ORIGINAL CLINICAL STUDY
Prevalence and Associated Factors of Neurovascular Contact
in Patients With Hemifacial Spasm
Supharat Jariyakosol, MD,* Parima Hirunwiwatkul, MD,* Sukalaya Lerdlum, MD,
and Chompunoot Phumratprapin, MD*
Purpose: This study aimed to observe the prevalence and associated
factors of neurovascular contact hemifacial spasm (HFS).
Design: This was a cross-sectional analytical study.
Methods: Medical records of patients with HFS in a neuro-ophthalmology
clinic in Thailand between June 2008 and June 2012 were reviewed. A
positive magnetic resonance imaging nding was dened as an adjacent
variant vessel that directly compressed or placed pressure on the affected
facial nerve. Prevalence and associated factors were analyzed.
Results: A total of 60 participants were enrolled, composed of 12 male
patients and 48 female patients with a median age of 54 years [inter-
quartile range (IQR), 44.0Y64.75] and a disease duration ranging from
4 months to 16 years (median, 2 years; IQR, 1.0Y6.0). The prevalence of
neurovascular contact HFS was 41.7%. Neurovascular contact HFS was
more prevalent among women, with an overall ratio of 3.33. In age group
analysis, the prevalence was higher among older patients. In univariate
analysis, right-sided symptoms and diabetes mellitus were statistically sig-
nicant in their association with neurovascular contact HFS (P = 0.040
and P = 0.029, respectively). Right-sided symptoms were signicant in
a multiple logistic regression analysis (P = 0.038), with an odds ratio
of 3.30 [95% condence interval (CI), 1.07Y10.15]. Diabetes mellitus
was not statistically signicant (P = 0.051), with an odds ratio of 9.99 (95%
CI 0.99Y96.34).
Conclusions: The prevalence of neurovascular contact in patients with
HFS was 41.7%. Right-sided symptoms were signicantly associated
with this condition.
Key Words: hemifacial spasm, neurovascular contact, 3-dimensional
fast imaging employing steady-state acquisition (FIESTA), associated
factors, prevalence
(Asia Pac J Ophthalmol 2015;4: 212Y215)
H emifacial spasm (HFS) is characterized by involuntary clonic
or tonic contraction of muscles innervated by the ipsilateral
facial nerve.1,2 Generally, HFS initially involves the orbicularis
oculi and gradually spreads to other parts of the face and even-
tually to the platysma.2
The etiology of HFS remains controversial. It is widely
accepted in several studies that most cases come from the
compression of the seventh cranial nerve at the root exit zone
(REZ) by adjacent structures such as the atherosclerotic, aber-
rant, or ectatic intracranial vascular system. Common vascu-
lar causes are the anterior inferior cerebellar artery, the posterior
inferior cerebellar artery, and the vertebral artery.1Y3 Ho et al4
From the Departments of *Ophthalmology, and Radiology, Faculty of
Medicine, Chulalongkorn University, Bangkok, Thailand.
Received for publication May 5, 2014; accepted August 6, 2014.
The authors have no funding or conicts of interest to declare.
Reprints: Supharat Jariyakosol, MD, Department of Ophthalmology, Faculty
of Medicine, Chulalongkorn University, Rama IV Road, Pathumwan,
Bangkok 10330, Thailand. E-mail: jsupharat@gmail.com.
Copyright * 2015 by Asia Pacic Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.1097/APO.0000000000000088
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Copyright 2015 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
explained that the REZ might be more susceptible to external
compression because the myelin of individual nerve bers is
thinner at this transitional zone than beyond the REZ. Other
sources of compression include arteriovenous malformation, an-
eurysm, different types of brain tumors, and bony abnormalities
of the skull, which are localized in the ipsilateral or contralate-
ral cerebellopontine angle, distorting the normal anatomy of the
ipsilateral facial nerve.1Y3 Many studies found the incidence of
tumor-induced HFS to be 0.3% to 2.5% of all patients with
HFS.5Y7 Peripheral facial nerve injury or previous Bell palsy can
also result in HFS.2
At present, neuroimaging for detecting neurovascular
contact in patients with HFS has already been developed. New
techniques which offer high resolution and quality include
3-dimensional (3D) fast imaging employing steady-state acqui-
sition (FIESTA), constructive interference in steady state (CISS),
and T1-weighted high-resolution isotropic volume examination.
Tarnaris et al8 compared the accuracy and sensitivity in magnetic
resonance angiography (MRA) and in CISS sequence magnetic
resonance imaging (MRI) and found that the CISS sequence in
an MRI is more sensitive in identifying neurovascular compression
than MRA.
Defazio et al9 suggested that HFS may be associated with
hypertension and age, but many other studies have not found a
relationship between these conditions. To our knowledge, the
relationship between neurovascular HFS and associated factors
was not studied.
In our study, we wanted to nd the prevalence and asso-
ciated factors of neurovascular contact in patients with HFS in
the neuro-ophthalmology clinic at King Chulalongkorn Memorial
Hospital.
MATERIALS AND METHODS
After the research was approved by the ethics committee
of King Chulalongkorn Memorial Hospital, the medical records
of patients with HFS in the neuro-ophthalmology clinic at
King Chulalongkorn Memorial Hospital from June 2008 to June
2012 were reviewed. Age, sex, laterality, family history, under-
lying diseases, duration of symptoms, hearing problems, neuro-
logical examinations, and MRI ndings were collected. Exclusion
criteria included patients who did not have complete medical
records and those with conditions where an MRI brain scan could
not be performed. All patients underwent MRI using Achieva 3
Tesla (Philips) or Signa Excite HD 1.5 Tesla (General Electric).
Magnetic resonance imaging techniques at minimum included
nonenhanced images, contrast-enhanced fat-suppressed T1-
weighted images, high-resolution fat-suppressed T2-weighted
images in axial and coronal planes, a section thickness of 3 mm,
and special pulse sequences for cranial nerves at the skull base
using axial 3D Driven Equilibrium (DRIVE) (Philips) or axial 3D
FIESTA (General Electric).
Magnetic resonance imaging brain ndings were reviewed
by the radiologist (S.L.) with a blind technique at least 2 times.
Positive ndings were dened as an adjacent variant vessel
& Volume 4, Number 4, July/August 2015
Asia-Pacic Journal of Ophthalmology & Volume 4, Number 4, July/August 2015 Neurovascular Contact in Patients With HFS

