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Open access

Microvascular decompression for developmental venous anomaly causing hemifacial spasm: illustrative case

Margaret Tugend and Raymond F Sekula Jr.

BACKGROUND

Developmental venous anomaly (DVA) is a rare cause of hemifacial spasm (HFS). The treatment of HFS caused by a DVA varies in the literature and includes medication management, botulinum toxin injections, and microvascular decompression (MVD).

OBSERVATIONS

A 64-year-old woman presented with right-sided HFS. Preoperative magnetic resonance imaging showed a DVA in the right inferior pons, with an enlarged segment compressing the facial nerve at its root detachment point prior to drainage into the superior petrosal sinus. MVD was performed, and the facial nerve was decompressed without sacrifice of the vein. Immediately following the procedure, the patient had significantly reduced spasms. The patient became spasm-free 3 months after MVD and maintained spasm freedom for 3 months. Six months after MVD, the patient had a partial return of spasms. At 8 months, the patient continued to have reduced and intermittent spasms in the right orbicularis oculi muscle.

LESSONS

MVD for HFS caused by a DVA is a safe procedure and can be effective at reducing spasm frequency and severity.

Open access

“Winged” Eagle’s syndrome: neurophysiological findings in a rare cause of spinal accessory nerve palsy. Illustrative cases

Eric C Mitchell, Kitty Y Wu, Fawaz Siddiqi, John Yoo, Pavlo Ohorodnyk, Douglas Ross, and Thomas A Miller

BACKGROUND

Eagle’s syndrome (ES) classically describes dysphagia, globus sensation, and otalgia from an elongated and calcified styloid process or stylohyoid ligament. Compression of the spinal accessory nerve (SAN) has not been reported as an associated feature of ES or related variants.

OBSERVATIONS

The authors describe two cases of an atypical “winged” variant with SAN palsy resulting from compression by a posteriorly angulated or calcified styloid process. Both patients exhibited lateral scapular winging and atrophy of the trapezius and sternocleidomastoid muscles. Electrophysiological studies demonstrated motor unit preservation; therefore, surgical exploration, styloidectomy, and SAN decompression were performed through a transcervical approach. Postoperatively, both patients had improvements in pain and shoulder mobility, the return of muscle strength, and electrophysiological evidence of trapezius reinnervation.

LESSONS

Compression of the SAN, which can be identified both clinically and on electrodiagnostic testing, is an atypical finding that can result from a posteriorly angulated or calcified styloid process. This winged variant of ES should be included in the differential for SAN palsy, and a multidisciplinary approach is recommended for assessment and management.

Open access

Trigeminal neuralgia secondary to osteoma and vascular compression: illustrative case

Chenglong Cao, Mingwu Li, Min Wu, and Xiaofeng Jiang

BACKGROUND

Trigeminal neuralgia (TN) is a common neurosurgical issue that has a detrimental impact on patients’ quality of life. Osteoma at the petrous apex is a rare etiology of TN. Here, the authors present a case involving the co-occurrence of petrous osteoma and a vascular loop around the trigeminal nerve. Both exerted pressure or compression on the exit of the trigeminal nerve.

OBSERVATIONS

A 46-year-old male presented with a 3-year history of persistent severe pain in the right side of his face. Magnetic resonance tomographic angiography of the trigeminal nerve revealed an abnormal signal in the right prepontine cistern, along with a vascular loop accompanying the right trigeminal nerve. A computed tomography scan of the skull indicated a nodular calcified density. The combined anterior transpetrosal approach for petrous osteoma and microvascular decompression (MVD) for the offending vessel were successfully performed. The patient was discharged without any complications or facial pain.

LESSONS

Although extremely rare, TN simultaneously secondary to petrous osteoma and offending vessels should be considered in the diagnosis. In this case, the combined surgical removal of petrous osteoma and MVD for the offending vessels proved to be an effective treatment for TN secondary to osteoma and vascular compression.

Open access

Management of rare atlantoaxial synovial cyst case with extension to the cerebellopontine angle: illustrative case

Shawn D’Souza, Vikram Seshadri, Harsh P Shah, Jan T Hachmann, and R. Scott Graham

BACKGROUND

Synovial cysts are a common finding in degenerative spine disease, most frequently involving the facet joints of the lumbar spine. Synovial cysts are less common in the cervical spine and rarely involve the atlantoaxial junction.

OBSERVATIONS

In this case report, the authors detail a unique presentation of a left atlantoaxial synovial cyst with large intracranial extension into the cerebellopontine angle causing progressive cranial nerve palsies resulting in tinnitus, vertigo, diminished hearing, gait imbalance, left trigeminal hypesthesia, left facial weakness, and dysarthria. The patient underwent a retromastoid craniectomy for resection of the synovial cyst, resulting in improvement and resolution of symptoms. Follow-up occurred at 6 weeks, 3 months, and 5 months postoperatively without recurrence on imaging.

