Facial phantom model: a low-cost and safe tool for teaching botulinum toxin application in neurology residencies / Modelo de manequim facial: uma ferramenta segura e de baixo custo para o ensino da aplicação de toxina botulínica nas residências em neurologia

Abstract Background The application of botulinum toxin (BoNT) in the treatment of blepharospasm and hemifacial spasm (HS) is a well-established practice. However, neurology residency programs often rely on real patients for training, which has limitations in terms of patient availability and skill acquisition. Objective Assess the efficacy of a new facial phantom model for acquiring motor skills in BoNT application. Methods An anthropomorphic facial phantom model was developed in collaboration with a medical training simulator start-up. A group of seven neurologists and one ophthalmologist with expertise in BoNT application evaluated the model using an adapted learning object review instrument (LORI). The instrument assessed aspects such as: content quality, alignment of learning objectives, feedback and adaptation, motivation, presentation design, and accessibility. Results The facial phantom model received high scores in the LORI evaluation, with the highest ratings given to alignment with learning objectives and motivation. The model also scored well in terms of accessibility, content quality, and presentation design. However, feedback and adaptation received a lower score due to the static nature of the model. Conclusion The facial phantom model shows promise as a valuable tool for teaching and developing competence in BoNT application for HS and blepharospasm. The model reduces the reliance on real patients for training, providing a broader and safer learning experience for neurology residents. It also provides a realistic learning experience and offers portability, cost-effectiveness, and ease of manufacturing for use in various medical training scenarios. It is an effective and accessible tool for teaching BoNT application.

Resumo Antecedentes A aplicação de toxina botulínica (TxB) no tratamento do blefaroespasmo e do espasmo hemifacial (EH) é uma prática bem estabelecida. No entanto, os programas de residência em neurologia frequentemente dependem de pacientes reais para treinamento, o que apresenta limitações em termos de disponibilidade de pacientes e aquisição de habilidades. Objetivo Avaliar a eficácia de um novo modelo de manequim facial para aquisição de habilidades motoras na aplicação de TxB. Métodos Foi desenvolvido um modelo antropomórfico de manequim facial em coloboração com uma empresa de simuladores de treinamento médico. Um grupo constituído por sete neurologistas e um oftalmologista com experiência em aplicação de TxB avaliou o modelo utilizando um instrumento adaptado de revisão de objeto de aprendizagem (LORI). O instrumento analisou aspectos como: qualidade do conteúdo, alinhamento dos objetivos de aprendizagem, feedback e adaptação, motivação, concepção da apresentação e acessibilidade. Resultados O modelo de manequim facial obteve pontuações altas na avaliação do LORI com os maiores escores em alinhamento com os objetivos de aprendizagem e motivação. O modelo também obteve boas pontuações em termos de acessibilidade, qualidade do conteúdo e concepção da apresentação. No entanto, o item feedback e adaptação recebeu uma pontuação média mais baixa, devido à natureza estática. Conclusão O modelo manequim facial mostra-se promissor como uma EH e blefaroespasmo. O modelo reduz a dependência de pacientes reais para treinamento portátil, de baixo custo e de fácil fabricação para uso em diversos cenários de treinamento, proporcionando uma experiência de aprendizagem mais ampla e segura para residentes de neurologia. Além disso, fornece uma experiência de aprendizagem realista e oferece portabilidade, economia e facilidade de fabricação para uso em vários cenários de treinamento médico. É uma ferramenta eficaz e acessível para o ensino da aplicação de TxB.

Profile of patients with essential blepharospasm and hemifacial spasm in the two largest ophthalmology reference centers in Brazil / Perfil dos pacientes com blefaroespasmo essencial e espasmo hemifacial nos dois maiores centros de referência em oftalmologia no Brasil

ABSTRACT Purpose: Information is scarce regarding the comprehensive profile of patients with essential blepharospasm and hemifacial spasm in Brazil. The present study aimed to assess the clinical features of patients with these conditions, followed up in two reference centers in Brazil. Methods: The study included patients with essential blepharospasm and hemifacial spasm, followed up at the Departments of Ophthalmology at Universidade Federal de São Paulo and Universidade de São Paulo. Apart from demographic and clinical features, past stressful events related to the first symptoms (triggering event), aggravating factors, sensory tricks, and other ameliorating factors for the eyelid spasms were assessed. Results: A total of 102 patients were included in this study. Most patients were female (67.7%). Essential blepharospasm was the most frequent movement disorder [51/102 patients (50%)], followed by hemifacial spasm (45%) and Meige's syndrome (5%). In 63.5% of the patients, the onset of the disorder was associated with a past stressful event. Ameliorating factors were reported by 76.5% of patients; 47% of patients reported sensory tricks. In addition, 87% of the patients reported the presence of an aggravating factor for the spasms; stress (51%) was the most frequent. Conclusion: Our study provides information regarding the clinical features of patients treated in the two largest ophthalmology reference centers in Brazil.

