ABSTRACT
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.
ABSTRACT
Introducción: La Academia Americana de Neurología propone que, para que un paciente sea candidato a descompresiva neurovascular trigeminal (DNV), se debe demostrar la presencia de contacto neurovascular a través de la resonancia magnética (RM). Sin embargo, recientes estudios han demostrado que la sensibilidad de la RM para diagnosticar un conflicto neurovascular (CNV) es muy variable. Estos conceptos antagónicos ubican al neurocirujano ante un verdadero dilema a la hora de tomar decisiones. El objetivo del presente estudio es evaluar la utilidad de la clínica y la RM como factor predictor de un verdadero CNV. Materiales y Métodos: Estudio analítico retrospectivo que incluye a 81 pacientes a los que se les realizó una DNV por neuralgia trigeminal (NT), desde enero de 2013 hasta abril de 2019, en la provincia de Tucumán. Resultados: Al considerar la serie completa: A) Un total de 65 pacientes cursaron con NT Típicas; de estos, 64 (98,5%) presentaron CNV durante la cirugía y B) De las 16 Atípicas, ninguna presentó CNV en el intraoperatorio. Al considerar los pacientes con NT primaria: A) un 98% de los pacientes con clínica de NT típica presentaran CNV en el intraoperatorio y B) hubo un grupo de pacientes donde se evidencio un CNV en el intraoperatorio pero en su RM preoperatoria no se objetivo el mismo (n=15), el valor predictivo negativo de la RM fue sólo un 6%. Conclusión: La clínica del paciente es más efectiva que la RM para decidir si realizar o no una cirugía de DNV.
Introduction: The American Academy of Neurology proposes that, for a patient to be a candidate for trigeminal neurovascular decompression (NVD), the presence of neurovascular contact must be demonstrated through magnetic resonance imaging (MRI). However, recent studies have shown that the sensitivity of MRI to diagnose a neurovascular conflict (NVC) is highly variable. These antagonistic concepts put, the neurosurgeon, in a real dilemma when making decisions about this entity. The aim of this study is to evaluate the usefulness of clinical and MRI as a predictor of a real NVC. Methods: This is a retrospective analytical study including 81 patients undergoing NVD to treat trigeminal neuralgia (TN), from January 2013 to April 2019, in Tucumán. Results: When considering the complete series: A) Of the total of 65 patients who had typical TN, 64 (98.5%) presented NVC during surgery and B) Of the 16 atypical TN, none of then presented NVC during the surgery. When considering patients with primary TN: A) 98% of the patients with typical NT presented a NVC during surgery and B) there was a group of patients where NVC was evidenced during surgery but it wasn`t noticed during the preoperative MRI (n=15), the negative predictive value of the MRI was only 6%. Conclusion: The patient's clinic is more effective than the MRI deciging whether or not to perform NVD surgery.
Subject(s)
Humans , Trigeminal Neuralgia , Therapeutics , NeuralgiaABSTRACT
INTRODUCTION: Neurovascular conflict is the most accepted hypothesis for the cause for trigeminal neuralgia. Microvascular decompression of the trigeminal nerve is the most common surgical treatment for these patients. However, despite advances in diagnostic techniques, neurovascular conflict is sometimes not detected during surgery. The aim of this paper is to systematically review all the options available to best manage this scenario. RESULTS: Several techniques that could be used during microvascular decompression for trigeminal neuralgia in the absence of neurovascular conflict have been described. The success rates of these techniques, pain recurrence rates and rates of complications are also reported. Finally, we provide suggestions based on our experience. CONCLUSIONS: There is no gold standard, but several techniques could be successfully used in the absence of neurovascular conflict. The use of destructive techniques, such as PSR, should be held as treatments of last resort.
