Classic Vascular Compression in Hemifacial Spasm

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Let's review nuance of technique for microvascular decompression surgery using another video of mine. This is a 56-year-old male who presented with severe right-sided hemifacial spasms. His pre-operative MRI demonstrated a vascular loop at the area of the facial nerve, at the root exit zone of the nerve, and along the axilla of the nerve, as you can see on this axial image. He subsequently underwent a right-sided retromastoid craniotomy using the standard curvilinear incision in the latter position. Following reflection of the scalp flap, he underwent an expanded burr hole, in order to expose the sigmoid sinus. You can see the transverse sinus is not exposed here. The bone is often thinned out and following exposure of the sinus the dura is opened in a curvilinear fashion. One of the important landmarks to remember here again is where the petrous bone turns to become the floor of the posterior fossa. This is where the location to start the microdissection along the lower cranial nerves. Here's gentle elevation of the cerebellum superomedially to expose the lower cranial nerves first. Here is a more demagnified view. The arachnoid membranes are sharply opened. Additional CSF is released. A meningeal branch is evident, again, clearly going to the meninges that can be sacrificed, if necessary. Here is the exposure of the root exit zone of the facial nerve. You can see the impressive amount of discoloration caused by this large vascular loop. This is the choroid plexus. A piece of shredded Teflon was used to mobilize the artery away from the brainstem, as well as the facial nerve. You can see probably soaked Gelfoam placed over the seventh and eighth cranial nerve to avoid any spasm of their vessels due to the intense light of the microscope. And here's a demagnified view of our operative corridor. The rubber dam that I often use to go around the cerebellum. The rubber dam protects the surface of the cerebellum and often leads to no injury on the cerebellar hemisphere, as you can see here. And you can see the magnified view of our operative corridor along the lower cranial nerves to reach the root exit zone of the facial nerve.

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