Staged Bilateral Microvascular Decompression for Bilateral Hemifacial Spasm

Bilateral hemifacial spasm (BHFS) is rare and typically arises from neurovascular compression of the facial nerve. Optimal treatment strategies, including the timing and laterality of microvascular decompression (MVD), remain uncertain. We report a case of a 43-year-old man with a 10-year history of left hemifacial spasm, and right-sided symptoms beginning 1 year prior to initial evaluation. Magnetic resonance imaging demonstrated bilateral neurovascular compression at the root exit zone. The patient underwent staged bilateral MVD-left MVD first, followed by right MVD after 6 months-resulting in complete resolution of symptoms without surgical complications. We also reviewed 15 previously published reports encompassing 51 BHFS cases to investigate clinical characteristics, imaging findings, and treatment outcomes. Among 23 patients who underwent MVD in these reports, 15 had unilateral and 8 had bilateral procedures; however, systematic documentation of contralateral symptom outcomes following unilateral MVD was available in only a few reports, limiting evidence-based comparisons between unilateral and bilateral surgical strategies. The present case, combined with the literature review, suggests that a staged approach-initial MVD on the more severely affected side followed by an observation period, with contralateral MVD reserved for persistent symptoms-can be a safe and effective strategy for BHFS. Careful imaging assessment, prioritization of the predominant symptoms, and individualized management are crucial for patients with BHFS.