J Neurosurg 74:650-652, 1991
Hemifacial spasm caused by a spontaneous dissecting aneurysm of the vertebral artery Case report KENGO MATSUMOTO, M.D., TOSHIKAZUSAIJO, M.D., HIDEYUKI KUYAMA,NLD., SHOJI ASARI, M.D., AND AKmA NISHIMOTO, M.D.
Department of Neurological Surgery. Okayama University Medical School. Okayama, Japan u, The authors describe the first reported case of dissecting aneurysm presenting with hemifacial spasm. The patient was a 58-year-old woman with left hemifacial spasm of 2 years' duration. Cranial nerve examination was otherwise normal and no other clinical symptoms were observed. Vertebral angiography revealed a fusiform enlargement of the left vertebral artery and contrast medium remaining in the intramural false lumen in the venous phase. Microvascular decompression of the facial nerve with wrapping of the aneurysm resulted in complete relief of the hemifacial spasm. KEY WORDS 9 dissecting aneurysm microvascular decompression
ISSECTINGaneurysms of the intracranial arteries are uncommon, 1'~6 and most reported cases have presented with subarachnoid hemorrhage (SAH) or ischemia. ~9 In a review of the literature, we found few reports of hemifacial spasm due to aneurysms 2"~~ and the aneurysms involved were cirsoid, 2 berry, ~~or fusiform, t2 This is the first reported case of hemifacial spasm due to a spontaneous dissecting aneurysm of the vertebral artery.
D
9 hemifacial spasm
Computerized tomography showed an enhancing mass in the left cerebellopontine angle (Fig. 1), and magnetic resonance imaging demonstrated a signalvoid ectatic vessel in the same region on the Tz-weighted study (Fig. 2). Vertebral angiography revealed a fusiform enlargement of the left vertebral artery, with the contrast medium remaining in the venous phase (Fig. 3). The opposite vertebral artery was smaller than the affected artery.
Operation. The patient underwent a paramedian Case Report
This 58-year-old woman had a 2-year history of leftsided hemifacial spasm, beginning in the area of the orbicularis oculi and spreading to involve all the muscles innervated by the left facial nerve. There was an episode of left occipital pain 4 years before admission. That headache persisted for a year and disappeared spontaneously. On admission, her only medical problem was intermittent hemifacial spasm. No symptoms such as headache, vertigo, tinnitus, loss of balance, or slurring of speech were reported. She had no history of trauma or systemic disease.
Examination. The patient had a blood pressure of 130/80 m m Hg and normal vital signs. Neurological examination demonstrated typical hemifacial spasm with intermittent clonic-tonic muscle contraction. No other abnormalities were noted on physical or neurological examination. 650
FIG. 1. Axial noncontrast (left) and contrast-enhanced (righOcomputerized tomography scans showing an enhancing mass (arrow) at the left cerebellopontine angle.
J. Neurosurg. / Volume 74/April, 1991
Hemifacial spasm due to dissecting aneurysm suboccipital craniectomy through a retromastoid skin incision. A large fusiform aneurysm of the vertebral artery was exposed with only minimal retraction of the cerebellar hemisphere. This aneurysm was compressing the brain stem and impinging on the root exit zone of the left facial nerve (Fig. 4). The surface of the aneurysm was whitish gray and a neovascular pattern was observed in the aneurysrn's outer wall. These findings suggested the diagnosis of a dissecting aneurysrn. The aneurysm was easily separated from surrounding structures and mobilized. It was then wrapped circumferentially with expanded polytetrafluoroethylene (Goretex) vascular graft material and coated with cyanoacrylate.
relieved of facial pain, but one had complete paralysis of the seventh and eighth nerves, and in the other the facial spasm remained unchanged. Maroon, etal., ~oreported a successfully treated case of a posterior fossa berry aneurysm that caused hemifacial spasm. The neck of the aneurysm was clipped and the dome was mobilized away from its adherence to the facial nerve and brain stem. A piece of polyvinyl chloride nonabsorbable sponge was then inserted between the dome of the aneurysm and the brain stem. Looser and Chen ~ reviewed the literature on hemifacial spasm and its surgical therapy; among 450 patients with hemifacial spasm, they found two cases (0.5%) with compression caused by aneurysm.
