Macrovascular Decompression for Hemifacial Spasm: Three-Dimensional Operative Video.

In 1%-2% of patients with symptomatic vascular compression of a cranial nerve, the compression may be due to a tortuous dolichoectatic vertebrobasilar artery. The most common technique used for microvascular decompression relies on the placement of a polytetrafluoroethylene (Teflon) pledget or other buffer between the root of the nerve and the offending vessel loop, thereby decompressing the cranial nerve. In cases of macrovascular compression by a large tortuous artery, these buffering techniques fail to produce lasting results with risk for cranial nerve compression-related deficit, specifically the facial nerve. In the Video 1, we demonstrate the use of a GORE-TEX (W.L. Gore & Associates Inc., Flagstaff, Arizona, USA) sling to transpose a dolichoectatic vertebral artery away from the facial nerve root entry. The patient consented to the procedure and to the publication of this video and their images. The technique demonstrated has been shown by other authors as well. Using GORE-TEX, we created a sling by cutting a slit into the GORE-TEX and looping it around the artery and then back through itself. We then used multiple aneurysm clips to attach the sling to a dural cuff made from the dura covering the petrous bone. While this technique completely resolved the compression from the vertebrobasilar artery, there was still a remaining vein contacting the nerve anterior to the artery. A Teflon pledget was placed between the vein and the root entry zone, as it was a pontine vein and we planned to preserve it. The patient recovered well without complication and was completely free from hemifacial spasm at >2 years long-term follow-up.