H emifacial spasm (HFS) is relatively rare, with an estimated incidence of 0.8 per 100,000 persons/year and an estimated prevalence of 7.4 per 100,000 men and 14.5 per 100,000 women. 2 The disease typically begins as infrequent twitches of an eyelid that progress over time in intensity, frequency, and extent of involvement of the ipsilateral facial muscles. HFS may cause significant disability due to annoying and distracting twitches and forceful spasms, and also by the loss of binocular vision associated with involuntary eye closure. The greatest impact on the quality of life for many patients is the psychological and social impact of the facial disfigurement caused by the disorder. 15,17 Surgical cure of HFS can be achieved with microvascular decompression (MVD) surgery, as pioneered by Jannetta in 1967, 12 and several series have demonstrated high rates of success and safety. 3,4,[6][7][8]10,11,13,20,21 The aim of this surgery is to alleviate culprit neurovascular compression (NVC) upon the facial nerve, most commonly at the facial root exit zone (fREZ). Only in rare cases is HFS caused by severe NVC of the cisternal portion of the facial nerve.4,5 The extent of the fREZ, however, has been variably defined and is often considered as only the Obersteiner-Redlich zone of transition between central oligodendrocytes and peripheral Schwann cell-derived myelin, just distal to the facial nerve detachment from the lateral pons. 19 We have previously em- OBJectiVe Microvascular decompression (MVD) surgery for hemifacial spasm (HFS) is potentially curative. The findings at repeat MVD in patients with persistent or recurrent HFS were analyzed with the aim to identify factors that may improve surgical outcomes. methOdS Intraoperative findings were determined from review of dictated operative reports and operative diagrams for patients who underwent repeat MVD after prior surgery elsewhere. Clinical follow-up was obtained from the hospital and clinic records, as well as telephone questionnaires. reSultS Among 845 patients who underwent MVD performed by the senior author, 12 had been referred after prior MVD for HFS performed elsewhere. Following repeat MVD, all patients improved and complete spasm resolution was described by 11 of 12 patients after a mean follow-up of 91 ± 55 months (range 28-193). Complications were limited to 1 patient with aggravation of preexisting hearing loss and mild facial weakness and 1 patient with aseptic meningitis without sequelae. Significant factors that may have contributed to the failure of the first surgery included retromastoid craniectomies that did not extend laterally to the sigmoid sinus or inferiorly to the posterior fossa floor in 11 of 12 patients and a prior surgical approach that focused on the cisternal portion of the facial nerve in 9 of 12 patients. In all cases, significant persistent neurovascular compression (NVC) was evident and alleviated more proximally on the facial root exit zone (fREZ). cONcluSiONS Most HFS patients will achieve spasm relief with thorough allevia...

No abstract

The treatment of small to medium sized vestibular schwannomas (VS) with Gamma Knife (GK) stereotactic radiosurgery is a well-documented treatment alternative to surgical resection, with prospective nonrandomized trials demonstrating facial nerve and hearing preservation rates favoring GK over microsurgery 1,2 . Tumor control rates have been described upwards of 94% in recent literature, with acceptable complication rates 3 when compared to microsurgery. Long term actuarial resection-free control rates have been documented at 98.3% [4][5][6] , emphasizing the lasting effect post-GK. Larger VS pose a difficult clinical challenge, with many authors favoring surgical resection due to concerns around radiation dosing and side effects. Differing recommendations currently exist in the literature in terms of the degree of resection. Recently, the suggestion of sub-total resection in order to reduce the volume to one more amenable to GK has arisen. ABSTRACT: Object: To review our institutional experience with Gamma Knife (GK) stereotactic radiosurgery in treating large vestibular schwannomas (VS) of 3 to 4 cm diameter. Methods: We conducted a retrospective cohort review of all patients treated with GK for VS at our institution between November 2003 and March 2012. Data on age, sex, VS volume, location and maximal diameter, House-Brackmann (HB) facial nerve scores pre and post-GK, Gardner-Robertson (GR) hearing score pre and post-GK, GK treatment parameters, VS response time, complications and clinical outcome was recorded Results: A total of 28 patients during the defined time period were identified. Three patients were lost to follow-up. Mean follow-up was 34.5 months. Tumor control occurred in 92%, and was maintained in 85.7% at two years. Facial nerve or hearing preservation occurred in all treated compared to pre-GK status, as per HB and GR grading. Transient complications occurred in 80%. Temporary vestibular dysfunction occurred in seven patients (28%). One patient (4%) had the permanent complication of worsening pre-GK hemifacial spasm. Four patients (16%) developed hydrocephalus post-GK. Conclusion: GK stereotactic radiosurgery as a primary treatment modality for large VS can provide acceptable tumor control rates with good facial nerve and hearing preservation, and low complication rates.RÉSUMÉ: Radiochirurgie par scalpel gamma dans les schwannomes vestibulaires de grande taille. Objectif : Le but de l'étude était de revoir notre expérience institutionnelle de l'utilisation de la radiochirurgie stétéotaxique par scalpel gamma (SG) dans le traitement des schwannomes vestibulaires (SV) de grande taille, soit de 3 à 4 cm de diamètre. Méthode : Nous avons effectué une revue rétrospective de cohorte de tous les patients traités par SG pour un SV dans notre institution entre novembre 2003 et mars 2012. Les données sur l'âge, le sexe, le volume du SV, sa localisation et son diamètre maximal, les scores à l'échelle de House-Backmann (HB) pour le nerf facial avant et après traitement par le SG, le score à l'échelle de Ga...

