Abstract Hemifacial spasm is characterized by painless and involuntary spasms of the muscles supplied by the facial nerve, most commonly involving the orbicularis oculi. The most common cause of hemifacial spasm is compression of the facial nerve's root by the anterior inferior, or posterior inferior, cerebellar arteries (AICA or PICA). However, in <1% of cases, the compression can be due to a dolichoectatic vertebral artery. Microvascular decompression using Teflon patties may be sufficient when the offending artery is small (eg, AICA or PICA). However, the size and tortuosity of the vertebral artery (especially one that is dolichoectatic) may require a more robust means of decompression (ie, “macrovascular decompression”). In this operative video we demonstrate our technique for managing a patient with hemifacial spasm due to a dolicoectatic vertebral artery. We use a Goretex® (W.L. Gore & Associates Inc, Newark, Delaware) sling secured to the dura of the posterior petrous ridge to suspend the vertebral and posterior inferior cerebellar arteries, thereby decompressing the root entry zone of the facial nerve. Teflon felt pieces are added as a second layer of security. Key steps to this technique include: (1) visualization of the root entry zone, (2) extensive arachnoid dissection to allow adequate mobilization of the vertebral artery, 12 and (3) securing the sling in a trajectory that prevents kinking of the vertebral artery and its branches. Hemifacial spasm, Microvascular decompression, Vertebral artery Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy111 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy111 “Macrovascular” Decompression of Dolichoectatic Vertebral Artery Causing Hemifacial Spasm Using Goretex Sling: 2-Dimensional Operative Video “Macrovascular” Decompression of Dolichoectatic Vertebral Artery Causing Hemifacial Spasm Using Goretex Sling: 2-Dimensional Operative Video Close Acknowledgment We would like to acknowledge Roberto Suazo for assistance with video preparation. The patient provided verbal consent for publication of her case. COMMENT This is a very interesting surgical video showcasing macrovascular decompression of a facial nerve due to compression from a dolicoectatic vertebral artery causing hemifacial spasm. A Goretex (W.L. Gore & Associates Inc) sling is fashioned and sutured to the adjacent dura to keep the vertebral artery away from the facial nerve. The technique demonstrated by the authors is simple to apply but requires good skills in this narrow surgical corridor. The neurosurgeon should remember to keep the Goretex sling loose around the vertebral artery in order to prevent any iatrogenic flow-limiting stenosis while incorporating a good thickness of dura in the suture in order to prevent the sling from detaching and the vessel from regaining its original configuration. It would be interesting to visualize whether any exaggerated vessel configuration would be noted with head rotation due to this sling attachment. The authors are to be commended for this nice result. Ziad A. Hage Charlotte, North Carolina Copyright © 2018 by the Congress of Neurological Surgeons This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Operative Neurosurgery – Oxford University Press
Published: May 22, 2018
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