RESUMO Objetivo: Há poucos dados sobre o perfil de pacientes com blefaroespasmo essencial e espasmo hemifacial no Brasil. O objetivo deste estudo é avaliar de forma mais abrangente as características clínicas dos pacientes portadores dessas doenças acompanhados em dois centros de referência em oftalmologia no Brasil. Métodos: Pacientes com blefaroespasmo essencial e espasmo hemifacial, acompanhados nos Departamentos de Oftalmologia da Universidade Federal de São Paulo e da Universidade de São Paulo foram incluídos neste estudo. Além dos dados clínicos e demográficos, foram avaliados também a presença de eventos estressantes relacionados ao início dos sintomas (evento desencadeante), fatores agravantes, truques sensoriais, e outros fatores de melhora. Resultados: Cento e dois pacientes foram incluídos no estudo. A maior parte dos pacientes era do sexo feminino (67,7%). Blefaroespasmo essencial foi a condição mais frequente, observada em 51 (50%) dos pacientes. Espasmo hemifacial correspondia a 45% dos casos, enquanto 5% dos pacientes apresentavam a Síndrome de Meige. 63,5% dos pacientes associaram o início dos sintomas com um evento estressante prévio. 76,5% dos pacientes relataram fatores de melhora para os espasmos; 47% relataram truques sensoriais. Além disso, 87% dos pacientes relataram fatores de piora; estresse (51%) foi o mais frequente. Conclusão: Este estudo fornece informações a respeito das características clínicas dos pacientes com blefaroespasmo essencial e espasmo hemifacial acompanhados nos dois maiores centros de referência em oftalmologia do Brasil.

Clinical comparison of modified postauricular transverse incision and traditional vertical incision for microvascular decompression in the treatment of hemifacial spasm / 中国医师进修杂志

Objective:To compare the effect of modified postauricular transverse incision and traditional vertical incision for microvascular decompression in the treatment of hemifacial spasm.Methods:Prospective study method was used. A total of 116 patients with hemifacial spasm in Handan Central Hospital from January 1, 2019 to January 1, 2020 were selected, and divided into two groups according to the admission order. Both groups underwent microvascular decompression; control group (57 cases) received traditional vertical incision, while treatment group (59 cases) received modified postauricular transverse incision. The brainstem auditory evoked potential (BAEP), pain degree, surgical indicators, facial aesthetic satisfaction and complications were compared between two groups.Results:After treatment, the BAEP of latency, wave interval and wave amplitude in the two groups increased compared with that before treatment, and the BAEP of latency, wave interval and wave amplitude in the treatment group were higher than those in the control group: (1.89 ± 0.15) ms vs. (1.62 ± 0.21) ms, (7.89 ± 0.15) ms vs. (6.25 ± 0.41) ms, (1.79 ± 0.19) ms vs. (1.54 ± 0.11) ms ( P<0.05). After treatment, the visual analogue score (VAS) of patients in the two groups decreased compared with that before treatment, and the VAS of patients in the treatment group was lower than that in the control group: (1.15 ± 0.27) points vs. (2.18 ± 0.24) points ( P<0.05). The operation time, intraoperative bleeding volume and postoperative scar length of patients in the treatment group were less than those in the control group: (60.41 ± 3.81) h vs. (76.87 ± 3.87) h, (30.18 ± 4.19) ml vs. (56.87 ± 4.15) ml and (4.18 ± 1.07) cm vs. (6.87 ± 1.05) cm ( P<0.05). The satisfaction rate of patients in the treatment group was higher than that in the control group: 91.53% (54/59) vs. 71.93% (41/57) ( P<0.05). The complication rate of patients in the treatment group was lower than that in the control group: 5.08% (3/59) vs. 21.05% (12/57) ( P<0.05). Conclusions:Compared with traditional vertical incision, the modified transverse incision for microvascular decompression in the treatment of hemifacial spasm can reduce intraoperative blood loss and postoperative scar area, enhance brainstem auditory evoked potential, and improve facial aesthetics, which is worthy of recommendation.

Application of preoperative and intraoperative electroneurophysiological examination for persons with hemifacial spasm / 中华物理医学与康复杂志

