Bong Arm Rhee

The Treatment Outcome of Elderly Patients with Idiopathic Trigeminal Neuralgia : Micro-Vascular Decompression versus Gamma Knife Radiosurgery

OBJECTIVE This study was designed to compare the efficacy of micro-vascular decompression (MVD) and Gamma knife radiosurgery (GKRS) for elderly idiopathic trigeminal neuralgia patients by analyzing the clinical outcome. METHODS In the past 10 years, 27 elderly patients were treated with MVD while 18 patients were treated with GKRS (>65-years-old). We reviewed their clinical characteristics and clinical courses after treatment as well as the treatment outcomes. For patients who were treated with MVD, additional treatment methods such as rhizotomy were combined in some areas. In GKRS, we radiated the root entry zone (REZ) with the mean maximum dose of 77.8 (70-84.3) Gy and one 4 mm collimator. RESULTS The mean age was 68.1 years for MVD, and 71.1 years for GKS group. The average time interval between first presenting symptom and surgery was 84.1 (1-361) months, and 51.4 (1-120) months, respectively. The mean follow-up period after the surgery was 35.9 months for MVD, and 33.1 months for GKRS. According to Pain Intensity Scale, MVD group showed better prognosis with 17 (63%) cases in grade I-II versus 10 (55.6%) cases in GKRS group after the treatment. The pain recurrence rate during follow up did not show much difference with 3 (11.1%) in MVD, and 2 (11.1%) in GKRS. After the treatment, 2 cases of facial numbness, and 1 case each of herpes zoster, cerebrospinal fluid (CSF) leakage, hearing disturbance, and subdural hematoma occurred in MVD Group. In GKRS, there was 1 (5.6%) case of dysesthesia but was not permanent. Three cases were retreated by GKRS but the prognosis was not as good as when the surgery was used as primary treatment, with 1 case of grade I-II, and 1 case of recurrence. The maximal relieve of pain was seen just after surgery in MVD group, and 1 year after treatment in GKRS group. CONCLUSION For trigeminal neuralgia patients with advanced age, MVD showed advantages in immediately relieving the pain. However, in overall, GKRS was preferable, despite the delayed pain relief, due to the lower rate of surgical complications that arise owing to the old age.

Hemifacial spasm caused by contralateral cerebellopontine angle meningioma: case report.

A large meningioma in the cerebellopontine angle manifested itself as a contralateral hemifacial spasm. On computed tomographic and magnetic resonance imaging scans, the brain stem was markedly displaced and distorted by the tumor. After total removal of the meningioma, the hemifacial spasm completely disappeared.

Microvascular Decompression for Hemifacial Spasm Associated with Vertebrobasilar Artery

OBJECTIVE Hemifacial spasm (HFS) is considered as a reversible pathophysiological condition mainly induced by continuous vascular compression of the facial nerve root exit zone (REZ) at the cerebellopontine angle. As an offending vessel, vertebrobasilar artery tends to compress much more heavily than others. The authors analyzed HFS caused by vertebrobasilar artery and described the relationships between microsurgical findings and clinical courses. METHODS Out of 1,798 cases treated with microvascular decompression (MVD) from Jan. 1980 to Dec. 2004, the causative vessels were either vertebral artery or basilar artery in 87 patients. Seventy-nine patients were enrolled in this study. Preoperatively, computed tomography (CT) or brain magnetic resonance (MR) imaging with 3-dimentional short range MR technique was performed and CT was checked immediately or 2-3 days after anesthetic recovery. The authors retrospectively analyzed the clinical features, the compression patterns of the vessels at the time of surgery and treatment outcomes. RESULTS There were 47 were male and 32 female patients. HFS developed on the left side in 52 cases and on the right side in 27. The mean age of onset was 52.3 years (range 19-60) and the mean duration of symptoms was 10.7 years. Many patients (39 cases; 49.1%) had past history of hypertension. HFS caused only by the vertebral artery was 8 cases although most of the other cases were caused by vertebral artery (VA) in combination with its branching arteries. Most frequently, the VA and the posterior inferior cerebellar artery (PICA) were the simultaneous causative blood vessels comprising 32 cases (40.5%), and in 27 cases (34.2%) the VA and the anterior inferior cerebellar artery (AICA) were the offenders. Facial symptoms disappeared in 61 cases (77.2%) immediately after the operation and 68 cases (86.1%) showed good outcome after 6 months. Surgical outcome just after the operation was poor in whom the perforators arose from the offending vessels concurrently (p<0.05). CONCLUSION In case where the vertebral artery is a cause of HFS, commonly branching arteries associated with main arterial compression on facial REZ requires more definite treatment for proper decompression because of its relatively poor results compared to the condition caused by other vascular compressive origins.