Postoperative Course. The postoperative course was uneventful and surgery resulted in complete relief of facial spasm.
Dissecting Aneurysm
Discussion
Literature Review
Spontaneous dissecting aneurysms of the cerebral artery are uncommon especially in the posterior fossa. ~'7j5~7 Most patients present with SAH or ischemia ~'~j~ and suffer from severe occipital headache
HemifaciaI spasm is a movement disorder of the face characterized by intermittent involuntary twitches of muscles innervated by the facial nerveY In most patients with hemifacial spasm the underlying cause is benign. These cases are presumed due to compression of the root exit zone of the facial nerve by an aberrant vessel, usually a branch of the anterior or posterior inferior cerebellar artery or vertebral artery. 36'~7 Other compressive lesions have occasionally been observed, including tumor, 8 vascular malformation, 14 or an aneurysm of the posterior circulation, j~ Hemifacial spasm caused by an aneurysm is quite rare) -9'~~ Campbell and K e e d f reported two patients with typical facial motor tic and trigeminal neuralgia who were found to have a cirsoid aneurysm of the basilar artery compressing the facial nerve on the affected side. These cases were treated by division of the sensory root on the trigeminal nerve with a hook. Both patients were
FIG. 2. Axial Tz-weighted magnetic resonance image revealing, a signal-void ectatic vessel (arrow) in the left cerebellopontine angle.
J. Neurosurg. / Volume 74/April. 1991
FIG. 3. Upper."Left vertebral angiograms, anteropostenor view, showing aneurysmal dilatation of the vertebral artery with slight narrowing distal to it in the arterial phase (left) and retention of contrast medium (arrow) in the venous phase (right). Lower: Left vertebral angiograms, lateral oblique view, showing fusiform dilatation distal to the posterior inferior cerebellar artery in the arterial phase (left) and retention of contrast medium in the intramural false lumen (arrow) in the venous phase (right). 651
K. Matsumoto, et al. References
FIG. 4. Operative exposure showing a large fusiform aneurysm compressing the brain stem and the root exit zone (REZ) of the facial nerve. Note the neovascular pattern (arrowheads) of the outer wall of the aneurysm. The loop of vessel overlying the eighth cranial nerve (VIII) is the anterior inferior cerebellar artery (AICA); however, in this case this did not cause the pathology. The seventh cranial nerve (VII) is largely hidden behind the eighth cranial nerve. DA = dissecting aneurysm; IX = ninth cranial nerve; X = 10th cranial nerve; PICA = posterior inferior cerebellar artery. and/or neck pain] s,19 Various neurological deficits including cranial nerves and long-tract signs were observed preoperatively. H5:9 In the case reported here there was a l-year history of occipital headache but it is unknown whether SAH occurred; when the patient was seen, her only complaint was hemifacial spasm. The angiographic findings of dissecting aneurysms are diverse. There have been descriptions of a pearland-string sign, fusiform dilatation, occlusion, rosettes, intimal flaps, proximal and/or distal dilatations, double lumina, retention of contrast medium, and intramural pooling. 