Objective:To analyze the diagnostic value of preoperative electromyography and spasticity assessment for patients with hemifacial spasm, and to define a relationship between intraoperative electrophysiological examination and prognosis in order to provide help for clinical diagnosis and treatment.Methods:Thirty-one patients with hemifacial spasm were selected for the clinical spasticity scoring and divided into a general spasm group ( n=27) and a severe spasm group ( n=4). All received preoperative neurophysiological examination to record their twitch discharge, facial nerve conduction velocity (MCV), lateral spread (LSR) of the spasm, brainstem auditory evoked potential (BAEP), and blink reflex. Electrophysiological monitoring then recorded intraoperative LSR. According to whether the LSR disappeared or not, the patients were divided into the LSR disappearance group (of 15) and the LSR residual group (of 16), and facial muscle activity was recorded again one, three and six months after the operation. Results:Preoperative EMG examination of both groups showed positive LSR and that facial nerve MCV was within the normal range. There were, though, significant differences between the two groups in the twitching discharge by needle electromyography, blink reflex and preoperative BAEP. One week after the operation, one member of the residual group and 3 from the disappearance patients of the former and latter group had recovered in terms of LSR, with 3 and 7 cases significantly relieved, respectively. Two months later, the corresponding figures were 5 and 7, 3 and 6, respectively. Half of a year after the surgery, 5 from the residual group and 12 from the disappearance group had fully recovered in terms of LSR, while 9 and 2 cases were significantly relieved. Altogether, there were significant differences within the two groups in terms of recovery among all the time points, with significantly better recovery in the LSR disappearance group than the LSR residual group at 1 week after operation, while there were no significant differences between the two groups in recovery 3 and 6 months after their operation.Conclusions:Preoperative electromyography can provide objective assessments of the scope, severity, and facial nerve excitability of patients with hemifacial spasm. Real-time intraoperative electrophysiology monitoring can help surgeons to objectively assess the effect of decompression and to find and avoid nerve traction injury in surrounding areas quickly.

Advances in diagnosis and treatment of primary hemifacial spasm / 中华全科医师杂志

Primary hemifacial spasm is a motor disorder of facial muscles related to facial nerve. During the attack, the facial muscles present irregular and involuntary clonus, which can be induced or aggravated by emotional excitement, mental tension and random facial movement, seriously affecting daily work and life. The pathogenesis, diagnosis, differential diagnosis and treatment of the primary hemifacial spasm have been studied extensively in recent years. This article reviews the progress in these aspects.

Espasmo hemifacial: experiencia en un centro terciario

Resumen El espasmo hemifacial consiste en un infrecuente trastorno del movimiento que afecta a la musculatura inervada por el nervio facial, en especial la de la hemicara superior. Existen dos formas clínicas, una primaria en la que la causa subyacente está representada por un conflicto neurovascular, y una secundaria, en la que la alteración del nervio facial es producida por algún tipo de lesión ocupante de espacio. Resulta de especial interés para el otorrinolaringólogo conocer esta entidad y ser capaz de diferenciar ambas formas clínicas dado el diferente enfoque terapéutico que pueden requerir. Aportamos una visión general de esta patología repasando su epidemiología y fisiopatología, además, de nuestra experiencia en forma de una serie de cuatro casos que ilustran las variadas formas de presentación de esta entidad, así como los signos y síntomas de alarma que pueden ayudar a realizar un correcto diagnóstico y manejo.

Abstract Hemifacial spasm consists of an unfrecuent movement disorder involving facial muscles, especially those from the upper half of the face. Two different clinical presentations are described. Primary hemifacial spasm is defined by a neurovascular conflict, and secondary occurs when facial nerve is damaged by a space occupying lesion. It is of special interest for the otorhinolaryngologist to get to know about this condition and to be able to acknowledge its clinical presentations due to the different therapeutical approach that may be needed for each of them. We contribute with a general vision of this entity reviewing its epidemiology and patophysiology. Furthermore, we show our experience by sharing a four-case series which we believe to illustrate the different ways of presentation as well as the alarm signs and symptoms that may be helpful in order to accomplish an accurate diagnose and treatment.

Descompresión Microvascular para el Tratamiento del Espasmo Hemifacial

Resumen El espasmo hemifacial se caracteriza por contracciones tonicoclónicas en los músculos inervados por el nervio facial, causado por la compresión del nervio facial por una arteria, generalmente la arteria cerebelosa anteroinferior o venas del ángulo pontocerebeloso. Suelen aparecer espontáneamente, debido a la tensión emocional, fatiga, y disminuyen durante el reposo. Se presenta entre los 13 a 77 años con una duración de los síntomas aproximadamente de ocho años. La inyección local de toxina botulínica puede ser efectiva en el tratamiento, y la descompresión microvascular está reservada para casos refractarios al tratamiento médico, con resolución completa entre el 85 al 93%. En este artículo, se resumen las principales características anatomo-clínicas, fisiopatológicas, y una descripción detallada de la descompresión microvascular como mejor opción terapéutica.

Abstract Hemifacial spasm is characterized by tonic-clonic contractions of the muscles innervated by the facial nerve. It is caused by compression of the facial nerve by a blood vessel, which usually is the anterior inferior cerebellar artery or the veins of the cerebello-pontine angle. It typically appears spontaneously, caused by emotional tension and fatigue, and it's reduced during rest. Likewise, it presents between the ages of 13 and 77 years, with a median duration of symptoms of eight years. Treatment with local botulinum toxin injection can be effective, and the Microvascular decompression is reserved for cases that are refractory to medical treatment, resulting in full spasm resolution in 85 to 93% of patients. This article summarizes the main anatomic-clinical and physio-pathological characteristics of hemifacial spasms. Additionally, a detailed description of microvascular decompression as the best therapeutic option is described in detail.