that directly compressed or placed pressure on the affected

facial nerve. TABLE 2. Magnetic Resonance Imaging Findings of
Neurovascular Contact in Patients With HFS
Statistical Analysis
MRI Findings No. Patients (%)
Prevalence was analyzed by proportion. Associated factors
were analyzed by W2 test, Mann-Whitney U test, Fisher exact test, Positive 25 (41.7)
and multiple logistic regression. Statistics were calculated using Negative 35 (58.3)
Statistical Package for the Social Sciences version 20.

RESULTS Table 4 shows that right-sided symptoms were signicantly

A total of 60 participants were enrolled in this study, com- associated with neurovascular contact HFS in the multiple logis-
posed of 12 male patients and 48 female patients. The median age tic regression analysis, with an odds ratio (OR) of 3.30 [95% con-
was 54.0 years [interquartile range (IQR), 44.0Y64.75] and the dence interval (CI), 1.07Y10.15]. Diabetes mellitus was not a
median disease duration was 2.0 years (IQR, 1.0Y6.0). Table 1 statistically signicant associated factor, with an OR of 9.99
shows the demographic and clinical features of the patients. The (95% CI, 0.99Y96.34). No variables were found signicantly as-
common underlying diseases were hypertension (38.3%), dyslip- sociated in age subgroup analysis.
idemia (23.3%), and diabetes mellitus (10%). Hearing problems
were a common comorbidity, which were found in 26.7% of the
participants. No patients had a family history of HFS. DISCUSSION
Table 2 shows that the prevalence of neurovascular con- The prevalence of neurovascular contact in patients with
tact in patients with HFS was 41.7%. Negative MRI ndings HFS was found to be 41.7%, which was higher than in most
were 58.3%. previous studies. This is a result of new developments in imaging
Prevalence categorized by age group is shown in Figure 1. technology, which can cut thinner slices to identify smaller
The prevalence of neurovascular contact in patients with HFS structures such as the focal compression area. Another reason for
increased with age and was highest in the age group of 60 years the higher prevalence could be the fact that our hospital is a ter-
and older. tiary care hospital, so a large number of patients are referred from
Table 3 shows the univariate analysis and distribution of many different hospitals because of failures in symptomatic
the variables. The association between right-sided symptoms and treatment, including medication or Botox injections.
underlying diabetes with neurovascular contact cause was statis- Although advanced MRA techniques (such as a 3D mag-
tically signicant (P = 0.040 and P = 0.029, respectively). netic resonance tomographic angiogram) are highly sensitive
for neurovascular contact,10 for patients with typical HFS, this
option may not be cost effective. That said, in some cases, it
TABLE 1. Demographic and Baseline Characteristics of the may be useful as a preoperative investigation before microvas-
Patients cular decompression surgery. In our hospital, in most cases, the
advanced thin-slice cut MRI technique was selected, in accor-
No. Patients (%) dance with the radiologists preference, including 3D FIESTA
1. Total no. patients 60 (100) and 3D T1-weighted high-resolution isotropic volume exami-
2. Sex nation to explore the specic REZ area. These techniques are
sufcient and comparable in image quality for showing the
Male 12 (20)
outline of the cranial nerves, adjacent organs, and the focal com-
Female 48 (80) pression that causes HFS. In those cases where an operation such
3. Age, median (IQR), y 54.0 (44Y64.75)
4. Duration, median (IQR), y 2.0 (1.0Y6.0)
5. Family history 0 (0)
6. Side of HFS
Right 31 (51.7)
Left 29 (48.3)
7. Unilaterality of HFS 60 (100)
8. Underlying disease
Hypertension 23 (38.3)
Diabetes mellitus 6 (10)
Dyslipidemia 14 (23.3)
Cardiovascular disease 4 (6.7)
Cerebrovascular disease 4 (6.7)
Parkinson disease 1 (1.7)
Multiple sclerosis 0 (0)
Bell palsy 1 (1.7)
9. Previous head trauma 1 (1.7)
10. Hearing problem 16 (26.7) FIGURE 1. Prevalence of neurovascular contact (NVC) in
11. Physical examination patients with HFS by age group. The prevalence of neurovascular
Facial weakness 1 (1.7) contact in patients with HFS was 41.7%. The prevalence of
HFS increased with age and was highest in patients older
Abnormal neurological examination 5 (8.3)
than age 60.