5'7"13'15'16'18-2~Among these findings, fusiform dilatation, proximal and/or distal narrowing, and retention of contrast medium are most characteristic) The sole pathognomonic sign of a dissecting aneurysm is a double lumen, revealed by the passage of contrast material in both true and false channels, but this is extremely rare. ~'~8.19 The indication for surgical treatment of vertebral dissecting aneurysms remains controversial./:9 These aneurysms have been treated by ligation or clipping of the proximal vertebral artery, or entrapment of the involved segment when the diameter of the opposite vertebral artery was equal to or larger than the affected artery; coating or wrapping of the lesion is performed when the affected artery is dominant. 1"5:1"13'1516"19Microvascular decompression, circumferential wrapping of the lesion with Goretex vascular graft, and coating by cyanoacrylate were the method of choice in our case, because the patient's only symptom was hemifacial spasm and the opposite vertebral artery was smaller than the affected artery. 652
1. Berger MS, Wilson CB: Intracranial dissecting aneurysms of the posterior circulation. Report of six cases and review of the literature. J Neurnsurg 61:882-894, 1984 2. Campbell E, Keedy C: Hemifacial spasm: a note on the etiology in two cases. J Neurosurg 4:342-347, 1947 3. Digre KB, Corbett J J, Smoker WRK, et al: CT and hemifacial spasm. Neurology 38:1111-1113, 1988 4. Echiverri HC, Rubino FA, Gupta SR, et al: Fusiform aneurysm of the vertebrobasilar arterial system. Stroke 20:1741-1747, 1989 5. Friedman AH, Drake CG: Subarachnoid hemorrhage from intracranial dissecting aneurysm. J Neurosurg 60: 325-334, 1984 6. Jannetta PJ, Abbasy M, Maroon JC, et al: Etiology and definitive microsurgical treatment of hemifacial stem. Operative techniques and results in 47 patients. J Nearosurg 47:321-328, 1977 7. Kulla L, Deymeer F, Smith TW, et al: Intracranial dissecting and saccular aneurysms in polycystic kidney disease. Report of a case. Arch Neurol 39:776-778, 1982 8. Levin JM, Lee JE: Hemifacial spasm due to cerebellopontine angle lipoma: case report. Neurology 37:337-339, 1987 9. Loeser JD, Chen J: Hemifacial spasm: treatment by microsurgical facial nerve decompression. Neurosurgery 13: 141-146, 1983 10. Maroon JC, Lunsford LD, Deeb ZL: Hemifacial spasm due to aneurysmal compression of the facial nerve. Arch Neurol 35:545-546, 1978 11. Miyazaki S, Yamaura A, Kamata K, et al: A dissecting aneurysm of the vertebral artery. Surg Neurol 21: 171-174, 1984 12. Moore AP: Postural fluctuation of hemifacial spasm. Case report. J Neurosurg 60:190-191, 1984 13. Nagao S, Kinugasa K, Bukeo T, et al: [Giant fusiform and dissecting aneurysms at the vertebro-basilarjunction: report of five cases and their clinicopathophysiological aspects.] No Shinkei Geka 15:1093-1100, 1987 (Jpn) 14. Pierry A, Gameron M: Clonic hemifacial spasm from posterior fossa arteriovenous malformation. J Neurol Neurosurg Psychiatry 42:670-672, 1979 15. Sekino H, Nakamura N, Katoh Y, et al: [Dissecting aneurysms of the vertebro-basilar system: clinical and angiographic observations.] No Shinkei Geka 9: 125-133, 1981 (Jpn) 16. Senter HJ, Sarwar M: Nontraumatic dissecting aneurysm of the vertebral artery. Case report. J Nearosurg 56: 128-130, 1982 17. Sobel D, Norman D, Yorke CH, et al: Radiography of trigeminal neuralgia and hemifacial spasm. AJNR 1: 251-253, 1980 18. Waga S, Fujimoto K, Morooka Y: Dissecting aneurysm of the vertebral artery. Surg Nearol 10:237-239, 1978 19. Yamaura A, Watanabe Y, Saeki N: Dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 72: 183-188, 1990 20. Yonas H, Agamanolis D, Takaoka Y, el al: Dissecting intracranial aneurysms. Surg Neurol 8:407-415, 1977
Manuscript received May 18, 1990. Accepted in final form September 25, 1990. Address reprint requests to: Kengo Matsumoto, M.D., Department of Neurological Surgery, Okayama University Medical School, 2-5-1 Shikata-cho, Okayama 700, Japan.