Needle-embedding treatment for hemifacial spasm: research progress / 中国针灸

The articles regarding needle-embedding treatment for hemifacial spasm published before September 30, 2019 were searched from SinoMed, Wanfang, CNKI, VIP and PubMed database, and were analyzed and summarized from treatment methods, acupoint selection, stage differentiation and action mechanism. As a result, 45 Chinese articles were obtained. The needle-embedding treatment was divided into intradermal needling and acupoint thread-embedding; the top five acupoints were Sibai (ST 2), Taiyang (EX-HN 5), Dicang (ST 4), Jiache (ST 6) and spasm trigger points. The basic research of needle-embedding treatment for hemifacial spasm is weak, and the literature regarding stage differentiation is insufficient, which are in need of further study.

Application of Methylprednisolone Sodium Succinate Combined with Tropisetron in Prevention of Nausea and Vomiting under Microvascular Decompression of Hemifacial Spasm / 中国医学科学院学报

Objective To evaluate the effect of methylprednisolone sodium succinate combined with tropisetron on postoperative nausea and vomiting(PONV)under microvascular decompression of hemifacial spasm.Methods From January to June 2019,485 patients undergoing microvascular decompression for facial spasm at Department of Neurosurgery,Peking University People's Hospital were randomly assigned into two groups with random number table method.For group A(n=242),2 ml saline was administrated by intravenous drip before induction and 5 mg tropisetron after operation.For group B(n=243),40 mg methylprednisolone sodium succinate was administrated by intravenous drip before induction and 5 mg tropisetron after operation.The anesthesia time,operation time,and incidence of PONV in 0-24 h and 24-48 h were recorded for the comparison of the remedial treatment rate of nausea and vomiting between the two groups.Results There was no significant difference in age,gender,smoking history,body mass index value,American Society of Anesthesiologists score,medical history,surgical side,PONV history,operation time or anesthesia time between the two groups(all P > 0.05).The incidence of PONV in group A was 35.5% and 18.2% during 0-24 h and 24-48 h,respectively,which was significantly higher than that(18.5%,χ

Tratamiento efectivo de la toxina botulínica tipo A en el espasmo hemifacial, Guantánamo 2018-2019 / Botulinum toxin type A efficient treatment in patients with hemifacial spasm, Guantanamo 2018-2019

RESUMEN Introducción: No se encuentran antecedentes de investigaciones que aborden resultados de la aplicación de toxina botulínica tipo A en pacientes con espasmo hemifacial en la provincia Guantánamo. Objetivo: Evaluar los resultados terapéuticos de la aplicación de toxina botulínica tipo A en pacientes con espasmo hemifacial atendidos en consulta de Neurología. Método: Se realizó un estudio descriptivo longitudinal de 21 pacientes atendidos en servicio de Neurología con espasmo hemifacial y tratamiento con toxina botulínica tipo A, desde enero 2018 hasta enero 2019. Las variables estudiadas fueron: edad, sexo, hemicara afectada, periodo de latencia, duración, desaparición del efecto clínico de toxina botulínica tipo A, y porciento de incapacidad funcional en pacientes al aplicar la escala de discapacidad antes y después de la aplicación del tratamiento. Resultados: Predominó el sexo femenino con 57,1%, edad mayor de 55 años con 57,14 %, lado afectado predominante el izquierdo con 57,14 %, el periodo de latencia de la toxina botulínica tipo A fue entre el tercer y décimo día con 14 pacientes para un 66,67 %, el tiempo máximo de duración del tratamiento fue de uno a dos meses con un 57,14 %, y la desaparición del efecto terapéutico de la toxina fue entre el tercer y cuarto mes con un 52,38%. Luego de la aplicación de la escala de evaluación clínica del espasmo hemifacial se evidenció disminución del porcentaje de pacientes con incapacidad funcional. Conclusiones: La toxina botulínica tipo A es efectiva en el tratamiento del espasmo hemifacial.

ABSTRACT Introduction: No research records were founded dressing the results of the application of botulinum toxin type A in patients with hemifacial spasm in Guantanamo province. Objective: to evaluate the therapeutic results of the application of botulinum toxin type A in patients with hemifacial spasm treated in a Neurology consultation. Method: a descriptive and longitudinal study was carried out in 21 patients attended in Neurology service with hemifacial spasm and botulinum toxin type A treatment, fromJanuary 2018 to January 2019. The variables studied were: age, gender, hemiface affected, latency period, duration, disappearance of the clinical effects of botulinum toxin type A, and percentage of functional disability in patients when applying the disability scale before and after the treatment. Results: Female cases predominated (57.1%), agesover 55 years (57.14 %), the most common affected side of the face was the left, with 57.14 %, the latency period of botulinum toxin type A was between the third to the tenth day in 14 of the patients (66.67 %), the maximum time of duration of treatment ranged from one to two months (57.14 %), and the disappearance of the therapeutic effect of the toxin in the patients was between the third to the fourth month (52.38%). After the application of the clinical assessment scale of hemifacial spasm, a decrease in the percentage of patients with functional disability was evidenced. Conclusions: Botulinum toxin type A is effective in the treatment of hemifacial spasm.

