 cases of meningeal SFT with ESGs. All cases presented with an extra-axial mass in the CPA, which is a rarer location for intracranial ESGs compared to the sellar region. Histologically, except for the presence of ESGs, there was no significant difference between current cases and ordinary SFTs. The ESGs demonstrated no cellular atypia, and although the spindle tumor cells were immunopositive for STAT6, the ESGs were negative in all cases, supporting that the ESGs are non-neoplastic components. In 1 case, ESGs were found only in the primary tumor and disappeared in recurrence/dissemination. Of note, molecular analysis identified NAB2 exon 4-STAT6 exon 2 in all cases. In conclusion, our results suggest that ESGs particularly in the CPA may be associated with SFTs and that meningeal SFTs with ESGs may be associated with the minor fusion variant of NAB2-STAT6 in the intracranial lesions.

Sequential Change of Facial Nerve Motor Function after Microvascular Decompression for Hemifacial Spasm: An Electrophysiological Study.

Hemifacial spasm (HFS) patients occasionally present with preoperative facial weakness (PFW) or develop delayed facial palsy (DFP) after microvascular decompression (MVD). This study is aimed to evaluate the neurophysiology underlying facial nerve motor dysfunction in HFS patients preoperatively and postoperatively. In all, 54 HFS patients without prior botulinum toxin injection who underwent MVD were retrospectively reviewed. The compound muscle action potential (CMAP) amplitude ratios of the affected and unaffected facial nerves, measured at 4 time points from preoperation to 1 year post-surgery, were aggregated. Clinical outcomes and the CMAP amplitude ratios were evaluated. Six patients (11.1%) presented with PFW, which correlated with advanced age (p = 0.007) and symptom duration (p = 0.001). The average duration to achieve PFW relief was 2.67 months postoperatively. The preoperative CMAP amplitude ratios of PFW patients were lower than those of patients without PFW (85.3% vs 95.7%). The ratios showed the lowest value at 1-week post-surgery in both groups (70.3% vs 90.9%), had a tendency toward improvement at 1 month, and finally recovered to almost the same level as that before the surgery at 1 year. Three patients (5.6%), whose CMAP ratios showed a persistent decrease from 1 week (56.5%) to 1 month (31%) after MVD, developed DFP. This study illustrates PFW in HFS patients reflects facial nerve axonal stress. MVD is effective in resolving spasm and PFW, without long-term damage to the facial nerve in most patients. In DFP patients, the direct and subsequent secondary axonal disorder develops on the postoperative facial nerve.

Intravenous fosphenytoin therapy for rescue of acute trigeminal neuralgia crisis in patients awaiting neurosurgical procedures: A cross-sectional study.

Few treatments exist for acute attacks of trigeminal neuralgia. Therefore, this study aimed to investigate the efficacy and safety of an intravenous fosphenytoin therapy protocol in a trigeminal neuralgia crisis. We conducted a single-center, retrospective, observational study of the records of 20 patients with trigeminal neuralgia who received intravenous fosphenytoin therapy (15 mg/mL in normal saline at 50 mg/min for 15 min, total 750 mg) during hospitalization between September 2015 and August 2020. Serum phenytoin concentration was measured 30 min post-infusion. Pain severity was evaluated using a numerical rating scale and was analyzed for statistical significance. The mean age of the patients was 67.5 years (female, 50.0%). The median numerical rating scale score (interquartile range) of pain severity was 2.35 (0-10), 0.65 (0-5), 0.15 (0-1), 2.00 (0-8), and 4.30 (0-10) at 15, 30, and 60 min, and 12 and 24 h, respectively (p < .001); the numerical rating scale score was 10 before treatment. Reduction in pain 24 h following treatment was significant. The mean phenytoin concentration was 12.8 µg/mL 30 min post-treatment. While mild dizziness occurred in four patients, all could walk independently within 60 min. The mean age and weight of patients with mild dizziness were significantly higher and lower, respectively (p < .001), than those of other patients. These results may provide physicians with new insights into the innovative therapeutic option of intravenous fosphenytoin and contribute to advancements in treating acute trigeminal neuralgia crisis.