Repeat stereotactic radiosurgery for progressive vestibular schwannomas after primary gamma knife radiosurgery.

PURPOSE: Limited data provides guidance on the management of vestibular schwannomas (VSs) that have progressed despite primary Gamma Knife radiosurgery (GKRS). The present article reports our long-term experience after repeat GKRS for VS with sustained progression after solely primary GKRS management. METHODS: A retrospective review of 1997 patients managed between 1987 and 2023 was conducted. Eighteen patients had sustained tumor progression after primary GKRS and underwent repeat GKRS. The median repeat GKRS margin dose was 11 Gy (IQR: 11-12), the median tumor volume was 2.0 cc (IQR: 1.3-6.3), and the median cochlear dose in patients with preserved hearing was 3.9 Gy (IQR: 3-4.1). The median time between initial and repeat GKRS was 65 months (IQR: 38-118). RESULTS: The median follow-up was 70 months (IQR: 23-101). After repeat GKRS, two patients had further tumor progression at 4 and 21 months and required partial resection of their tumors. The 10-year actuarial tumor control rate after repeat GKRS was 88%. Facial nerve function was preserved in 13 patients who had House-Brackmann grade 1 or 2 function at the time of repeat GKRS. Two patients with serviceable hearing preservation (Gardner-Robertson grade 1 or 2) at repeat GKRS retained that function afterwards. In patients with tinnitus, vestibular dysfunction, and trigeminal neuropathy, symptoms remained stable or improved for 16/16 patients, 12/15 patients, and 10/12 patients, respectively. One patient developed facial twitching in the absence of tumor growth 21 months after repeat GKRS. CONCLUSIONS: Repeat GKRS effectively controlled tumor growth and preserved cranial nerve outcomes in most patients whose VS had sustained progression after initial primary radiosurgery.

Immediate lengthening temporalis myoplasty for facial palsy reconstruction following facial nerve inclusive total parotidectomy.

Immediate lengthening temporalis myoplasty (Labbé procedure) for immediate dynamic facial reanimation after nerve-inclusive parotidectomy in the elderly population is undocumented in the literature. The aim of this work was to determine whether the Labbé approach could achieve immediate, good functional and static results in elderly patients with acquired facial palsy. A retrospective analysis of five patients with parotid malignancies involving the facial nerve who underwent parotidectomy and an immediate Labbé procedure was performed. The House-Brackmann and Sunnybrook scores for facial palsy were used as objective measurements of the functional outcome. All patients underwent total parotidectomy, neck dissection, Labbé procedure, immediate temporary tarsorrhaphy, brow lift, and postoperative radiotherapy. Mean patient age was 83 (range 73-87) years. The average resected tumour size was 3.54 cm. The mean duration of surgery was 324 min and length of hospital stay 4 days. All patients experienced an improvement in House-Brackmann of one grade postoperative (grade V to IV in four, grade VI to V in one); the Sunnybrook score improved by 31 points on average (mean preoperative 3.8 vs postoperative 34.8). An immediate Labbé procedure following ablative parotid malignancy resection is a reliable and safe reconstructive procedure in a carefully selected elderly population, providing acceptable immediate static and dynamic hemifacial mimetic function and eliminating an additional facial palsy correction procedure.

Amphiphysin-IgG autoimmune sciatic neuropathy and facial neuropathy related to primary central nervous system lymphoma: A case report.

We reported a 61-year-old man presented with 10-month progressing left sciatic neuropathy and 10-day right facial neuropathy. Serum amphiphysin-IgG was positive. 18F-FDG PET/CT of the whole body showed no signs of malignancy. Treatment with plasma exchange and oral prednisone relieved the symptoms. Nine months later, right hemiparesis and seizure of right limbs developed. 18F-FDG and 18F-PBR06 (18 kDa translocator protein, TSPO) radioligand PET/MRI of the whole body revealed intense uptake in the intracranial lesions. Intracranial lymphoma was diagnosed by stereotactic needle brain biopsy. Mononeuropathies could be paraneoplastic syndromes. TSPO shows high uptake in intracranial lymphoma on 18F-PBR06 PET images.