Hemifacial Spasm Associated with Chiari Type I Malformation: Surgical Considerations and Case Report

Hemifacial spasm (HS) is a movement disorder characterized by paroxysmal and irregular contractions of the muscles innervated by the facial nerve. Chiari malformation type I (CM I) is a congenital disease characterized by caudal migration of the cerebellar tonsils, and surgical decompression of foramen magnum structures has been used for treatment. The association of HS with CM I is rare, and its pathophysiology and therapeutics are speculative. There are only a few cases reported in the literature concerning this association. The decompression of the posterior fossa for the treatment of CM I has been reported to relieve the symptoms of HS, suggesting a relation between these diseases. However, the possible complications of posterior fossa surgery cannot be underrated. We report the case of a 66-year-old patient, in ambulatory follow-up due to right HS, no longer responding to botulinum toxin treatment. Magnetic resonance imaging (MRI) of the skull revealed compression of the facial nerve and CM I. The patient underwent surgery for HS by neurovascular microdecompression of the facial nerve via right lateral suboccipital craniectomy, but presented significant clinical worsening in the postoperative period even though the cerebellum edema related to surgical manipulation was mild. Due to the clinical worsening, the patient underwent a median suboccipital craniectomy with decompression of the foramenmagnum structures. After this second surgery, the patient had progressive improvement and was discharged from the hospital for ambulatory care.

Asistencia Endoscópica en la Descompresión Microquirúrgica del Hemiespasmo Facial / Endoscopic Assistance in Microsurgical Decompression of Facial Hemiespasm

Introducción: El hemiespasmo facial primario (HFP) se produce por la hiperexcitabilidad del nervio facial y sus núcleos de origen como consecuencia de la compresión vascular. La cirugía de descompresión neurovascular se plantea como alternativa al tratamiento médico refractario. Objetivos: Presentar nuestra experiencia respecto a esta patología. Material y métodos: Se realizó una revisión retrospectiva de pacientes operados por HPF refractarios a tratamiento médico en nuestra institución en los últimos 5 años (periodo 2014-2019). Todos fueron intervenidos vía retrosigmoidea. Se evaluaron datos demográficos, evaluación prequirúrgica y evolución postoperatoria. Resultados: Se operaron 4 pacientes bajo técnica microquirúrgica asistido por endoscopía. Edad promedio 52 años (rango 41-61) con una relación femenino masculino 3:1. El 25% (n=1) presentaba paresia facial grado 2 (HB) en el prequirúrgico. No hubo cambios en cuanto al grado de paresia facial en el postoperatorio en ningún caso. Sólo un paciente registró caída leve en la audiometría postquirúrgica. El 75% (n=3) resolvieron el HFP. Conclusión: Si bien nuestra serie es acotada a un número reducido de pacientes, la cirugía descompresiva microvascular es efectiva como alternativa al tratamiento médico refractario del HFP.

Introduction: Primary hemifacial spasm (PHS) is defined as the hyper excitability of the nerve due to the compression of the facial nerve or its nuclei, most commonly by a vascular structure. The surgical indication for microvascular decompression is resistance to pharmacological treatment or severe adverse effects. Objectives: To present our experience in the surgical treatment of this pathology with this novel technique. Materials and methods: We retrospectively reviewed all patients (n=4) with a diagnosis of PHS, who underwent endoscope-assisted microvascular decompression surgery in our institution during the last 5 years. In all the cases, we choose the retrosigmoid approach. We evaluated demographic data, preoperative evaluation, and post-operative evolution. Results: Endoscope-assisted microvascular decompression was the surgical technique in all the patients. The median age was 52 years, the female-male ratio of 3:1. Only one patient presented a grade 2 facial palsy (House-Brackmann scale) in the preoperative evaluation; there were no significant changes in the post-operative evaluation in any patient. Only one patient experienced worsening in the post-operative audiometric follow-up. The 75% (n=3) of the patients solved the HFP after the surgical treatment. Conclusion: By taking into account our experience in this small case series, we can support the concept that endoscope-assisted microvascular decompression is as effective as the open surgical treatment of the PHS.

