Richard L. Harper

Microvascular decompression for hemifacial spasm: Long-term results from 114 operations performed without neurophysiological monitoring

OBJECT Microvascular decompression (MVD) of the facial nerve is an effective treatment for hemifacial spasm (HFS), but the procedure is associated with a significant risk of complications such as hearing loss and facial weakness. Many surgeons advocate the use of intraoperative brainstem auditory evoked response (BAER) monitoring in an attempt to improve surgical outcomes. The authors critically assessed a large series of patients with HFS who underwent MVD without neurophysiological monitoring. METHODS The authors retrospectively identified 114 consecutive patients, with a history of HFS and without a history of HFS surgery, in whom MVD was performed by a single surgeon without the use of neurophysiological monitoring. Postoperative outcomes were determined by reviewing records and through telephone interviews. At least 1 year of postoperative follow-up data were available for 91 of the 114 patients, and the median follow-up duration in all cases was 8 years (range 3 months-23 years). A Kaplan-Meier analysis showed that 86% of the patients were spasm free at 10 years postoperatively. RESULTS There were no surgical deaths or major deficits, and complications included 1 case of postoperative deafness, 1 of permanent subtotal hearing loss, and 10 of delayed facial palsy, 2 of which did not completely resolve at last follow-up. The outcomes, rates of hearing loss, and other complications compared well with those reported in studies in which investigators used intraoperative monitoring. CONCLUSIONS The results suggest that MVD without neurophysiological monitoring is a safe and effective treatment option in patients with HFS. Although BAER monitoring may be a valuable adjunct to surgery at centers experienced with the modality, the absence of intraoperative monitoring should not prevent neurosurgeons from performing MVD in patients with HFS.

Intraosseous Capillary Hemangioma of the Frontal Bone

A 31-year-old woman with a history of slowly progressive proptosis associated with blepharoptosis was found radiographically to have a lytic lesion of the frontal bone. Complete surgical excision of the bony mass was performed. Histopathologically the tumor was a capillary hemangioma. Follow-up information two years later showed that the patient was alive and well, without clinical evidence of recurrence. Plain x-ray films appear to be more reliable for diagnosis than computed tomography exhibiting the characteristic sunburst pattern of intraosseous hemangiomas.

Spontaneous Clivus Hematoma: Case Report and Literature Review

A spontaneous extra-axial hematoma extending from the dorsum sella to the foramen magnum is described. Although two cases of clivus epidural hematomas have been reported previously, review of the literature failed to reveal any case reports of spontaneous hematomas in this region.

Recurrent hemifacial spasm following minor trauma: report of a case.

Late recurrences after microvascular decompression for hemifacial spasm or trigeminal neuralgia are rare. We present an atypical case of recurrence one and a half years after successful microvascular decompression for hemifacial spasm associated with direct trauma. Implications for the management of recurrences and the judicious use of polymer adhesives such as fibrin glue are discussed.

Nuclear magnetic resonance diagnosis of an anaplastic astrocytoma

A patient presented with an 8-month history of a progressive left homonymous visual field deficit, left hemiparesis, and a left thalamocortical sensory deficit that was not detectable by repeated conventional neurodiagnostic evaluations. Proton nuclear magnetic resonance (NMR) imaging revealed a right parietal lesion characterized by a prolonged T2 (spin-spin relaxation time). At surgery, the mass proved to be an anaplastic astrocytoma. NMR appears to be more sensitive than x-ray computerized tomography scanning in some patients with malignant gliomas and offers the clinician an additional probe with which to evaluate these patients.