[The neuropathy of marginal mandibular branch of the facial nerve]. / Izolirovannoe porazhenie kraevoi nizhnechelyustnoi vetvi litsevogo nerva.

OBJECTIVE: To analyze the diagnosis, treatment and rehabiltation of patients with marginal mandibular branch of the facial nerve (MMB). MATERIAL AND METHODS: We have collected 6 patients (mean age 40 [33.8; 44] years) with isolated lesion of MMB that innervates the depressor labii inferioris and chin muscle. The illness duration without any improvement was 35 [13; 44] days. Diagnosis and treatment were carried out according to the special algorithm developed and implemented at the N.V. Sklifosovsky Research Institute of Emergency Medicine. RESULTS: With needle myography of the muscle that lowers the lower lip, the change in the ratio of the maximum amplitudes of the interference pattern (MAIP) in all patients exceeded 15%, and in 2 cases it was more than 90%. Comparing with the healthy face side, a change of the MAIP ratio less than 90% was considered as the biomarker of favorable prognosis, with conservative treatment recommendations, e.g. the set of exercises with targeted effects on depressor labii inferioris. With regular exercises, patients noted positive dynamics of restoring the symmetry of the smile in 1-2 months of the disease, full recovery - in 4-5 months. In case of exercises rejection, there was no positive dynamics. A change in the MAIP ratio more than 90% or the absence of motor unit potentials was considered as the biomarker of an unfavorable outcome and an indication for surgical treatment. After surgical treatment, the improvement occurred within 4-5 months. In conservative treatment group, there were no positive changes even with regular exercises. CONCLUSION: The diagnosis of an isolated lesion of MMB is established clinically using a protocol of step-by-step assessment of facial muscle function, and tactics is determined by needle myography with depressor labii inferioris. Even with favorable myographic predictors, spontaneous recovery may not occur, exercises with a targeted effect on the depressor labii inferioris are required, and in the presence of unfavorable predictors, surgical treatment is reccomended.

Facial nerve palsy in neurosarcoidosis: clinical course, neuroinflammatory accompaniments, ancillary investigations, and response to treatment.

BACKGROUND: Facial nerve palsy is a cardinal manifestation of neurosarcoidosis, but dedicated studies of this disease feature have not been conducted. We sought to clarify the impact of facial palsy on the diagnosis of neurosarcoidosis, its subsequent clinicoradiographic evolution, and eventual treatment decisions. METHODS: A single-center retrospective analysis of patients with neurosarcoidosis and facial palsy was conducted over the preceding 10 years (01/01/2011-08/12/2021). RESULTS: 23/218 (10.6%) patients with neurosarcoidosis developed facial neuropathy. It was the inaugural manifestation of neurosarcoidosis in 17/23 (73.9%) and presented in isolation of other neurologic deficits or extra-facial MRI abnormalities in 12/23 (52.2%). At onset, facial palsy was unilateral in 20/23 (87.0%), and multiple cranial neuropathies were seen in 8/23 (34.8%). Non-facial inflammatory MRI abnormalities were observed in 6/15 (40.0%) patients at onset with leptomeningitis being most common (5/15, 33.3%). 13/23 (56.5%) experienced a second attack of neurosarcoidosis at a median of 8 months, including 3/23 (13.0%) with recurrent facial palsies. In the 12 patients with isolated facial paresis at onset, 4/12 (33.3%) remained free of new deficits or neuroimaging abnormalities by last follow-up. 17/23 (73.9%) eventually required initiation of steroid-sparing immunosuppressants, almost all for development of non-facial disease. The final median House-Brackmann score was 1. CONCLUSION: Facial neuropathy occurred less commonly than historically reported, and it often acts as a forerunner to systemic sarcoidosis and more widespread neurologic disease. Recurrent attacks of neurosarcoidosis occur early at high frequency following facial palsy. Recovery of facial nerve function is typically excellent.

