- Department of Neurosurgery, Papardo Piemonte Hospital, University of Messina, Messina, Italy
- Department of Neuroradiology, Papardo Piemonte Hospital, University of Messina, Messina, Italy
- Department of Neurosurgery, University of Palermo, Palermo, Italy
- Department of Neurosurgery, Papardo Piemonte Hospital, University of Messina, Messina, Italy
Department of Neurosurgery, Papardo Piemonte Hospital, University of Messina, Messina, Italy
DOI:10.4103/2152-7806.136887Copyright: © 2014 Alafaci C This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Alafaci C, Granata F, Cutugno M, Grasso G, Salpietro FM, Tomasello F. Presurgical evaluation of hemifacial spasm and spasmodic torticollis caused by a neurovascular conflict from AICA with 3T MRI integrated by 3D drive and 3D TOF image fusion: A case report and review of the literature. Surg Neurol Int 16-Jul-2014;5:108
How to cite this URL: Alafaci C, Granata F, Cutugno M, Grasso G, Salpietro FM, Tomasello F. Presurgical evaluation of hemifacial spasm and spasmodic torticollis caused by a neurovascular conflict from AICA with 3T MRI integrated by 3D drive and 3D TOF image fusion: A case report and review of the literature. Surg Neurol Int 16-Jul-2014;5:108. Available from: http://sni.wpengine.com/surgicalint_articles/presurgical-evaluation-of-hemifacial-spasm-and-spasmodic-torticollis-caused-by-a-neurovascular-conflict-from-aica-with-3t-mri-integrated-by-3d-drive-and-3d-tof-image-fusion-a-case-report-and-review-o/
Background:Hemifacial spasm (HS) and spasmodic torticollis (ST) are well-known disorders that are caused by a neurovascular conflict. HS is characterized by irregular, involuntary muscle contractions on one side of the face due to spasms of orbicularis oris and orbicularis oculi muscles, and is usually caused by vascular compression of the VII cranial nerve. ST is an extremely painful chronic movement disorder causing the neck to involuntary turn to the side, upward and/or downward. HS is usually idiopathic but it is rarely caused by a neurovascular conflict with the XI cranial nerve.
Case Description:We present a case of a 36-year-old woman with a 2-year history of left hemifacial spasm and spasmodic torticollis. Pre-surgical magnetic resonance imaging MRI examination was performed with 3TMRI integrated by 3Ddrive and 3DTOF image fusion. Surgery was performed through a left suboccipital retrosigmoid craniectomy. The intraoperative findings documented a transfixing artery penetrating the facial nerve and a dominant left anteroinferior cerebellar artery (AICA) in contact with the anterior surface of the pons and lower cranial nerves. Microvascular decompression (MVD) was performed. Postoperative course showed the regression of her symptoms.
ConclusionsTransfixing arteries are rarely reported as a cause of neurovascular conflicts. The authors review the literature concerning multiple neurovascular conflicts.
Keywords: Hemifacial spasm, microvascular decompression, neurovascular conflict, spasmodic torticollis, transfixing artery
Neurovascular conflict syndrome is due to an abnormal contact between cranial nerves and arterial or venous vessels, causing an active cranial nerve dysfunction.[
Generally, the abnormal contact between nerve and offending vessel can take the form of a “cross compression” or “sandwich compression” which is the entrapment of the nerve between two vascular structures. The possible alterations in the nerve course are stretching, bending, grooving, or delamination of the fibers due to a transfixing artery.
HS is characterized by irregular, involuntary muscle contractions on one side of the face due to spasms of orbicularis oris and orbicularis oculi muscles, and is usually caused by a vascular compression of the VII cranial nerve. ST is a painful chronic movement disorder causing the neck to involuntary turn to the side, upward and/or downward. HS is usually idiopathic but in a few number of cases, it can be due to a neurovascular conflict with the XI cranial nerve.
Magnetic resonance imaging MRI examination clearly visualizes the complex neurovascular anatomy within the cisternal spaces. Virtual MRI techniques are currently used to presurgically simulate microvascular decompression (MVD), giving a clear depiction of the contact between cranial nerves and offending vessels with an optimal correlation with intraoperative patterns.[
We describe an interesting case of a rare association of HS, ST and hemiparesis caused by two different neurovascular conflicts by the same vessel (AICA). We also focus on pre-surgical 3T MRI examination, integrated by bidimensional image fusion.