Cerebellopontine angle tumors causing hemifacial spasm: types, incidence, and mechanism in nine reported cases and literature review

ObjectiveAlthough hemifacial spasm is usually caused by vascular compression around the root exit zone of the facial nerve, it is sometimes brought on by a cerebellopontine angle tumor. We reviewed and analyzed data from past experience with hemifacial spasm induced by cerebellopontine angle tumors.MethodsNine patients of a total 2,050, who had presented with hemifacial spasms associated with cerebellopontine angle tumors between 1986 and 2009, were reviewed.ResultsTwo vestibular schwannomas, five meningiomas, and two epidermoid tumors were included in this study. Hemifacial spasm occurred on the same side of the lesion in eight patients whereas it occurred on the opposite side of the lesion in one patient. With respect to the pathogenesis of hemifacial spasms, offending vessels were found in six patients, tumor encasement of the facial nerve in one patient, hypervascular tumor compression of the facial nerve without offending vessels in one patient, and a huge tumor compressing the brain stem and, thus, contralateral facial nerve compression in one patient. Hemifacial spasm was resolved in seven patients, whereas in two patients with a vestibular schwannoma and an epidermoid tumor, it improved transiently and then recurred in a month.ConclusionsEach type of tumor had different characteristics with respect to the induction of hemifacial spasm; therefore, it is suggested that neurosurgeons, who are planning surgeries both for the purposes of relieving hemifacial spasm and removal of cerebellopontine angle tumor, should thoroughly prepare appropriate approaches and specific dissecting strategies according to each causative lesion.

Radiosurgical considerations in the treatment of large cerebral arteriovenous malformations.

OBJECTIVE In order to establish the role of Gamma Knife radiosurgery (GKS) in large intracranial arteriovenous malformations (AVMs), we analyzed clinical characteristics, radiological features, and radiosurgical outcomes. METHODS Between March 1992 and March 2005, 28 of 33 patients with large AVMs (> 10 cm(3) in nidus-volume) who were treated with GKS underwent single session radiosurgery (RS), and the other 5 patients underwent staged volumetric RS. Retrospectively collected data were available in 23 cases. We analyzed treatment outcomes in each subdivided groups and according to the AVM sizes. We compared the estimated volume, defined as primarily estimated nidus volume using MR images, with real target volume after excluding draining veins and feeding arteries embedded into the nidus. RESULTS Regarding those patients who underwent single session RS, 44.4% (8/18) had complete obliteration; regarding staged volumetric RS, the obliteration rate was 40% (2/5). The complete obliteration rate was 60% (6/10) in the smaller nidus group (10-15 cm(3) size), and 25% (2/8) in the larger nidus group (over 15 cm(3) size). One case of cerebral edema and two cases (8.7%) of hemorrhage were seen during the latent period. The mean real target volume for 18 single sessions of RS was 17.1 cm(3) (10.1-38.4 cm(3)), in contrast with the mean estimated volume of 20.9 cm(3) (12.0-45.0 cm(3)). CONCLUSION The radiosurgical treatment outcomes of large AVMs are generally poor. However, we presume that the recent development in planning software and imaging devices aid more accurate measurement of the nidus volume, therefore improving the treatment outcome.

Multi-modality treatment for intracranial arteriovenous malformation associated with arterial aneurysm.

