International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198 Int J Case Rep Images 2019;10:101015Z01MG2019. www.ijcasereportsandimages.com Gold et al. 1 CLINICAL IMAGE PEER REVIEWED | OPEN ACCESS Vertebral artery dolichoectasia leading to hemifacial spasm Menachem Gold, George El Hasbani, Richard Assaker, Jose Francisco Vargas, Munir H. Idriss, Kamal Tarabine, Alexander Rabinovich CASE REPORT A 45-year-old male presented to the ophthalmology clinic complaining of constant twitching in the left face for three years, associated with a moderate left temporal headache. He was noted to have tonic-clonic contractions of the left orbicularis oculi and oris muscles (Figure 1, Video 1). MR imaging through the posterior fossa (Figure 2) demonstrated compression of the pons at the facial nerve root entry zone by an ectatic left vertebral artery. The patient’s symptoms improved with botulinum neurotoxin injections. The most common etiology of hemifacial spasm is compression of the facial nerve as it emerges from the brainstem by ectatic vessels. DISCUSSION Vertebrobasilar dolichoectasia is a rare dilative arteriopathy defined as elongation or widening of the intracranial vertebral and/or basilar arteries [1]. Hemifacial spasm (HFS) involves involuntary and painless spasms of the muscles supplied by the facial nerve Menachem Gold 1 , George El Hasbani 2 , Richard Assaker 3 , Jose Francisco Vargas 3 , Munir H. Idriss 3 , Kamal Tarabine 4 , Alexan- der Rabinovich 5 Affiliations: 1 Lincoln Medical and Mental Health Center, De- partment of Radiology, Weill Cornell Medical Center, Bronx, New York, United States; 2 American University of Beirut Medical Center, Department of Dermatology, Beirut, Leba- non; 3 Lincoln Medical and Mental Health Center, Depart- ment of Internal Medicine, Bronx, New York, United States; 4 Lebanese American University Medical Center, Department of Radiology, Beirut, Lebanon; 5 Lincoln Medical and Mental Health Center, Department of Ophthalmology, The Mount Si- nai Hospital, Bronx, New York, United States. Corresponding Author: Dr. Georges El Hasbani, MD, Ameri- can University of Beirut Medical Center, Department of Dermatology, Research Assistant, Beirut, Lebanon; Email: [email protected]Received: 28 January 2019 Accepted: 28 February 2019 Published: 26 March 2019 Figure 1: Patient had tonic-clonic contractions of the left orbicularis oculi and oris muscles. Figure 2(A, B): MR imaging through the posterior fossa demonstrated compression of the pons at the facial nerve root entry zone by an ectatic left vertebral artery. starting with spasm of the orbicularis muscle and then progressing to involve all the facial muscles [2]. Although the compression of the facial nerve can be caused by tumors or bony abnormalities, compression by a blood vessel is the most common [2]. The diagnosis of HFS due to
Transcript
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101015Z01MG2019. www.ijcasereportsandimages.com
Gold et al. 1
CLINICAL IMAGE PEER REVIEWED | OPEN ACCESS
Vertebral artery dolichoectasia leading to hemifacial spasm
Menachem Gold, George El Hasbani, Richard Assaker, Jose Francisco Vargas, Munir H. Idriss, Kamal Tarabine,
Alexander Rabinovich
CASE REPORT
A 45-year-old male presented to the ophthalmology clinic complaining of constant twitching in the left face for three years, associated with a moderate left temporal headache. He was noted to have tonic-clonic contractions of the left orbicularis oculi and oris muscles (Figure 1, Video 1). MR imaging through the posterior fossa (Figure 2) demonstrated compression of the pons at the facial nerve root entry zone by an ectatic left vertebral artery. The patient’s symptoms improved with botulinum neurotoxin injections. The most common etiology of hemifacial spasm is compression of the facial nerve as it emerges from the brainstem by ectatic vessels.
DISCUSSION
Vertebrobasilar dolichoectasia is a rare dilative arteriopathy defined as elongation or widening of the intracranial vertebral and/or basilar arteries [1]. Hemifacial spasm (HFS) involves involuntary and painless spasms of the muscles supplied by the facial nerve
Menachem Gold1, George El Hasbani2, Richard Assaker3, Jose Francisco Vargas3, Munir H. Idriss3, Kamal Tarabine4, Alexan-der Rabinovich5
Affiliations: 1Lincoln Medical and Mental Health Center, De-partment of Radiology, Weill Cornell Medical Center, Bronx, New York, United States; 2American University of Beirut Medical Center, Department of Dermatology, Beirut, Leba-non; 3Lincoln Medical and Mental Health Center, Depart-ment of Internal Medicine, Bronx, New York, United States; 4Lebanese American University Medical Center, Department of Radiology, Beirut, Lebanon; 5Lincoln Medical and Mental Health Center, Department of Ophthalmology, The Mount Si-nai Hospital, Bronx, New York, United States.Corresponding Author: Dr. Georges El Hasbani, MD, Ameri-can University of Beirut Medical Center, Department of Dermatology, Research Assistant, Beirut, Lebanon; Email: [email protected]
Received: 28 January 2019Accepted: 28 February 2019Published: 26 March 2019
Figure 1: Patient had tonic-clonic contractions of the left orbicularis oculi and oris muscles.