LESSONS

The authors describe acute and long-term management of a unique presentation of an atlantoaxial synovial cyst including retromastoid craniectomy, intervals for follow-up for recurrence, and possible treatment options in cases of recurrence. A systematic literature review was also performed to explore all reported cases of craniocervical junction synovial cysts and subsequent surgical management.

Open access

Missed pituitary microadenoma during endoscopic transsphenoidal surgery for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing with symptom relief: illustrative case

Juan Silvestre G. Pascual, Madeleine de Lotbiniere-Bassett, Katrina Hannah D. Ignacio, David Ben-Israel, Jessica M. Clark, and Yves P. Starreveld

BACKGROUND

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is a rare headache disorder that has been associated with pituitary adenomas. Resection has been posited to be curative.

OBSERVATIONS

A 60-year-old female presented with a 10-year history of SUNCT, which had been medically refractory. Sellar magnetic resonance imaging (MRI) showed a 2 × 2 mm nodule in the right anterolateral aspect of the pituitary. Endoscopic endonasal transsphenoidal resection of the pituitary microadenoma with neuronavigation was performed. The patient felt immediate relief from the headaches. Postoperative MRI showed persistence of the pituitary microadenoma and the resection tract to be inferomedial to the lesion. The right middle and partial superior turbinectomy site was close to the sphenopalatine foramen (SPF). The patient was discharged on postoperative day 1 and remained headache-free without any medications at the 4-month follow-up.

LESSONS

Resection of pituitary lesions associated with SUNCT may not necessarily be the cause of SUNCT resolution. Manipulation of the middle and superior turbinate close to the SPF may lead to a pterygopalatine ganglion block. This may be the mechanism of cure for SUNCT in patients with related pituitary lesions who undergo endonasal resection.

Open access

Trigeminal neuralgia secondary to vascular compression and neurocysticercosis: illustrative case

Mao Vásquez, Luis J. Saavedra, Hector H. García, Evelyn Vela, Jorge E. Medina, Miguel Lozano, Carlos Hoyos, and William W. Lines-Aguilar

BACKGROUND

Trigeminal neuralgia (TN) is a frequent neurosurgical problem negatively influencing the quality of life of patients. The standard surgical treatment is microvascular decompression for primary cases and decompression of the mass effect, mainly tumors, for secondary cases. Neurocysticercosis (NCC) in the cerebellopontine angle is a rare etiology of TN. The authors report a case in which NCC cysts around the trigeminal nerve coexisted with a vascular loop, which compressed the exit of the trigeminal nerve from the pons.

OBSERVATIONS

A 78-year-old woman presented with a 3-year history of persistent severe pain in the left side of her face, refractory to medical treatment. On gadolinium-enhanced magnetic resonance imaging, cystic lesions were observed around the left trigeminal nerve and a vascular loop was also present and in contact with the nerve. A retrosigmoid approach for cyst excision plus microvascular decompression of the trigeminal nerve was successfully performed. There were no complications. The patient was discharged without facial pain.

LESSONS

Albeit rare, TN secondary to NCC cysts should be considered in the differential diagnosis in NCC-endemic regions. In this case, the cause of the neuralgia was probably both problems, because when both were treated, the patient improved.

Open access

Simultaneous microvascular decompression for trigeminal neuralgia and hemifacial spasm involving a dolichoectatic vertebral artery in an elderly patient: illustrative case

Neelan J. Marianayagam, Hanya M. Qureshi, Sagar Vasandani, Shaurey Vetsa, Muhammad Jalal, Kun Wu, and Jennifer Moliterno

BACKGROUND

Hyperactive cranial neuropathies refractory to medical management can often be debilitating to patients. While microvascular decompression (MVD) surgery can provide relief to such patients when an aberrant vessel is compressing the root entry zone (REZ) of the nerve, the arteries of elderly patients over 65 years of age can be less amenable to manipulation because of calcifications and other morphological changes. A dolichoectatic vertebral artery (DVA), in fact, can lead to multiple cranial neuropathies; therefore, a strategy for MVDs in elderly patients is useful.

OBSERVATIONS

A 76-year-old man presented with medically refractory trigeminal neuralgia (TN) and hemifacial spasm (HFS). A DVA was the conflicting vessel at the left REZs of the trigeminal and facial nerves. The authors performed a retrosigmoid craniotomy for MVD of the DVA with Teflon padding at both REZs in approximately 1 hour of operative time. The patient was free of facial pain and spasm immediately after surgery and at follow-up.

LESSONS

The authors described the case of an elderly patient with both TN and HFS caused by compression of a DVA. Simultaneous MVD with Teflon padding at both REZs provided symptomatic relief with limited surgical time. This can be a particularly useful and straightforward surgical strategy in the elderly population.