Eight years experience with botulinum toxin A and eyelid surgery in the treatment of hemifacial spasm / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To report the therapeutic outcomes of botulinum toxin A(Botox)and eyelid surgery in patients with hemifacial spasm(HFS).<p>METHODS: Patients' images and medical notes were retrospectively reviewed with subsequent analysis of both the therapeutic outcomes and complications of Botox injections. <p>RESULTS: The information of 76 patients(Female=58)with HFS who received a minimum of 4 Botox injections were included. The mean follow-up interval was 83±50(20-112)mo with an average of 16±10(4-34)injections. The peak incidence was between 55 and 64 years and the average age of onset was 66±11(32-85)years. Up to 23% of patients with HFS had aberrant vascular structures(Right=8, Left=7)in close relationship to the facial nerve(MRI=14, CT=1), where the vertebral artery(<i>n</i>=6)was the most involved vessel followed by the anterior inferior cerebellum artery(<i>n</i>=5). Patients with primary HFS had a shorter effective duration(2.5 <i>vs</i> 3.1mo, <i>P</i><0.05), a longer onset time(4.1 <i>vs</i> 3.8d, <i>P</i>=0.739)and a lower Subjective Spasm Alleviation score(SSAs)(1.7 <i>vs</i> 1.9, <i>P</i>=0.179)than those with secondary HFS. Twelve of the 19 patients with pre-existing eyelid diseases underwent surgical correction including upper blepharoplasty(<i>n</i>=12), limited myectomy(<i>n</i>=7), browplasty(<i>n</i>=7)and advancement of levator aponeurosis(<i>n</i>=5). Five(41.7%)of those with surgical correction and suboptimal response to Botox showed improvement 6mo after surgery \〖onset time(<i>P</i>=0.0256), effective duration(<i>P</i>=0.374)and SSAs(<i>P</i>=0.0161)\〗. Those 12 patients with eyelid surgery had a lower complication rate than those without eyelid surgery(23% <i>vs</i> 42%, <i>P</i>≤0.05).<p>CONCLUSION: Botox is an effective and safe treatment for HFS. We found that patients with primary HFS had a less favorable therapeutic outcome with Botox than those with secondary HFS. Eyelid surgery for patients with concurrent eyelid diseases can augment the effect of subsequent Botox injections by improving patient satisfaction and reducing complication rate.

Ocular surface status in patients with hemifacial spasm under long-lasting treatment with botulinum A toxin: A comparative fellow eye study

Purpose: The purpose of this study was to assess the effect of long-lasting botulinum A toxin injections on ocular surface parameters and to further investigate the relationship between these parameters and the duration of the treatment. Methods: In this retrospective study, patients with unilateral hemifacial spasm who were receiving botulinum A toxin injections for at least 1 year were analyzed. Healthy contralateral eyes acted as controls. The ocular surface examination included Ocular Surface Disease Index questionnaire, Schirmer test type I, tear film break-up time (TFBUT), tear osmolarity, corneal sensitivity, and corneal fluorescein staining. Results: Twenty-six patients (6 males and 20 females; mean age 76.4 ± 8.9 years) were included in the study. The mean duration of the treatment was 7.2 ± 5.4 years, and the mean frequency of injections was of one every 3.3 ± 0.4 months. TFBUT, Schirmer test, and corneal sensitivity were significantly lower in the eye homolateral to hemifacial spasm compared with the contralateral one (5.9 ± 3.2 vs 7.5 ± 4.2 s, P = 0.001; 6.2 ± 3.4 vs 9.2 ± 6.6 mm, P = 0.031; 50.8 ± 3.7 mm vs 52.3 ± 2.9 mm, P = 0.048, respectively). One month after the last injection, TFBUT further decreased from 5.9 ± 3.2 to 2.3 ± 1.2 s (P = 0.028). A significant positive correlation was found between the duration of treatment and tear osmolarity (? = 0.542, P = 0.025). Conclusion: Patients with hemifacial spasm under long-lasting treatment with serial botulinum A toxin injections showed a reduction in tear film production and stability, as well as corneal sensitivity in the treated eye compared with the contralateral one. Tear film stability further decreased 1 month after the last injection.

Endoscope-assisted retrosigmoid approach in hemifacial spasm: our experience / Abordagem retrosigmóidea assistida por endoscopia em espasmo hemifacial: nossa experiência

Abstract Introduction: The use of surgical decompression of facial hemispasm due to the loop in the internal auditory canal is not always accepted due to the risk related to the surgical procedure. Currently a new surgical technique allows surgeons to work in safer conditions. Objective: To report the results with endoscope-assisted retrosigmoid approach for facial nerve microvascular decompression in hemifacial spasm due to neurovascular conflict. The surgical technique is described. Methods: We carried out a prospective study in a tertiary referral center observing 12 (5 male, 7 female) patients, mean age 57.5 years (range 49-71) affected by hemifacial spasm, that underwent to an endoscope assisted retrosigmoid approach for microvascular decompression. We evaluated intra-operative findings, postoperative HFS resolution and complication rates. Results: Hemifacial spasm resolution was noticed in 9/12 (75%) cases within 24 h after surgery and in 12/12 (100%) subjects within 45 days. A significant (p < 0.001) correlation between preoperative historical duration of hemifacial spasm and postoperative recovery timing was recorded. Only 1 patient had a complication (meningitis), which resolved after intravenous antibiotics with no sequelae. No cases of cerebrospinal fluid leak, facial palsy or hearing impairment were recorded. Hemifacial spasm recurrence was noticed in the only subject where the neurovascular conflict was due to a vein within the internal auditory canal. Conclusions: The endoscope assisted retrosigmoid approach technique offers an optimal visualization of the neurovascular conflict thorough a minimally invasive approach, thus allowing an accurate decompression of the facial nerve with low complication rates. Due to the less invasive nature, the procedure should be considered in functional surgery of the cerebellar pontine angle as hemifacial spasm treatment, specially when the procedure is performed by an otolaryngologist.