Figure 2(A, B): MR imaging through the posterior fossa demonstrated compression of the pons at the facial nerve root entry zone by an ectatic left vertebral artery.
starting with spasm of the orbicularis muscle and then progressing to involve all the facial muscles [2]. Although the compression of the facial nerve can be caused by tumors or bony abnormalities, compression by a blood vessel is the most common [2]. The diagnosis of HFS due to
International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101015Z01MG2019. www.ijcasereportsandimages.com
Gold et al. 2
VAD necessitates imaging techniques whereby magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) are the optimal imaging techniques for demonstrating the compression [3]. The two most commonly reported treatments for hemifacial spasm in the literature are botulinum toxin injections and surgical microvascular decompression. Botulinum toxin injection is clinically successful for long term management with low incidence of adverse effects [4]. It has been usually used as a first line treatment [5]. In our case, few Botox injections helped alleviate the patient’s symptoms for a prolonged period. Surgical microvascular decompression is the permanent treatment option. However, a small chance of serious complications do exist such as deafness, severe facial paralysis, cerebellar hematoma, brain stem infarct, and very rarely death [6].
CONCLUSION
Vertebrobasilar dolichoectasia (VBS) can rarely compress the facial nerve at the root leading to hemifacial spasm. The diagnosis necessitates the use of MRI or
MRA. Treating with Botox injections have been effective. Although surgical microvascular decompression is the permanent treatment option, several serious side effects have been reported.
REFERENCES
1. Vanikieti K, Cheecharoen P, Jindahra P, Lueangaram S, Padungkiatsagul T. Atypical oculopalatal tremor as the presentation of vertebral artery dolichoectasia. Int Med Case Rep J 2016;9:273–7.
2. Rahman EA, Trobe JD, Gebarski SS. Hemifacial spasm caused by vertebral artery dolichoectasia. Am J Ophthalmol 2002;133(6):854–6.
3. Yaltho TC, Jankovic J. The many faces of hemifacial spasm: Differential diagnosis of unilateral facial spasms. Mov Disord 2011;26(9):1582–92.
4. Czyz CN, Burns JA, Petrie TP, Watkins JR, Cahill KV, Foster JA. Long-term botulinum toxin treatment of benign essential blepharospasm, hemifacial spasm, and Meige syndrome. Am J Ophthalmol 2013;156(1):173–7.e2.
5. Wang X, Thirumala PD, Shah A, et al. Effect of previous botulinum neurotoxin treatment on microvascular decompression for hemifacial spasm. Neurosurg Focus 2013;34(3):E3.
6. Qi H, Zhang W, Zhang X, Zhao C. Microvascular decompression surgery for hemifacial spasm. J Craniofac Surg 2016;27(1):124–7.
Gold M, El Hasbani G, Assaker R, Vargas JF, Idriss MH, Tarabine K, Rabinovich A. Vertebral artery dolichoectasia leading to hemifacial spasm. Int J Case Rep Images 2019;10:101015Z01MG2019.
Article ID: 101015Z01MG2019
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doi: 10.5348/101015Z01MG2019CL
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Author ContributionsMenachem Gold – Substantial contributions to conception and design, Acquisition of data, Analysis
Video 1: Hemifacial spasm involving the left orbicularis oris and orbicularis oculi muscles.
Video 1 URL: http://www.ijcasereportsandimages.com//archive/article-full-text/101015Z01MG2019
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International Journal of Case Reports and Images, Vol. 10, 2019. ISSN: 0976-3198
Int J Case Rep Images 2019;10:101015Z01MG2019. www.ijcasereportsandimages.com
Gold et al. 3
and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedGeorge El Hasbani – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedRichard Assaker – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedJose Francisco Vargas – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedMunir H. Idriss – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedKamal Tarabine – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedAlexander Rabinovich – Substantial contributions to conception and design, Acquisition of data, Analysis
and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone.
Consent StatementWritten informed consent was obtained from the patient for publication of this clinical image.
Conflict of InterestAuthors declare no conflict of interest.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
