Vertebral artery dolichoectasia leading to hemifacial spasm

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 , Alexander Rabinovich 5   Affiliations: 1    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 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].

Figure 1 :
Figure 1: Patient had tonic-clonic contractions of the left orbicularis oculi and oris muscles.

Figure 2 (
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.
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.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 published George 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 published Richard 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 published Jose 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 published Munir 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 published Kamal 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 published Alexander 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 Lincoln Medical and Mental Health Center, Department of Radiology, Weill Cornell Medical Center, Bronx, New York, United States; 2 American University of Beirut Medical Center, Department of Dermatology, Beirut, Lebanon; 3 Lincoln Medical and Mental Health Center, Department 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 Sinai Hospital, Bronx, New York, United States.