Endovascular treatment of hemifacial spasm associated with a cerebral arteriovenous malformation using transvenous embolization: case report

Hemifacial spasm caused by vertebral artery aneurysm treated by endovascular coil embolization

BACKGROUND

Hemifacial spasm (HFS) caused by vertebral artery (VA) aneurysms is rare. Several cases of HFS caused by VA aneurysms treated by endovascular parent artery occlusion (PAO) have been reported. Recently, we treated a rare case of HFS caused by a saccular VA aneurysm at the bifurcation of the posterior inferior cerebellar artery (PICA), which was successfully treated by endovascular coil embolization, preserving the parent artery, and PICA. We discuss endovascular treatment for HFS induced by VA aneurysms with a literature review.

CASE DESCRIPTION

A 59-year-old man presented with the left HFS persisting for 2 months. Magnetic resonance imaging revealed a left saccular VA-PICA aneurysm and demonstrated that a left facial nerve was compressed by the aneurysm at the root exit zone. Angiography revealed that the PICA was branching from the aneurysm neck. Endovascular coil embolization was performed using the balloon remodeling technique to preserve the left VA and PICA. HFS disappeared after treatment.

CONCLUSION

Although microvascular decompression was commonly accepted for the standard treatment of HFS, coil embolization of aneurysms without PAO may be an effective treatment for HFS caused by VA aneurysms.

Transvenous embolization of brain arteriovenous malformations: a review of techniques, indications, and outcomes

Endovascular embolization of brain arteriovenous malformations (AVMs) is conventionally performed from a transarterial approach. Transarterial AVM embolization can be a standalone treatment or, more commonly, used as a neoadjuvant therapy prior to microsurgery or stereotactic radiosurgery. In contrast to the transarterial approach, curative embolization of AVMs may be more readily achieved from a transvenous approach. Transvenous embolization is considered a salvage therapy in contemporary AVM management. Proposed indications for this approach include a small (diameter < 3 cm) and compact AVM nidus, deep AVM location, hemorrhagic presentation, single draining vein, lack of an accessible arterial pedicle, exclusive arterial supply by perforators, and en passage feeding arteries. Available studies of transvenous AVM embolization in the literature have reported high complete obliteration rates, with reasonably low complication rates. However, evaluating the efficacy and safety of this approach is challenging due to the limited number of published cases. In this review the authors describe the technical considerations, indications, and outcomes of transvenous AVM embolization.

Transvenous retrograde AVM embolization: Indications, techniques, complications and outcomes

Objective Transvenous retrograde arteriovenous malformation (AVM) embolization (TRAE) has been proposed. The present study was to review the techniques, their conjunctions and effectiveness. Methods Eligible related articles were identified by searching the PubMed and Web of Science databases using "transvenous" and "arteriovenous malformation." Results A total of 16 eligible studies, with 60 cases of AVM treated with TRAE, were analyzed. Prior to TRAE procedure, transarterial Onyx 18 was performed in 23 (38.3%), cyanoacrylate in three (5%) and coiling in two (3.3%), neurosurgery in one (1.7%) and radiosurgery in three (5%). These prior treatments were used to reduce the size of the nidus to <3 cm and TRAE was performed. One anterior choroidal artery aneurysm was coiled before TRAE. Systemic hypotension (blood pressure<100 mmHg) occurred in six (10%) patients and local hypotension (proximal arterial temporary balloon protection) in five (8.3%) patients. Complete obliteration was achieved in 56 (93.3%) AVMs, four (6.7%) with residual, of which one was supplemented with radiosurgery. During mean one-year follow-up (1 month to 3.2 years), there were five cases (8.3%) of permanent disability and one (1.7%) mortality resulting from initial hemorrhage. Fifty-four (90%) patients were independent (mRS ≤ 2) at follow-up. Ruptured AVMs and Spetzler-Martin I-III were associated with a high cure rate. Conclusion According to previous reports, selected AVMs could undergo TRAE. TRAE is safe and curative with Onyx after the nidus size is reduced sufficiently by transarterial embolization, neurosurgery or radiosurgery, with or without the aid of proximal arterial temporary balloon protection.

Tenth case of bilateral hemifacial spasm treated by microvascular decompression: Review of the pathophysiology

BACKGROUND

Bilateral hemifacial spasm (BHFS) is a rare neurological syndrome whose diagnosis depends on excluding other facial dyskinesias. We present a case of BHFS along with a literature review.

METHODS

A 64-year-old white, hypertense male reported involuntary left hemiface contractions in 2001 (aged 50). In 2007, right hemifacial symptoms appeared, without spasm remission during sleep. Botulinum toxin type A application produced partial temporary improvement. Left microvascular decompression (MVD) was performed in August 2013, followed by right MVD in May 2014, with excellent results. Follow-up in March 2016 showed complete cessation of spasms without medication.

RESULTS

The literature confirms nine BHFS cases bilaterally treated by MVD, a definitive surgical option with minimal complications. Regarding HFS pathophysiology, ectopic firing and ephaptic transmissions originate in the root exit zone (REZ) of the facial nerve, due to neurovascular compression (NVC), orthodromically stimulate facial muscles and antidromically stimulate the facial nerve nucleus; this hyperexcitation continuously stimulates the facial muscles. These activated muscles can trigger somatosensory afferent skin nerve impulses and neuromuscular spindles from the trigeminal nerve, which, after transiting the Gasser ganglion and trigeminal nucleus, reach the somatosensory medial posterior ventral nucleus of the contralateral thalamus as well as the somatosensory cortical area of the face. Once activated, this area can stimulate the motor and supplementary motor areas (extrapyramidal and basal ganglia system), activating the motoneurons of the facial nerve nucleus and peripherally stimulating the facial muscles.