J. Neurosurg. / Volume 74/April, 1991
Hemifacial spasm caused by a spontaneous dissecting aneurysm of the vertebral artery Case report KENGO MATSUMOTO, M.D., TOSHIKAZUSAIJO, M.D., HIDEYUKI KUYAMA,NLD., SHOJI ASARI, M.D., AND AKmA NISHIMOTO, M.D.
Department of Neurological Surgery. Okayama University Medical School. Okayama, Japan u, The authors describe the first reported case of dissecting aneurysm presenting with hemifacial spasm. The patient was a 58-year-old woman with left hemifacial spasm of 2 years' duration. Cranial nerve examination was otherwise normal and no other clinical symptoms were observed. Vertebral angiography revealed a fusiform enlargement of the left vertebral artery and contrast medium remaining in the intramural false lumen in the venous phase. Microvascular decompression of the facial nerve with wrapping of the aneurysm resulted in complete relief of the hemifacial spasm. KEY WORDS 9 dissecting aneurysm microvascular decompression
ISSECTINGaneurysms of the intracranial arteries are uncommon, 1'~6 and most reported cases have presented with subarachnoid hemorrhage (SAH) or ischemia. ~9 In a review of the literature, we found few reports of hemifacial spasm due to aneurysms 2"~~ and the aneurysms involved were cirsoid, 2 berry, ~~or fusiform, t2 This is the first reported case of hemifacial spasm due to a spontaneous dissecting aneurysm of the vertebral artery.
D
9 hemifacial spasm
Computerized tomography showed an enhancing mass in the left cerebellopontine angle (Fig. 1), and magnetic resonance imaging demonstrated a signalvoid ectatic vessel in the same region on the Tz-weighted study (Fig. 2). Vertebral angiography revealed a fusiform enlargement of the left vertebral artery, with the contrast medium remaining in the venous phase (Fig. 3). The opposite vertebral artery was smaller than the affected artery.
Operation. The patient underwent a paramedian Case Report
This 58-year-old woman had a 2-year history of leftsided hemifacial spasm, beginning in the area of the orbicularis oculi and spreading to involve all the muscles innervated by the left facial nerve. There was an episode of left occipital pain 4 years before admission. That headache persisted for a year and disappeared spontaneously. On admission, her only medical problem was intermittent hemifacial spasm. No symptoms such as headache, vertigo, tinnitus, loss of balance, or slurring of speech were reported. She had no history of trauma or systemic disease.
Examination. The patient had a blood pressure of 130/80 m m Hg and normal vital signs. Neurological examination demonstrated typical hemifacial spasm with intermittent clonic-tonic muscle contraction. No other abnormalities were noted on physical or neurological examination. 650
FIG. 1. Axial noncontrast (left) and contrast-enhanced (righOcomputerized tomography scans showing an enhancing mass (arrow) at the left cerebellopontine angle.
J. Neurosurg. / Volume 74/April, 1991
Hemifacial spasm due to dissecting aneurysm suboccipital craniectomy through a retromastoid skin incision. A large fusiform aneurysm of the vertebral artery was exposed with only minimal retraction of the cerebellar hemisphere. This aneurysm was compressing the brain stem and impinging on the root exit zone of the left facial nerve (Fig. 4). The surface of the aneurysm was whitish gray and a neovascular pattern was observed in the aneurysrn's outer wall. These findings suggested the diagnosis of a dissecting aneurysrn. The aneurysm was easily separated from surrounding structures and mobilized. It was then wrapped circumferentially with expanded polytetrafluoroethylene (Goretex) vascular graft material and coated with cyanoacrylate.
relieved of facial pain, but one had complete paralysis of the seventh and eighth nerves, and in the other the facial spasm remained unchanged. Maroon, etal., ~oreported a successfully treated case of a posterior fossa berry aneurysm that caused hemifacial spasm. The neck of the aneurysm was clipped and the dome was mobilized away from its adherence to the facial nerve and brain stem. A piece of polyvinyl chloride nonabsorbable sponge was then inserted between the dome of the aneurysm and the brain stem. Looser and Chen ~ reviewed the literature on hemifacial spasm and its surgical therapy; among 450 patients with hemifacial spasm, they found two cases (0.5%) with compression caused by aneurysm.