Resumo Introdução: O uso de descompressão cirúrgica do espasmo hemifacial devido ao loop no canal auditivo interno nem sempre é aceito devido ao risco relacionado ao procedimento cirúrgico. Atualmente, uma nova técnica cirúrgica permite trabalhar em condições seguras. Objetivo: Relatar os resultados que obtivemos com a abordagem retrosigmóidea assistida por endoscopia para a descompressão microvascular do nervo facial em casos de espasmo hemifacial devido a conflito neurovascular. A técnica cirúrgica é descrita. Método: Realizamos um estudo prospectivo em um centro de referência terciária observando 12 pacientes (5M, 7F), com média de idade de 57,5 (intervalo 49-71) anos com espasmo hemifacial submetidos a uma abordagem retrosigmóide assistida por endoscopia para descompressão microvascular. Foram avaliados os achados intraoperatórios, a resolução pós-operatória do espasmo hemifacial e as taxas de complicações. Resultados: A resolução do espasmo hemifacial foi observada em 9/12 (75%) dos casos nas 24 horas após a cirurgia e em 12/12 (100%) dos indivíduos até 45 dias. Uma correlação significativa (p < 0,001) entre a duração do histórico pré-operatório de espasmo hemifacial e o tempo de recuperação pós-operatório foi registrado. Apenas um paciente apresentou uma complicação (meningite), que foi resolvida após administração de antibióticos por via intravenosa sem sequelas. Nenhum caso fístula liquórica, paralisia facial ou deficiência auditiva foi registrado. A recorrência do espasmo hemifacial foi observada em único indivíduo em quem o conflito neurovascular foi causado por um vaso no interior do canal auditivo interno. Conclusões: A técnica da abordagem retrosigmóidea assistida por endoscopia oferece uma ótima visualização do conflito neurovascular através de uma abordagem minimamente invasiva, permite assim uma descompressão precisa do nervo facial com baixas taxas de complicações. Por ser menos invasivo, o procedimento deve ser considerado na cirurgia funcional do ângulo pontocerebelar como tratamento de espasmo hemifacial, especialmente quando o procedimento é feito por um otorrinolaringologista.

The value of needle electrode recording facial nerve F wave and its related parameters in hemifacial spasm / 中国神经精神疾病杂志

Objective To optimize the method to elicit the facial nerve F wave and to establish its reference values and its related parameters, in order to provide an electrophysiological basis for facial nerve assessment in patients with hemifacial spasm (HFS). Methods Thirty-six healthy volunteers and 22 patients with HFS underwent this project. Compound muscle action potentials (CAMP, or M waves) and F waves were elicited by stimulating the marginal mandibular branch of the facial nerve and recorded with needle electrodes placed in the mentalis muscle. The association between F parameters and Cohen Grading of the HFS patients were analyzed. Results There were no significant differences in F parameters between men and women or between the two sides in control subjects. Minimal latency of F wave (Fmin) and mean latency of F wave (Fmean) had positive correlations with head circumference (Fmin r=0.449, P=0.013; Fmean r=0.391, P=0.033), but had no correlations with age nor height. Patients with HFS had prolonged duration of F wave (Fdura) in spasm side, compared with normal side (13.1 ms vs. 9.5 ms, P<0.01) and healthy subjects (13.1 ms vs. 9.7 ms, P<0.001), and increased ratio of F-wave amplitude and M-wave amplitude (F/M) in spasm side, compared with normal side (6.9% vs. 3.8%, P<0.001) and healthy subjects (6.9% vs. 3.7%, P<0.001). F/M exhibited a positive correlation with Cohen Grading (r=0.538, P=0.001). Conclusion A clear facial nerve F wave can be achieved by stimulating the marginal mandibular branch of the facial nerve, which provides an objective basis for evaluation of the facial nerve function in HFS patients with increased F/M and prolonged Fdura.

Intraoperative Neurophysiological Monitoring during Microvascular Decompression Surgery for Hemifacial Spasm

Hemifacial spasm (HFS) is due to the vascular compression of the facial nerve at its root exit zone (REZ). Microvascular decompression (MVD) of the facial nerve near the REZ is an effective treatment for HFS. In MVD for HFS, intraoperative neurophysiological monitoring (INM) has two purposes. The first purpose is to prevent injury to neural structures such as the vestibulocochlear nerve and facial nerve during MVD surgery, which is possible through INM of brainstem auditory evoked potential and facial nerve electromyography (EMG). The second purpose is the unique feature of MVD for HFS, which is to assess and optimize the effectiveness of the vascular decompression. The purpose is achieved mainly through monitoring of abnormal facial nerve EMG that is called as lateral spread response (LSR) and is also partially possible through Z-L response, facial F-wave, and facial motor evoked potentials. Based on the information regarding INM mentioned above, MVD for HFS can be considered as a more safe and effective treatment.