The Effect of Prescription Isodose Variation on Tumor Control and Toxicities in Stereotactic Radiosurgery for Sporadic Vestibular Schwannoma: Propensity Score-Matched Case-Control Study.

Objective Vestibular schwannoma (VS) treated with Gamma Knife stereotactic radiosurgery (SRS) was typically performed at 50% isodose line (IDL50); however, the impact of IDL variation on outcomes is poorly understood. This study aimed to compare tumor control (TC) and toxicities between treatment at 40% (IDL40) and 50% (IDL50). Methods Sporadic/unilateral VS patients treated with SRS dose 12 to 14 Gy and prescription isodose volume ≤10cm 3 were included. Propensity score matching was applied to IDL40 cohort to generate an IDL50 companion cohort, adjusting for age and prescription isodose volume. After exclusion of patients with follow-up <24 months, there were 30 and 28 patients in IDL40 and IDL50 cohorts, respectively. Results Median follow-up time was 96 months (24-225 months). Actuarial and radiographic TC rates were 91.8% and clinical TC was 96.2% both at 5 and 10 years. TC was higher in IDL40 cohort but not significant (96.4 vs. 86.7%; p = 0.243). Hearing preservation (HP) rates were 71.9 and 39.2% at 5- and 10-year intervals, with significantly higher rates of HP noted in IDL40 cohort (83.3 vs. 57.1% at 5-year interval; 62.5 vs. 11.4% at 10-year interval; p = 0.017). Permanent facial neuropathy occurred in two patients, both from the IDL50 cohort (3.5%). Rates of post-SRS steroid treatment or shunt placement for hydrocephalus were slightly higher in IDL50 patients (6.9 vs. 17.9%; p = 0.208 and 3.3 vs. 7.1%; p = 0.532). Conclusion For treatment of VS with SRS, dose prescription at IDL40 or IDL50 provides excellent long-term TC and toxicity profiles. IDL40 may be associated with improved long-term HP.

Chronic inflammatory demyelinating polyneuropathy with hypoglossal nerve involvement and inverted Beevor's sign: case report.

BACKGROUND: Cranial nerve involvement is not commonly encountered in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP); this is especially true for involvement of the hypoglossal nerve. Neither Beevor's sign nor its inverted form has previously been described in CIDP. CASE PRESENTATION: A 28-year-old man presented with distal-predominant limb weakness and numbness at the age of 18. A diagnosis of CIDP was made, which was confirmed by electrodiagnostic evidence of demyelination. He responded well to intravenous immunoglobulin and glucocorticoid treatment and achieved remission for 5 years. However, the same symptoms relapsed at the age of 28 and lasted for 10 months. On examination, in addition to limb sensory impairment and muscle weakness, mild bilateral facial paresis, tongue atrophy and fasciculations, and inverted Beevor's sign were also observed. A brief literature review of cranial nerve involvements in CIDP and Beevor's sign or its inverted form were also performed. CONCLUSIONS: Cranial nerves may be affected in patients with CIDP. Facial palsy is most frequently present, while hypoglossal nerve involvement is rare. Inverted Beevor's sign can appear in CIDP patients.

Neural mobilization in Bell's palsy: A case report.

Background: Bell's palsy (BP) is a sudden onset of signs and symptoms of facial nerve dysfunction. The treatment of choice is corticosteroids and antiviral drugs. These drugs are risky for individuals with pre-existing conditions such as diabetes, high blood pressure, and digestive disturbances. Therefore, a beneficial complementary therapy would add to the success of treatment.Clinical Presentation: A 42-year-old male presented with left side facial paralysis and asymmetry. The patient received neural mobilization along with routine physical therapy for 1 hour, 5 days a week, for 3 weeks. A follow-up was scheduled at the 8th week.Clinical Relevance: Neural mobilization technique of the facial nerve is a novel and safe addition to the conservative treatment of BP.