Postoperative Course. The postoperative course was uneventful and surgery resulted in complete relief of facial spasm.
Dissecting Aneurysm
Discussion
Literature Review
Spontaneous dissecting aneurysms of the cerebral artery are uncommon especially in the posterior fossa. ~'7j5~7 Most patients present with SAH or ischemia ~'~j~ and suffer from severe occipital headache
HemifaciaI spasm is a movement disorder of the face characterized by intermittent involuntary twitches of muscles innervated by the facial nerveY In most patients with hemifacial spasm the underlying cause is benign. These cases are presumed due to compression of the root exit zone of the facial nerve by an aberrant vessel, usually a branch of the anterior or posterior inferior cerebellar artery or vertebral artery. 36'~7 Other compressive lesions have occasionally been observed, including tumor, 8 vascular malformation, 14 or an aneurysm of the posterior circulation, j~ Hemifacial spasm caused by an aneurysm is quite rare) -9'~~ Campbell and K e e d f reported two patients with typical facial motor tic and trigeminal neuralgia who were found to have a cirsoid aneurysm of the basilar artery compressing the facial nerve on the affected side. These cases were treated by division of the sensory root on the trigeminal nerve with a hook. Both patients were
FIG. 2. Axial Tz-weighted magnetic resonance image revealing, a signal-void ectatic vessel (arrow) in the left cerebellopontine angle.
J. Neurosurg. / Volume 74/April. 1991
FIG. 3. Upper."Left vertebral angiograms, anteropostenor view, showing aneurysmal dilatation of the vertebral artery with slight narrowing distal to it in the arterial phase (left) and retention of contrast medium (arrow) in the venous phase (right). Lower: Left vertebral angiograms, lateral oblique view, showing fusiform dilatation distal to the posterior inferior cerebellar artery in the arterial phase (left) and retention of contrast medium in the intramural false lumen (arrow) in the venous phase (right). 651
K. Matsumoto, et al. References
FIG. 4. Operative exposure showing a large fusiform aneurysm compressing the brain stem and the root exit zone (REZ) of the facial nerve. Note the neovascular pattern (arrowheads) of the outer wall of the aneurysm. The loop of vessel overlying the eighth cranial nerve (VIII) is the anterior inferior cerebellar artery (AICA); however, in this case this did not cause the pathology. The seventh cranial nerve (VII) is largely hidden behind the eighth cranial nerve. DA = dissecting aneurysm; IX = ninth cranial nerve; X = 10th cranial nerve; PICA = posterior inferior cerebellar artery. and/or neck pain] s,19 Various neurological deficits including cranial nerves and long-tract signs were observed preoperatively. H5:9 In the case reported here there was a l-year history of occipital headache but it is unknown whether SAH occurred; when the patient was seen, her only complaint was hemifacial spasm. The angiographic findings of dissecting aneurysms are diverse. There have been descriptions of a pearland-string sign, fusiform dilatation, occlusion, rosettes, intimal flaps, proximal and/or distal dilatations, double lumina, retention of contrast medium, and intramural pooling. 5'7"13'15'16'18-2~Among these findings, fusiform dilatation, proximal and/or distal narrowing, and retention of contrast medium are most characteristic) The sole pathognomonic sign of a dissecting aneurysm is a double lumen, revealed by the passage of contrast material in both true and false channels, but this is extremely rare. ~'~8.19 The indication for surgical treatment of vertebral dissecting aneurysms remains controversial./:9 These aneurysms have been treated by ligation or clipping of the proximal vertebral artery, or entrapment of the involved segment when the diameter of the opposite vertebral artery was equal to or larger than the affected artery; coating or wrapping of the lesion is performed when the affected artery is dominant. 