CONCLUSIONS

We believe that bilateral MVD is the best approach in cases of BHFS.

Endovascular management of arteriovenous malformations of the brain

Arteriovenous malformations (AVMs) of the brain are rare, complex, vascular lesions that can result in significant morbidity and mortality. Modern treatment of brain AVMs is a multimodality endeavor, requiring a multidisciplinary team with expertise in cerebrovascular neurosurgery, endovascular intervention, and radiation therapy in order to provide all therapeutic options and determine the most appropriate treatment regimen depending on patient characteristics and AVM morphology. Current therapeutic options include microsurgical resection, radiosurgery (focused radiation), and endovascular embolization. Endovascular embolization is primarily used as a preoperative adjuvant before microsurgery or radiosurgery. Palliative embolization has been used successfully to reduce the risk of hemorrhage, alleviate clinical symptoms, and preserve or improve neurological function in inoperable or nonradiosurgical AVMs. Less frequently, embolization is used as 'primary therapy' particularly for smaller, surgically difficult lesions. Current embolic agents used to treat brain AVMs include both solid and liquid agents. Liquid agents including N-butyl cyanoacrylate and Onyx are the most commonly used agents. As newer embolic agents become available and as microcatheter technology improves, the role of endovascular treatment for brain AVMs will likely expand.

Endovascular treatment of hemifacial spasm associated with a petrosal DAVF using transarterial Onyx embolization. A case report

This paper reports that decompression of the facial nerve by transarterial Onyx embolization may relieve hemifacial spasm (HFS) caused by dilated veins due to a right petrosal dural arteriovenous fistula (DAVF). A 56-year-old man suffered severe chronic right HFS associated with a dilated right petrosal vein lying in the vicinity of the facial nerve. The right petrosal DAVF was reached through the middle meningeal artery using a transfemoral arterial approach and was occluded with Onyx 18 (M.T.I.- ev3, Irvine, CA, USA). There was complete remission of HFS without recurrence after two months of follow-up. This case supports vascular compression in the pathogenesis of HFS and suggests that facial nerve injury caused by a DAVF could be treated with transarterial Onyx embolization.

Resolution of Hemifacial Spasm after Surgical Obliteration of a Tentorial Arteriovenous Fistula: Case Report

OBJECTIVE AND IMPORTANCE:

We describe a patient with a tentorial dural arteriovenous fistula who presented with ipsilateral hemifacial spasm.

CLINICAL PRESENTATION:

A 50-year-old man sought treatment for left facial twitching that worsened over 6 months. Magnetic resonance imaging and catheter angiography demonstrated a left tentorial dural arteriovenous fistula.

INTERVENTION:

The patient underwent a retrosigmoid craniotomy and ligation of the draining vein at the site of the fistula. Intraoperative angiography showed complete obliteration of the fistula. The patient's hemifacial spasm improved significantly after the fistula was obliterated.

CONCLUSION:

Posterior fossa arteriovenous fistulas can present with a hemifacial spasm related to compression of the facial nerve by arterialized leptomeningeal veins. Microsurgical obliteration of the fistula can resolve the related symptoms.

Endovascular treatment of vertebral artery aneurysm manifesting as progressive hemifacial spasm

A 62-year-old woman presented with right hemifacial spasm persisting for 6 months. Brain magnetic resonance imaging and digital subtraction angiography showed a wide-neck aneurysm of the intracranial portion of the right vertebral artery. The patient underwent endovascular trapping of the aneurysm by coil embolization of the parent vessel on both sides of the aneurysm. The patient experienced gradual disappearance of the hemifacial spasm within 3 months. No relapses occurred during a follow-up period of 3 years. Magnetic resonance imaging revealed shrinkage of the vertebral artery aneurysm which had compressed the facial nerve. Endovascular trapping of a vertebral artery aneurysm can be used to treat hemifacial spasm caused by an aneurysm instead of surgical microvascular decompression.

Fusiform aneurysm of the vertebral artery presenting hemifacial spasm treated by intravascular embolization: case report

BACKGROUND

A rare case of fusiform vertebral artery aneurysm causing hemifacial spasm was successfully treated by intravascular embolization.

CASE DESCRIPTION

A 53-year-old man presented with left hemifacial spasm persisting for 2 years. No other clinical symptoms were observed. Vertebral angiography revealed a fusiform aneurysm of the left vertebral artery, and thin-slice spoiled gradient-recalled acquisition magnetic resonance imaging demonstrated the aneurysm compressing the root exit zone of the left facial nerve. The parent artery was occluded together with the aneurysm by intravascular embolization with Guglielmi detachable coils (GDCs). The patient is free of left hemifacial spasm without any complication.

CONCLUSION

Hemifacial spasm caused by aneurysms, especially fusiform aneurysms, is quite rare but can be treated by parent artery occlusion and coiling the aneurysm with GDCs.

New concepts in adult brain arteriovenous malformations

Brain arteriovenous malformations are currently attracting increasing attention among clinicians as modern brain imaging techniques facilitate both diagnostic and follow-up evaluation. Their frequent presentation in young individuals, at times with flagrant clinical effects caused by cerebral hemorrhages or seizure disorders, keeps clinicians alert to any improvement in treatment strategies. Recent technical advances in surgical, endovascular, and radiation therapy add to the constantly accumulating data on clinical features, natural course, and treatment outcome in adult arteriovenous malformation patients. This review focuses on new concepts in arteriovenous malformation etiology, classification, treatment, and study approaches.