Intraoperative Neurophysiological Monitoring during Microvascular Decompression Surgery for Hemifacial Spasm

Hemifacial spasm (HFS) is due to the vascular compression of the facial nerve at its root exit zone (REZ). Microvascular decompression (MVD) of the facial nerve near the REZ is an effective treatment for HFS. In MVD for HFS, intraoperative neurophysiological monitoring (INM) has two purposes. The first purpose is to prevent injury to neural structures such as the vestibulocochlear nerve and facial nerve during MVD surgery, which is possible through INM of brainstem auditory evoked potential and facial nerve electromyography (EMG). The second purpose is the unique feature of MVD for HFS, which is to assess and optimize the effectiveness of the vascular decompression. The purpose is achieved mainly through monitoring of abnormal facial nerve EMG that is called as lateral spread response (LSR) and is also partially possible through Z-L response, facial F-wave, and facial motor evoked potentials. Based on the information regarding INM mentioned above, MVD for HFS can be considered as a more safe and effective treatment.

Blepharospasm with elevated anti-acetylcholine receptor antibody titer / Blefaroespasmo com título elevado de anticorpos antirreceptores de acetilcolina

ABSTRACT Objective: To determine whether serum levels of anti-acetylcholine receptor antibody (anti-AChR-Abs) are related to clinical parameters of blepharospasm (BSP). Methods: Eighty-three adults with BSP, 60 outpatients with hemifacial spasm (HFS) and 58 controls were recruited. Personal history, demographic factors, response to botulinum toxin type A (BoNT-A) and other neurological conditions were recorded. Anti-AChR-Abs levels were quantified using an enzyme-linked immunosorbent assay. Results: The anti-AChR Abs levels were 0.237 ± 0.022 optical density units in the BSP group, which was significantly different from the HFS group (0.160 ± 0.064) and control group (0.126 ± 0.038). The anti-AChR Abs level was correlated with age and the duration of response to the BoNT-A injection. Conclusion: Patients with BSP had an elevated anti-AChR Abs titer, which suggests that dysimmunity plays a role in the onset of BSP. An increased anti-AChR Abs titer may be a predictor for poor response to BoNT-A in BSP.

RESUMO Objetivo: Determinar se os níveis séricos do anticorpo antirreceptor de acetilcolina (anti-AChR-Abs) estão relacionados aos parâmetros clínicos do blefaroespasmo (BSP). Métodos: Fora recrutados 83 adultos com BSP, 60 pacientes ambulatoriais com espasmo hemifacial (HFS) e 58 controles. Foi aplicado um questionário para registrar história pessoal, fatores demográficos, resposta à toxina botulínica tipo A (BoNT-A) e outras condições neurológicas. Os níveis de anti-AChR-Abs foram quantificados usando um ensaio imunoenzimático. Resultados: O nível de anti-AChR-Abs foi de 0,237 ± 0,022 unidades de densidade óptica (OD) no grupo BSP, significativamente diferente em comparação com o grupo HFS (0,160 ± 0,064) e o grupo controle (0,126 ± 0,038). O nível de anti-AChR-Abs se correlacionou com a idade e a duração da resposta à injeção de BoNT-A. Conclusão: Pacientes com BSP apresentaram títulos elevados de anti-AChR-Abs, o que sugere que a desimunidade desempenha um papel no surgimento de BSP. O aumento do título de anti-AChR-Abs pode ser um preditor de resposta insuficiente à BoNT-A em BSP.

Édouard Brissaud: distinguished neurologist and Charcot's pupil / Édouard Brissaud: distinto neurologista e pupilo de Charcot

ABSTRACT Professor Charcot had several pupils in his famous neurological service at the Salpêtrière Hospital in Paris, France. Among them, Édouard Brissaud was one of Charcot's favorite pupils, temporarily becoming his successor after Charcot's death. Brissaud's neurological contributions were significant, including the description of hemifacial spasm, "geste antagoniste" in dystonia, pseudobulbar affect, post-traumatic stress disorder, the Brissaud-Sicard syndrome, and Brissaud's sign. Additionally, Brissaud was the first to suggest that Parkinson's disease pathology could be related to the substantia nigra.

RESUMO Professor Charcot teve vários discípulos em seu famoso serviço de neurologia no hospital Salpêtrière, em Paris, França. Dentre eles, Édouard Brissaud foi um dos pupilos favoritos de Charcot. Após a morte de Charcot, em 1893, Brissaud foi o seu sucessor temporário. Suas contribuições neurológicas foram muito expressivas, incluindo a descrição do espasmo hemifacial, do "geste antagoniste", da paralisia pseudobulbar, do transtorno de estresse pós-traumático, a síndrome de Brissaud-Sicard, e também do sinal de Brissaud. Além disso, Brissaud, sugeriu pela primeira vez no mundo, que a patologia da doença de Parkinson poderia estar relacionada à substância negra.