The analysis of results was limited to a systematic review and qualitative analysis of the eligible studies. Based on this systematic review we identified 8 studies reporting a statistically significant effect of pre-operative depression on post-operative pain and 10 studies reporting no statistically significant effect of pre-operative depression on post-operative pain. Therefore, the quality of presented data is poor and makes it challenging to answer further questions. Large epidemiologic studies in this field are needed to provide further evidence.

We describe a rare case and novel management strategy of painful trigeminal neuropathy caused by an arachnoid cyst confined to Meckel's cave. A 57-year-old female presented with several years of progressive trigeminal pain and signs of trigeminal deafferentation, including sensory loss, corneal anesthesia and mastication muscle atrophy. Medical treatment with carbamazepine provided partial and temporary pain control. Surgical treatment was eventually performed by aspiration of the arachnoid cyst through the foramen ovale using a percutaneous approach. The patient experienced relief of pain and improvement of numbness and muscle strength. To our knowledge, this is the first case description of a percutaneous drainage of a Meckel's cave arachnoid cyst.

The majority of MS-TN patients become medically refractory and require multiple repeat surgical procedures. MS-TN procedures were associated with high rates of pain recurrence and our data suggests reoperation within 1 year is often necessary. Optimal management strategy in this patient population remains to be determined. Patients need to be counseled on managing expectations as treatments commonly afford only temporary relief.

BACKGROUND The natural history of unilateral moyamoya disease (MMD) progressing to bilateral MMD remains an enigma in modern vascular neurosurgery. Few, small series with limited follow-up have reported relatively high rates of contralateral stenosis progression. OBJECTIVE To review our large series of unilateral MMD patients and evaluate radiographic and surgical progression rates, and identify any factors associated with progression. METHODS We included all unilateral MMD cases treated from 1991 to 2017 in an observational study. We examined time to contralateral radiographic progression and contralateral progression requiring surgery. Using Cox regression analysis, we evaluated factors potentially associated with contralateral progression. RESULTS There were 217 patients treated for unilateral MMD. About 71% were female, and the average age at first surgery was 33.8 yr. Average follow-up was 5.8 yr (range 1-22 yr). A total of 18 patients (8.3%) developed contralateral progression. And 8 of these (3.7%) developed progression requiring bypass surgery. Baseline stenosis and hyperlipidemia (HLD) were significantly associated with radiographic progression (hazard ratio [HR] = 9.7, P = .006; HR = 4.0, P = .024). Baseline stenosis was associated with surgical progression (HR = 44.2, P = .002). Results were similar when controlling for possible confounders using multivariate regression. CONCLUSION Previous series showed relatively high rates of progression in unilateral MMD (15%-30%), but these studies were small and long-term follow-up was rarely available. Our large series indicates that the rate of progression is lower than previously reported but still warrants yearly noninvasive screening. These data may provide indirect support for statin therapy in MMD.

OBJECTIVEPerforator arteries, the absence of an aneurysm discrete neck, and the often-extensive nature of posterior circulation fusiform aneurysms present treatment challenges. There have been advances in microsurgical and endovascular approaches, including flow diversion, and the authors sought to review these treatments in a long-term series at their neurovascular referral center.METHODSThe authors performed a retrospective chart review from 1990 to 2018. Primary outcomes were modified Rankin Scale (mRS) scores and Glasgow Outcome Scale (GOS) scores at follow-up. The authors also examined neurological complication rates. Using regression techniques, they reviewed independent and dependent variables, including presenting features, aneurysm location and size, surgical approach, and pretreatment and posttreatment thrombosis.RESULTSEighty-four patients met the inclusion criteria. Their mean age was 53 years, and 49 (58%) were female. Forty-one (49%) patients presented with subarachnoid hemorrhage. Aneurysms were located on the vertebral artery (VA) or posterior inferior cerebellar artery (PICA) in 50 (60%) patients, basilar artery (BA) or vertebrobasilar junction (VBJ) in 22 (26%), and posterior cerebral artery (PCA) in 12 (14%). Thirty-one (37%) patients were treated with microsurgical and 53 (63%) with endovascular approaches. Six aneurysms were treated with endovascular flow diversion. The authors found moderate disability or better (mRS score ≤ 3) in 85% of the patients at a mean 14-month follow-up. The GOS score was ≥ 4 in 82% of the patients. The overall neurological complication rate was 12%. In the regression analysis, patients with VA or PICA aneurysms had better functional outcomes than the other groups (p < 0.001). Endovascular strategies were associated with better outcomes for BA-VBJ aneurysms (p < 0.01), but microsurgery was associated with better outcomes for VA-PICA and PCA aneurysms (p < 0.05). There were no other significant associations between patient, aneurysm characteristics, or treatment features and neurological complications (p > 0.05). Patients treated with flow diversion had more complications than those who underwent other endovascular and microsurgical strategies, but the difference was not significant in regression models.CONCLUSIONSPosterior circulation fusiform aneurysms remain a challenging aneurysm subtype, but an interdisciplinary treatment approach can result in good outcomes. While flow diversion is a useful addition to the armamentarium, traditional endovascular and microsurgical techniques continue to offer effective options.