1"5:1"13'1516"19Microvascular decompression, circumferential wrapping of the lesion with Goretex vascular graft, and coating by cyanoacrylate were the method of choice in our case, because the patient's only symptom was hemifacial spasm and the opposite vertebral artery was smaller than the affected artery. 652
1. Berger MS, Wilson CB: Intracranial dissecting aneurysms of the posterior circulation. Report of six cases and review of the literature. J Neurnsurg 61:882-894, 1984 2. Campbell E, Keedy C: Hemifacial spasm: a note on the etiology in two cases. J Neurosurg 4:342-347, 1947 3. Digre KB, Corbett J J, Smoker WRK, et al: CT and hemifacial spasm. Neurology 38:1111-1113, 1988 4. Echiverri HC, Rubino FA, Gupta SR, et al: Fusiform aneurysm of the vertebrobasilar arterial system. Stroke 20:1741-1747, 1989 5. Friedman AH, Drake CG: Subarachnoid hemorrhage from intracranial dissecting aneurysm. J Neurosurg 60: 325-334, 1984 6. Jannetta PJ, Abbasy M, Maroon JC, et al: Etiology and definitive microsurgical treatment of hemifacial stem. Operative techniques and results in 47 patients. J Nearosurg 47:321-328, 1977 7. Kulla L, Deymeer F, Smith TW, et al: Intracranial dissecting and saccular aneurysms in polycystic kidney disease. Report of a case. Arch Neurol 39:776-778, 1982 8. Levin JM, Lee JE: Hemifacial spasm due to cerebellopontine angle lipoma: case report. Neurology 37:337-339, 1987 9. Loeser JD, Chen J: Hemifacial spasm: treatment by microsurgical facial nerve decompression. Neurosurgery 13: 141-146, 1983 10. Maroon JC, Lunsford LD, Deeb ZL: Hemifacial spasm due to aneurysmal compression of the facial nerve. Arch Neurol 35:545-546, 1978 11. Miyazaki S, Yamaura A, Kamata K, et al: A dissecting aneurysm of the vertebral artery. Surg Neurol 21: 171-174, 1984 12. Moore AP: Postural fluctuation of hemifacial spasm. Case report. J Neurosurg 60:190-191, 1984 13. Nagao S, Kinugasa K, Bukeo T, et al: [Giant fusiform and dissecting aneurysms at the vertebro-basilarjunction: report of five cases and their clinicopathophysiological aspects.] No Shinkei Geka 15:1093-1100, 1987 (Jpn) 14. Pierry A, Gameron M: Clonic hemifacial spasm from posterior fossa arteriovenous malformation. J Neurol Neurosurg Psychiatry 42:670-672, 1979 15. Sekino H, Nakamura N, Katoh Y, et al: [Dissecting aneurysms of the vertebro-basilar system: clinical and angiographic observations.] No Shinkei Geka 9: 125-133, 1981 (Jpn) 16. Senter HJ, Sarwar M: Nontraumatic dissecting aneurysm of the vertebral artery. Case report. J Nearosurg 56: 128-130, 1982 17. Sobel D, Norman D, Yorke CH, et al: Radiography of trigeminal neuralgia and hemifacial spasm. AJNR 1: 251-253, 1980 18. Waga S, Fujimoto K, Morooka Y: Dissecting aneurysm of the vertebral artery. Surg Nearol 10:237-239, 1978 19. Yamaura A, Watanabe Y, Saeki N: Dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 72: 183-188, 1990 20. Yonas H, Agamanolis D, Takaoka Y, el al: Dissecting intracranial aneurysms. Surg Neurol 8:407-415, 1977
Manuscript received May 18, 1990. Accepted in final form September 25, 1990. Address reprint requests to: Kengo Matsumoto, M.D., Department of Neurological Surgery, Okayama University Medical School, 2-5-1 Shikata-cho, Okayama 700, Japan.
J. Neurosurg. / Volume 74/April, 1991