A 36-year-old female with a 2-year history of left HS and ST was admitted to our department in October 2012. The spasm was initially confined to the superior orbicularis oculi muscle, but gradually affected the entire left side of the face. Spasm was presenting with a frequency of 5-10 episodes per day and was painful causing severe limitations in the normal daily life. She had been treated with botulinum toxin two times before admission but the effect was temporary. Preoperative neurological examination documented a mild left hemiparesis, involuntary contractions of perioral and periorbital muscles of the left face and torticollis caused by intermittent tonic spasm of the left neck muscles. We also examined the blink reflex with registration from orbicularis muscle of the left eye and square muscle of the left chin (depressor labii inferioris). We performed stimulation of the left supraorbital nerve and chin nerve, but no R1 response after stimulation of both nerves was recorded. Electrophysiological findings conclusively proved the absence of ephaptic transmission at the level of the left VII cranial nerve.
Presurgical MRI examination was performed using a 3T superconductive scanner. MRI basal examination showed a dominant left AICA in contact with ipsilateral IX, X and XI cranial nerves. Bidimensional image fusion was subsequently performed and another anomalous contact between a small AICA distal branch and the left facial nerve was demonstrated. MRI data were transferred to an independent workstation in order to obtain a “3D fusion.” To visualize the neurovascular conflict between AICA and lower cranial nerves [
Anteroinferior cerebellar artery (AICA) - IX, Xand XI c.n. at the intracisternal tract. (a) Axial 3D T2 drive image (b) axial 3D TOF image, and (c-e) 3D T2 axial bidimensional image fusion. (a) AICA (blue arrow) impacts IX, X and XI cranial nerve at the intracisternal tract (red arrow) (b) Only the tortuous AICA is visible (red arrows) (c and d) Simultaneous display of artery (red color) and nerves (blue color). (e) Contact between AICA (red color) and XI cranial nerve (blue color)
AICA distal branch – VII cranial nerve (c.n.) conflict. (a) Magnetic resonance angiogram (MRA) with maximum intensity projection (MIP), (b) 3D T2 axial bidimensional image fusion, and (c) 3D T2 coronal bidimensional image fusion. (a) Moderate scoliosis of the basilar trunk with a long cisternal route of a “dominant” left AICA (arrow) (b) AICA distal branch (white arrow) and VII c.n. at the intracisternal tract (yellow arrow) (c) The VII c.n. (yellow arrow) is slightly raised by the offending vessel (white arrow). (d) Schematic representation of the compression modality in case of “transfixing artery”
MVD was performed via a suboccipital retrosigmoid approach. The intraoperative findings showed a small distal branch of the left AICA transfixing the facial nerve in the intracisternal tract and a left dominant AICA marking the pons and, caudally, the lower cranial nerves, mainly the XI. After gentle retraction of the V cranial nerve, the VII nerve was dissected parallel to the axis at the site of arterial transfixing point to facilitate splitting up of the artery from the nerve. Microvascular decompression was performed with small pieces of autologous muscle at the point in which the transfixing artery penetrated the nerve, and between AICA, lower cranial nerve and brain stem, allowing the shifting of the vessel from the above-mentioned structures [
Intraoperative findings (a) A left dominant AICA turns in the cerebello-pontine cistern, conflicting with the lower cranial nerves (c.n.) and the anterior surface of the pons. A small branch of AICA penetrates the VII c.n., under the V c. n. (b) The V c.n. is gently pushed on a side to better evaluate the artery transfixing the VII c.n. (c) A small piece of autologous muscle is interposed between the proximal AICA, the XI c.n and pons. (d) MVD for VII c.n.: A small piece of muscle is interposed around the transfixing artery in the area where the nerve is penetrated. No rhyzotomy is performed
HS is caused by pulsatile vascular compression upon the facial nerve root exit zone. This 23 mm area, considered synonymous with the Obersteiner-Redlich zone, is a transition zone (TZ) between central and peripheral axonal myelination situated at the nerves detachment from the pons. More proximally the facial nerve is exposed on the pontine surface and emerges from the pontomedullary sulcus. Neurovascular compression is one of the main causes of HS, and the most common offending vessels are the AICA, the PICA, the vertebral artery or a large vein.[
Complex neurovascular conflicts are rare disorders and very few cases have been reported in the literature.[
MVD was performed in order to resolve all conflicts. MVD, in our opinion, prevents nerve's injury related to other procedures, such as rhizotomy that usually carries postoperative facial sensory impairment. The patient was studied with presurgical 3TMRI, integrated by bidimensional image fusion. We previously used this technique, with presurgical 1.5 T MRI, in a group of 32 patients who underwent MVD. This gave a clear picture of the contact between cranial nerves and the offending vessel. In our opinion, however, the small artery transfixing the VII cranial nerve would not have been detected in 1.5 T MRI examination.
Simple microvascular decompression represents an excellent modality of treatment in cases of transfixing artery and, compared to other treatment modalities such as partial rhizotomy, it carries less risk of facial nerve injuries. MVD can also be used in order to resolve multiple neurovascular conflicts in the same patients. Presurgical 3T MRI with 3D fusion images provides an excellent picture of multiple neurovascular conflicts which well correlate with intraoperative findings.
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