The conflicting vessels in hemifacial spasm: Literature review and anatomical-surgical implications

Since several decades, it has been established that so-called primary hemifacial spasm is linked to neuro-vascular conflicts in the facial nerve, especially its root exit zone (REZ). Based on our review of the detailed publications of literature (2489 patients), together with our own series (340 patients), the responsible vessels found at surgery were: the posterior inferior cerebellar artery in 47.2%, the anterior inferior cerebellar artery in 45.9%, the vertebro-basilar artery in 17.5%, another (smaller) artery in 11.7%. Participation of veins was very diversely estimated according to series: 4.9% on average. Multiple neuro-vascular conflicts in a same individual were frequently observed, in the order of 20 to 30% according to authors, 37% in our series. Also, abnormal conformation of the posterior fossa may play a role, such as flatness of the posterior fossa or exiguity of the cerebello-pontine angle cistern. Whatever, most neurovascular conflicts are located at brainstem and/or ventrocaudally to the facial REZ, in the order of 95% of the patients. The anatomical location and conformation of the compressive vessel(s) are crucial in determining the difficulties to identify the responsible conflict(s) and to perform effective and safe decompression. Main difficulties are encountered in cases with arteriosclerotic megadolicho-vertebrobasilar artery, at brainstem, especially when PICA and/or AICA come in association, or for neurovascular conflict(s) located at the cisternal or the intrameatal portions of the facial root. Later ones can be alone or in addition to NVC at brainstem/REZ.