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TABLE 3. Results of Univariate Regression and Distribution of the Variables

Variable MRI Positive (n = 25) MRI Negative (n = 35) P OR 95% CI

1. Sex, male, % 24.0 17.1 0.513 1.53 0.43Y5.44
2. Age, median (IQR), y 56.8 (45.0Y65.2) 52.2 (44.2Y63.8) 0.155 1.03 0.99Y1.08
3. Duration, median (IQR), y 2 (0.9Y6.0) 2 (1.5Y6.0) 0.868 1.00 0.88Y1.13
4. Family history, yes 0 0 V V V
5. Side, right, % 36.0 62.9 0.040 3.01 1.04Y8.74
6. Laterality, unilateral, % 100 100 V V V
7. Hypertension, % 44 34.3 0.445 1.51 0.53Y4.32
8. Diabetes, % 20 2.9 0.029 8.50 0.93Y78.02
9. Dyslipidemia, % 28 20 0.470 1.56 0.47Y5.18
10. Cardiovascular disease, % 4 8.6 0.634 0.44 0.04Y4.54
11. Cerebrovascular disease, % 4 8.6 0.634 0.44 0.04Y4.54
12. Parkinson disease, % 4 0 0.417 2.36 V
13. Multiple sclerosis, % 0 0 V V V
14. Bell palsy, % 0 2.9 1.000 V V
15. Head trauma, % 4 0 0.420 2.36 V
16. Hearing problem, % 24.0 28.6 0.773 0.79 0.24Y2.56
17. Facial weakness, % 0 2.9 1.000 V V
18. Abnormal neurological examination, % 8.0 8.6 1.000 0.93 0.14Y6.00

as microvascular decompression is necessary, an MRA may be
considered for further investigation.
This study found a relationship between right-sided symp-
toms and neurovascular contact in HFS. To our knowledge, no
anatomical relationship was explainable. Further study is neces-
sary to explore this relationship.
In reviewing previous studies, diabetes mellitus was
not found to be a strongly associated factor. Diabetes mellitus
was detected as a non-statistically signicant associated factor
in this study (P = 0.051), but the result showed a high OR (OR,
9.99; 95% CI, 0.99Y96.34). A limitation of this study was the
relatively small sample size, which may not have sufcient
power to detect signicant association, and this was reected in
the very wide CI. The pathophysiology of vascular disease
common in diabetes involves abnormalities in endothelial cells,
vascular smooth muscle cells, and platelet function. These ab-
normalities contribute to the cellular events that cause athero-
sclerosis.11 We hypothesized that atherosclerotic change may
lead to tortuosity of vessels and cause the pulsatile compression
of the facial nerve at the REZ. Further studies with a larger
patient sample are required to determine the association be-
tween diabetes mellitus and neurovascular contact in patients
with HFS.
Defazio et al9 found that hypertension was signicantly
associated with the outcome in the left-sided group (P = 0.008;
OR, 4.0; 95% CI, 1.4Y11.5). In our study, hypertension was
not a statistically signicant associated factor (P = 0.445; OR,
1.51), but we found that this condition was the most common
underlying disease among participants.
TABLE 4. Results of Multiple Logistic Regression Analysis of
the Variables
Covariate OR 95% CI P
Diabetes mellitus 9.79 0.99Y96.34 0.051
Right side 3.30 1.07Y10.15 0.038
The vertebrobasilar artery was the most common area of
vascular compression in our study. Frazier et al12 explained
that arteriosclerotic changes were prone to develop in the verte-
brobasilar artery in patients with accompanied hypertension, di-
abetes mellitus, hyperlipidemia, and obesity.
The limitations of this study were the small sample size
and the fact that the MRI strength was not dened because of
the retrospective review of data. However, most MRI tech-
niques used were advanced and ensured highly sensitive de-
tection of neurovascular compression. Leal et al13 found that
3 T MRI demonstrated a statistically signicant improvement
compared with the same protocol using 1.5 T in visualization of
veins in neurovascular compression of the trigeminal nerve and
in determination of the exact compression site. However, there
was no statistically signicant improvement in detecting arterial
neurovascular compression and determining the severity of com-
pression. Further studies are warranted to compare the diagnostic
accuracy between 3 and 1.5 T in detecting neurovascular contact
in patients with HFS.
In conclusion, the prevalence of neurovascular contact at
the REZ in patients with HFS was 41.7%. The prevalence was
higher in the older age group. Right-sided symptoms were sig-
nicantly associated with this condition. This knowledge may
aid in the decision-making process for imaging investigation of
patients with HFS.
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V Confucius

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