Decompression Surgery in Elderly Patients with Hemifacial Spasm Refractory to Botulinum Toxin.

BACKGROUND: Botulinum toxin is an effective treatment for hemifacial spasm in elderly patients. However, some patients do not tolerate the side effects and frequency of botulinum toxin treatments. OBJECTIVES: The purpose of this study was to evaluate the characteristics and outcomes of a cohort of elderly patients referred by neurologists for surgical decompression of the facial nerve following botulinum toxin treatment. METHODS: In a prospective cohort study, logistic regression was used to detect potential predictors of spasm-freedom after surgical decompression of the facial nerve in elderly patients that received ≤8 and >8 botulinum toxin treatments for hemifacial spasm before surgery. Age, sex, side, preoperative symptom duration, and preoperative botulinum toxin treatment were assessed as potential predictors of spasm-freedom at last follow-up. RESULTS: Of 76 elderly patients with hemifacial spasm treated with botulinum toxin and microvascular decompression, with at least 2-years of follow-up (median, 44.5 months), 84.2% were spasm-free at last follow-up. Age (P = 0.38), sex (P = 0.59), side (P = 0.15), preoperative symptom duration (P = 0.7), and number of preoperative botulinum toxin treatments (P = 0.3) were not predictors of long-term spasm-freedom. Permanent ipsilateral hearing loss was the most frequent complication (3.9%). CONCLUSION: This study provides evidence that elderly patients can undergo botulinum toxin treatment for hemifacial spasm without compromising their likelihood of achieving spasm-freedom with future surgical decompression. Therefore, surgical decompression of the facial nerve is an effective therapy for elderly patients with hemifacial spasm refractory to botulinum toxin.

Outcomes of Trigeminal Ganglion Sparing Surgical Resection of Nonacoustic Cerebellopontine Angle Tumors Causing Trigeminal Neuralgia.

OBJECTIVE: Tumors may be responsible for up to 5% of trigeminal neuralgia cases. Predictors of long-term pain relief after surgical resection of various cerebellopontine angle tumor types are not well understood. Previous studies found that size and extent of resection predict long-term pain status, although resection of tumor involving the trigeminal ganglion may be associated with high morbidity. This study evaluated predictors of TN pain freedom after resection of a nonacoustic CPA tumor, with avoidance of any portion involving the TG. METHODS: In a retrospective cohort study, we evaluated clinical outcomes and complications after surgical resection of nonacoustic CPA tumors with purposeful avoidance of the TG causing trigeminal neuralgia. The primary outcome was pain-freedom. We performed logistic regression analyses to examine the relationship between pain-freedom at last follow-up and age, side of symptoms, preoperative symptom duration, tumor diameter, tumor type, and concurrent neurovascular compression (NVC). RESULTS: Of 18 patients with nonacoustic CPA tumors causing TN treated with surgical resection, 83.3% were pain-free at last follow-up (mean 44.6 months). Age (P = 0.12), side (P = 0.41), preoperative symptom duration (P = 0.85), tumor diameter (P = 0.29), tumor type (P = 0.37), and NVC presence (P = 0.075) were not associated with long-term pain freedom. CONCLUSIONS: This study provides additional evidence that various tumor types causing TN may safely undergo surgical resection and decompression of the trigeminal nerve to treat TN. This study presents a cohort of patients that underwent resection of a nonacoustic CPA tumor, with purposeful avoidance of the TG to minimize complications, demonstrating high rates of long-term pain freedom.

Primary central nervous system post-transplant lymphoproliferative disorder after allogeneic stem cell transplantation: a case report.

Purpose: Primary central nervous system, diffuse large B-cell lymphoma, post-transplant lymphoproliferative disorder in the cerebellopontine angle after an allogeneic stem cell transplantation has never been reported in the literature. Typically, diffuse large B-cell lymphoma is non-polyploid. We report the first case of a patient with polyploid post-transplant lymphoproliferative disorder in the cerebellopontine angle who presented with back pain. Case presentation: A 45-year-old man with a history of nodular sclerosing classic Hodgkin lymphoma stage IIB treated with systemic chemotherapy, external radiation and autologous stem cell transplant and double umbilical cord allogeneic transplant presented with several weeks of back pain. He was found to have a small right cerebellopontine angle mass thought to be consistent with a meningioma. Patient presented again two weeks later with acute onset of severe headache, right sided ptosis, right facial numbness, weakness and possible seizure event. Repeat MRI scans showed an interval and significant increase of the right cerebellopontine angle lesion. Biopsy of the cerebellopontine angle lesion was planned with suspicion of lymphoma. Intraoperative pathology consultation findings were not consistent with an acoustic neuroma, meningioma, or epidermoid cyst. Lymphoma could not be definitively identified by intra-operative frozen section. However, it was suspected, and a portion of fresh specimen was submitted for flow cytometry analysis. A near total resection of the tumor and decompression of the brainstem was achieved. Final pathologic analysis was positive for post-transplant lymphoproliferative disorder, monomorphic type, diffuse large B-cell lymphoma, non-germinal center B-cell type, EBV+, post-transplant (allogeneic stem cell) setting (post-transplant lymphoproliferative disorder (PTLD), monomorphic type, diffuse large B-cell lymphoma, non-germinal center B-cell type (non-GCB), EBV-positive under pre-2022 WHO terminology). The patient began a high-dose methotrexate-based regimen (the MATRIX regimen). Conclusions: Our case illustrates an unusual presentation of post-transplant lymphoproliferative disorder in the cerebellopontine angle in a patient with a remote history of allogeneic stem cell transplantation. It demonstrates the importance of keeping primary central nervous system post-transplant lymphoproliferative disorder on the differential for patients who present with back pain or headache that have a history of allogeneic stem cell transplant.

Microvascular decompression for developmental venous anomaly causing hemifacial spasm: illustrative case.

BACKGROUND: Developmental venous anomaly (DVA) is a rare cause of hemifacial spasm (HFS). The treatment of HFS caused by a DVA varies in the literature and includes medication management, botulinum toxin injections, and microvascular decompression (MVD). OBSERVATIONS: A 64-year-old woman presented with right-sided HFS. Preoperative magnetic resonance imaging showed a DVA in the right inferior pons, with an enlarged segment compressing the facial nerve at its root detachment point prior to drainage into the superior petrosal sinus. MVD was performed, and the facial nerve was decompressed without sacrifice of the vein. Immediately following the procedure, the patient had significantly reduced spasms. The patient became spasm-free 3 months after MVD and maintained spasm freedom for 3 months. Six months after MVD, the patient had a partial return of spasms. At 8 months, the patient continued to have reduced and intermittent spasms in the right orbicularis oculi muscle. LESSONS: MVD for HFS caused by a DVA is a safe procedure and can be effective at reducing spasm frequency and severity.