OBJECTIVE Intracranial arteriovenous malformation (AVM) associated with aneurysm has been infrequently encountered and the treatment for this malady is challenging. We report here on our clinical experience with AVMs associated with arterial aneurysms that were managed by multimodality treatments, including clipping of the aneurysm, microsurgery, Gamma-knife radiosurgery (GKS) and Guglielmi detachable coil (GDC) embolization. METHODS We reviewed the treatment plans, radiological findings and clinical courses of 21 patients who were treated with GKS for AVM associated with aneurysm. RESULTS Twenty-seven aneurysms in 21 patients with AVMs were enrolled in this study. Hemorrhage was the most frequent presenting symptom (17 patients : 80.9%). Bleeding was caused by an AVM nidus in 11 cases, aneurysm rupture in 5 and an undetermined origin in 1. Five patients were treated for associated aneurysm with clipping followed by GKS for the AVM and 11 patients were treated with GDC embolization combined with GKS for an AVM. Although 11 associated aneurysms remained untreated after GKS, none of them ruptured and 4 aneurysms regressed during the follow up period. Two aneurysms increased in size despite the disappearance of the AVM nidus after GKS and then these aneurysms were treated with GDC embolization. CONCLUSION If combined treatment using microsurgery, GKS and endovascular treatment can be adequately used for these patients, a better prognosis can be obtained. In particular, GKS and GDC embolization are considered to have significant roles to minimize neurologic injury.

Hemifacial spasm caused by fusiform aneurysm at vertebral artery-posterior inferior cerebellar artery junction.

Hemifacial spasm induced by intracranial aneurysm is a rare clinical condition. A 45-year-old male patient presented with a 3-year history of progressive involuntary twitching movement on right face. On radiological study, a dilated vascular lesion compressing the brain stem was found at the junction of vertebral artery and posterior inferior cerebellar artery. On operative field, we found the posterior inferior cerebellar artery and the fusiform aneurysm compressing root exit zone of facial nerve. Microvascular decompression was performed and the facial symptom was relieved without complications.

Microvascular decompression for hemifacial spasm due to four offending vessels: a case report.

A 65-year-old woman presented with left facial involuntary movement and facial palsy for eight years. Brain magnetic resonance image (MRI) and magnetic resonance angiography (MRA) revealed multiple vascular compression of facial nerve root exit zone (REZ). Standard retromastoid suboccipital craniectomy and arachnoid dissection were performed. Right vertebral artery (VA), left VA, left anterior inferior cerebellar artery (AICA), and left posterior inferior cerebellar artery (PICA) compressed the facial nerve in that order. The offending vessels were dissected away from the facial nerve and transposed sequentially. Teflon was interposed between the arteries and the nerve. Electrophysiological monitoring showed disappearance of the abnormal hemifacial spasm response during the operation. The offending vessels were right VA, left VA, left AICA, and left PICA. Postoperatively, the patients involuntary movement was completely resolved. We report a rare case of hemifacial spasm caused by four offending vessels that was treated by microvascular decompression (MVD) with wide arachnoid dissection.

Trigeminal neuralgia caused by persistent primitive trigeminal artery.

A 66-year-old man presented with typical trigeminal neuralgia (TN). Magnetic resonance angiography (MRA) revealed a primitive trigeminal artery (PTA) that came into contact with the trigeminal nerve. Based on MRA, we performed microvascular decompression (MVD). In the operational field, we confirmed the PTA location and performed MVD successfully. Postoperatively, the patients pain subsided without any complications.

Hemifacial Spasm Developed after Contralateral Vertebral Artery Ligation

Although the mechanism of hemifacial spasm (HFS) is not yet well established, vascular compression of the facial nerve root exit zone and hyperexcitability of the facial nucleus have been suggested. We report a case of HFS in the setting of coinciding intracranial hemorrhage (ICH) of the pons and proximal ligation of the contralateral vertebral artery (VA) for the treatment of a fusiform aneurysm of the distal VA and discuss the possible etiologies of HFS in this patient. A 51-year-old male with an ICH of the pons was admitted to our hospital. Neuroimaging studies revealed an incidental fusiform aneurysm of the right VA distal to the origin of the posterior inferior cerebellar artery. Eight months after proximal ligation of the VA the patient presented with intermittent spasm of the left side of his face. Pre- and post-ligation magnetic resonance angiography revealed an enlarged diameter of the VA. The spasm completely disappeared after microvascular decompression.