Large Vertebral Artery and MVD for Hemifacial Spasm

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Occasionally a very large vertebral artery can be the offending vessel and be found during MVD for hemifacial spasm. Let's see what are the options to handle this finding during surgery. This is an elderly patient who presented with a longstanding history of right-sided hemifacial spasm and on MRI was found to have this torturous large artery compressing the axilla, the facial nerve, leading to a hemifacial spasm. We attempted a retromastoid craniotomy on the right side. To orient all of us, you can see the large vessel. You can see the eighth cranial nerve. You can see the seventh cranial nerve that has been pushed superiorly due to this dilotatic vessel. I did not believe there was enough space to use the sling technique and mobilize this artery by putting a suture around it. I feel that such sling procedure can be quite risky, and therefore we placed shredded Teflon between the artery and the nerve as much as possible. And by just putting these small pieces of Teflon and gently moving this artery, we were able to accomplish quite a bit. Again, the described techniques of placing a aneurysm clip and suturing the aneurysm clip to the petrous dura or placing another suture around the artery and mobilizing it laterally, I believe these techniques could be potentially risky due to possible risk of thrombosis and emboli forming within the vessel and going distally, causing ischemia. Therefore, small pieces of Teflon and patience most likely can relieve some of the spasms in this patient, and this was really the final product, as you can see the Teflon move the artery for a good amount away from the nerve, and this patient had significant improvement long term in his spasms. Thank you.

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