Repositioning Technique for the Decompression of Symptomatic Dolichoectatic Vertebrobasilar Pathology: A Comprehensive Review of Sling Characteristics and Surgical Experience

Macrovascular Decompression for Hemifacial Spasm Using Sling Technique

Hemifacial spasm (HFS) is a painless, involuntary twitching of the facial muscles that usually involves the orbicularis oculi muscle.^1,2 It is commonly caused by the anterior inferior cerebellar artery or posterior inferior cerebellar artery.^1,2 However, a dolichoectatic vertebrobasilar artery (VBA) can impinge the facial nerve.¹ Macrovascular decompression with sling transposition is a common management paradigm.^1-9 We present a case of a 56-year-old male who presented with left-sided HFS, pulsatile tinnitus, and hearing loss for the past 2 years. The patient underwent a retrosigmoid craniotomy and Gore-Tex sling transposition of a dolichoectatic VBA (Video 1). Complete improvement of symptoms was noted postoperatively with no associated complications. We review the preoperative workup, operative technique, relevant anatomy, and literature and provide technical pearls for this procedure.

[Interposition and transposition techniques of vascular decompression for hemifacial spasm]

OBJECTIVE

To analyze the vessels compressing facial nerve root exit zone and efficacy of interposition and transposition techniques of vascular decompression for hemifacial spasm.

MATERIAL AND METHODS

Vascular compression was evaluated in 110 patients. Implant interposition between vessels and nerve was performed in 52 cases, transposition of arteries without contact between implants and nerve - in 58 patients.

RESULTS

Compressing vessels were anterior (44), posterior (61) inferior cerebellar, vertebral (28) arteries and veins (4). Multiple compressing vessels were found in 27 cases. Premeatal meningioma and jugular schwannoma were accompanied by vascular compression in 2 cases. Immediate regression of symptoms was observed in 104 patients, partial regression - in 6 patients. Transient facial paresis (4) and impaired hearing (5) were noted after implant interposition. Redo vascular decompression was performed in one case.

CONCLUSION

The most common compressing vessels were cerebellar arteries, vertebral artery and veins. Transposition of arteries is highly effective technique with low incidence of VII-VII nerve dysfunction but relatively slow regression of symptoms.

Use of n-butyl-2-cyanoacrylate for microvascular decompression in a Jehovah's witness patient

OBJECTIVE

We report the application of n-butyl-2-cyanoacrylate (n-BCA) in microvascular decompression (MVD) surgery for a Jehovah's Witness patient. To our best knowledge, this is the first case wherein n-BCA has been employed as an adhesive to the offending artery.

CASE PRESENTATION

A 55-year-old female Jehovah's Witness patient was suffering from serious right hemifacial spasm. Although MVD surgery was needed, the patient resisted any curative medical treatment involving the application of whole blood products, including fibrin glue. Thus, we proposed several choices using artificial materials, including n-BCA as an adhesive, and received informed consent from the patient.

RESULT

MVD was performed on the dolichoectatic right vertebral artery and right posterior inferior cerebellar artery. The abnormal vessel response disappeared during the procedure and transposition using n-BCA of the concerned vessels was successful. The patient experienced a favorable postoperative clinical course and has been free from the spasm for a year. No abnormal findings were detected in the radiological examination during the follow-up period.

CONCLUSION

Although careful follow-up is mandatory, n-BCA is a possible alternative option in MVD surgery.