Retrospective analysis of ocular neuropathies in diabetic dogs following cataract surgery.

OBJECTIVES: To describe and compare the cumulative incidence and clinical progression of ocular neuropathies in diabetic dogs vs nondiabetic dogs following cataract surgery. METHODS: Medical records of 196 diabetic and 442 nondiabetic dogs who underwent cataract surgery between 2004 and 2015 were reviewed. The percentage of patients affected by neuropathy and potential risk factors were compared between groups. RESULTS: Patients with diabetes mellitus (DM) were 20.4 times more likely to develop an ocular neuropathy than patients without DM (12.24% vs 0.68%). Twenty-four diabetic patients were affected by mononeuropathies or polyneuropathies including Horner's syndrome (n = 20), facial neuropathy (n = 5), and neurogenic keratoconjunctivitis sicca (NKCS) (n = 5). The odds of a diabetic patient developing Horner's syndrome and NKCS were 86.3 and 20.7 times higher than a nondiabetic patient, respectively. The average duration of DM prior to diagnosis of neuropathy was 659 days (range 110-2390 days; median 559 days). Complete resolution was achieved in 10 of 22 neuropathies (45%) within an average of 248 days (range 21-638 days; median 187 days) after diagnosis. CONCLUSIONS: The odds of developing an ocular neuropathy, specifically Horner's syndrome and NKCS, are statistically higher in diabetic patients compared to nondiabetic patients. Neuropathies were observed as a long-term complication in this group of diabetic patients, and complete resolution of the neuropathy was observed in less than half of the affected population.

Combined isolated trigeminal and facial neuropathies from perineural invasion by squamous cell carcinoma: A case series and review of the literature.

Perineural invasion is a targeted cellular proliferation guided by neurotrophins, rather than a simple diffusion of tumor in a path of least resistance. Invasion of cranial nerves by squamous cell carcinoma can represent an important diagnostic dilemma. It commonly presents as a distinct clinical neurological syndrome of combined isolated trigeminal and facial neuropathies. The focal cancer source may have been overlooked or remain occult. This case series illustrates diverse clinical presentations and neuroimaging challenges in four patients with squamous cell carcinoma of the cranial nerves. Anatomical pathways linking the trigeminal and facial nerves are reviewed, with emphasis on the auriculotemporal and pterygopalatine nerves. A successful neuroimaging strategy requires a targeted multimodality analysis of specific anatomical loci at the base of the skull. Attention must be directed to subtle radiological findings, such as obliteration of fat planes and linear enhancement along nerve branches, rather than bulky tumor tissue or bony invasion. Despite advances in microsurgical dissection and targeted radiotherapy, recovery of established neuropathic deficits is not expected. The prognosis remains poor in cases of advanced disease, emphasizing the importance early diagnosis by clinical acumen and focused neuroimaging.

Clinical Experience of Gamma Knife Rediosurgery for Acoustic Neurinomas

Microsurgical tumor removal is the treatment of choice to relieve the mass effect for the treatment of acoustic neurinoma patients. Gamma knife radiosurgery is another treatment option for patients with tumor size of less than approximately 4cm. Between May, 1990 and March, 1994, 55 tumor lesions from 50 patients were treated with gamma knife radiosurgery at Asan Medical Center. Following microsurgery, 20 patients underwent gamma knife radiosurgery for tumors not removed surgically. The remaining 30 patients underwent gamma knife radiosurgery alone. For an average follow-up period of 26 months(ranging from 6 to 45 months), 37 lesions out of 39 lesions responded, giving a tumor growth control rate of 94.9%. Facial neuropathy and trigeminal neuropathy were noted in 8% and 6%, respectively. According to these results, it is suggested that gamma knife radiosurgery in an effective altrnative therapeutic modality for the management of small to moderate sized acoustic neurinomas.