Hiroshi Shimano

Microvascular Decompression for Hemifacial Spasm Associated with Bilateral Vertebral Artery Compression.

BACKGROUND Microvascular decompression (MVD) has been established as an effective treatment for hemifacial spasm (HFS). However, replacement of bilateral vertebral arteries (VAs) from the root exit zone (REZ) is difficult and requires special techniques. Reports of HFS cases associated with bilateral VA compression are quite rare. This study investigated the characteristics of these arteries and methods for safe and definite decompression. METHODS Among 131 patients who underwent MVD for HFS, 33 patients (25.2%) had associated VA compression; 4 patients (3.1%) had bilateral VA compression. Sufficient dissection of the arachnoid membrane allowed good visualization around the REZ, and the dolichoectatic VAs were successfully transposed and fixed to the nearby dura mater in 3 cases. RESULTS The offending arteries were bilateral VAs plus the posterior inferior cerebellar artery in 2 cases, bilateral VAs plus the anterior inferior cerebellar artery-posterior inferior cerebellar artery in 1 case, and bilateral VAs in 1 case. The contralateral VA of the symptomatic side was more ectatic, dolichoectatic, and tougher than the ipsilateral VA in 3 patients and was difficult to remove. In 3 patients treated with the transposition method, complete resolution of spasm was experienced immediately after surgery. Minimal residual spasm occurred in 1 patient treated with the interposition method. Transient facial palsy developed in 1 case, and moderate hearing loss developed in another case. CONCLUSIONS HFS caused by bilateral VA compression is rare; however, replacement of VAs from the REZ is not easy because such VAs are invariably dolichoectatic and tough. Treatment of such cases requires special techniques.

Model analysis of coil embolization of cerebral aneurysms : prediction of thrombus formation in aneurysms based on the coil embolization rate

Abstract Objectives: Intra-aneurysmal coil embolization has been established as a common method for the intravascular treatment of cerebral aneurysms, but few studies have evaluated its long-term results. Because there is no sufficient objective landmark of complete embolization, determination of its application depends on a surgeons experience. Methods: A glass cerebral aneurysm model was produced, and the changes in intra-aneurysmal hemodynamics were examined. Nylon thread with a diameter of 0.33 mm, resembling the coils clinically used for embolization, was used to fill in the model. After perfusion of glycerin solution to represent human blood, the half life of a dye injected into the aneurysm was optically measured, and the relationship between the half life and the volume embolization rate (VER) of nylon thread in the aneurysm was examined. Results: : The maximal VER obtained by filling nylon thread in the aneurysm was 41.7 ± 2.9%. The half life of the dye increased with the VER and was significantly increased at VER > 30%. Discussion: The half life of the dye in the aneurysm reflected stagnation of intra-aneurysmal hemodynamics, suggesting that the prolongation of the half life enhances thrombus formation. The results of this study suggested that VER > 30% is sufficient for effective coil embolization.

Significance of Anomalous Anterior Inferior Cerebellar Artery–Posterior Inferior Cerebellar Artery Common Trunk Compression in Microvascular Decompression for Hemifacial Spasm

BACKGROUND The anterior inferior cerebellar artery-posterior inferior cerebellar artery (AICA-PICA) common trunk anomaly is reportedly one of the most common vessel variants in the posterior circulation, but reports of hemifacial spasm (HFS) associated with AICA-PICA common trunk are very rare. In the present study, we describe methods of microvascular decompression (MVD) for HFS caused by AICA-PICA common trunk compression. METHODS Among 159 patients who underwent MVD for HFS, 16 patients had compression of the root exit zone by the AICA-PICA common trunk anomaly. The types of compression were classified into 2 groups: common trunk artery compression group and branching vessel compression group. RESULTS The common trunk artery compression group consisted of 11 patients (69%), and the branching vessel compression group consisted of 5 patients (31%). The rostral branch (feeding the original AICA territory) coursed between the seventh and eighth cranial nerves in 5 patients, and in 13 patients (81%), the offending vessel harbored perforators around the root exit zone. Among 16 patients, 14 (87.5%) required interposition of the common trunk or the branching vessel, and in 2 patients, decompression was completed by the transposition method. Fifteen patients experienced sufficient results, and 1 had severe residual spasm. Transient facial palsy developed in 2 patients. No patients encountered recurrence. CONCLUSIONS Reports concerning decompression methods of AICA-PICA common trunk anomaly are very rare. The tortuosity of the common trunk and perforators from the offending vessel make the usual repositioning of the offending artery much more difficult, and adequate decompression techniques are required for successful MVD.

Reappearance of Cranial Nerve Dysfunction Symptoms Caused by New Artery Compression More than 20 Years after Initially Successful Microvascular Decompression: Report of Two Cases

Reappearance of symptoms of cranial nerve dysfunction is not uncommon after successful microvascular decompression (MVD). The purpose of this study was to report two quite unusual cases of recurrent and newly developed hemifacial spasm (HFS) caused by a new conflicting artery more than 20 years after the first successful surgery. In Case 1, the first MVD was performed for HFS caused by the posterior inferior cerebellar artery (PICA) when the patient was 38 years old. After 26 symptom-free years, HFS recurred on the same side of the face due to compression by the newly developed offending AICA. In Case 2, the patient was first operated on for trigeminal neuralgia by transposition of the AICA at 49 years old, but 20 symptom-free years after the first MVD, a new offending PICA compressed the facial nerve on the same side, causing HFS. These two patients underwent reoperation and gained satisfactory results postoperatively. Reappearance of symptoms related to compression of the root exit zone (REZ) by a new offending artery after such a long symptom-free interval since the first effective MVD is rare. Here, we describe two such unusual cases and discuss how to manage and prevent such reappearance of symptoms after a long time interval.