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Case Presentation

Intern 吳廷浩指導醫師: 梁啟源/林剛旭 醫師

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General Data

病歷NO. Q121056104 姓名 :林X川 43y/o 床號 : 1121-1 入院日期 : 0940717

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Right hand numbness in this morning

This 43 y/o male patient has no other

systemic disease. He smoke 1 PPD for

20 years but quit for 4 months. Since

yesterday, he felt dizziness. Last noon,

and right hand numbness developed

suddenly and recovered soon. Last night,

it happened again.

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This morning, Right hand numbness developed

again. Right face tremor and then numbness,

deviated to right with dysarthria, dysphasia and

drooling developed transiently. At LMD,

hypertension was noted and anti-HTN drug was

taken. At our ER, brain CT showed no ICH or

mass lesion. Under the impression of stroke, he

was admitted.

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Social Hx, Past Hx

Alcohol drinking: sometimesBetel nut chewing: 10#/QD for 7 years Cigarette smoking(+): Quit now

Hypertension: NILDiabetes mellitus: NILOperative history: left foot fracture s/p splint reduction Allergy: No known allergy

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Physical ExaminationGeneral appearance:Vital sign: BT: 36.6C PR: 60/min RR: 16/min BP: 132/97mmHgNeurological examination:Consciosness clear, GCS E4V5M6Speech:slurredCranial nerve:Eye:pupil isocoric,EOM full,no nystagmus,no ptosis,VF normalNo face numbness, open and close mouth normalFacial nerve: no central palsyTongue protruding no deviationNeck: supple no Kernig sign, no Brudzinski signMuscle status no atrophyMuscle tone no rigidity, no spasticity, no tremorMuscle power 5/5DTR ++/++Babinski sign -/-Sensory modalities: Numbness over right upper limbsPainful sensation over left hip

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LaboratoryLaboratory : 07/18 07:39 Blood TG 237 mg/dl

07/18 07:39 Blood TCH 220 mg/dl07/18 07:39 Blood U A 6.0 mg/dl 07/18 07:39 Blood HDL-C 46 mg/dl 07/18 07:39 Blood GLU-AC 87 mg/dl 07/17 10:30 Blood BUN 14 mg/dl 07/17 10:30 Blood CRE 1.0 mg/dl 07/17 10:30 Blood GOT/AST 19 IU/L 07/17 10:30 Blood GLU 123 mg/dl 07/17 10:30 Blood K 3.50 mmol/L 07/17 10:30 Blood Na 139.3 mmol/L 07/17 10:30 Blood APTT 28.0 sec 07/17 10:30 Blood Control 28.5 sec

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07/17 10:30 Blood WBC 8.16 *10^3/ul 07/17 10:30 Blood RBC 5.26 *10^6/ul 07/17 10:30 Blood Hb 16.7 g/dl 07/17 10:30 Blood Ht 48.9 % 07/17 10:30 Blood MCV 93.0 fl 07/17 10:30 Blood MCH 31.7 pg 07/17 10:30 Blood MCHC 34.2 % 07/17 10:30 Blood PL 216 *10^3/ul 07/17 10:30 Blood RDW-CV 12.6 % 07/17 10:30 Blood MPV 10.1 fl 07/17 10:30 Blood PT 9.7 sec 07/17 10:30 Blood Control 10.0 sec 07/17 10:30 Blood INR 0.97 07/17 10:30 Blood N.seg. 60.1 % 07/17 10:30 Blood Lym. 33.2 % 07/17 10:30 Blood Mono. 4.5 % 07/17 10:30 Blood Eosin. 1.7 % 07/17 10:30 Blood Baso. 0.5 %

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The MRA study of the brain shows normal contour of the vessels without significant stenosis and without vascular malformation.

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Clinical Course

The patient was admitted due to right face tremor and then numbness, deviated to right with dysarthria, dysphagia and drooling developed transiently. The tentative diagnosis was CVA or focal seizure. Brain CT didn`t show significant finding. However, his right hemifacial spasm continued without improvement and didn`tresponse to dilatin.

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Brain MRI with contrast was arranged and showed no lesion over brain or right facial nerve which was compatible with ENT`s opinion. Tegretol and neurontin was prescribed and his symptoms dramatically relieved. No other newly symptoms was complained except slurred Speech (improved). Now, the patient was under stable condition and would follow up at OPD.

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Chapter 355. Trigeminal Neuralgia, Bell's Palsy, and Other Cranial Nerve Disorders…Harrison’s IM 16E

….. be due to an irritative lesion of the facial nerve (e.g., an acoustic neuroma, an aberrant artery that compresses the nerve, or a basilar artery aneurysm). However, in the most common form of hemifacial spasm, the cause and pathology are unknown …

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Hemifacial spasm can be treated successfully with carbamazepine or, if this drug fails, with baclofen. Refractory cases due to vascular compression usually respond to surgical decompression of the facial nerve …

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Problem

Is any other choice for hemifacial spasm?Botulinum!

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Structure of PICO

Patient/Problem: Hemifacial spasmIntervention: botulinumComparison, if any: placeboOutcome: Benefit/Long term follow

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Process of Searching Evidence

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Treatment of hemifacial spasm with botulinum toxin

Department of Neurology, University of California, San Francisco.

The effectiveness of botulinum toxin injections in 11 patients with hemifacial spasm was investigated in a prospective placebo-controlled blinded study.

Muscle Nerve. 1992 Sep;15(9):1045-9

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The patients were treated with four sets of injections to various facial muscles, selected by clinical evaluation. Three injections were with graded doses of toxin and one was with placebo.The order of injections was random and unknown to the patients. Results were scored both subjectively by patient assessment of symptoms and objectively by blinded review of videotapes made one month after each injection.

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Subjective improvement occurred after 79% of injections with botulinum toxinOnly 1 patient improved after placebo. Objective improvement was seen after 84% of injections with botulinum toxin.

The most frequent side effect was facial weakness, seen after 97% of injections of botulinum toxin. Facial bruising (20%), diplopia (13%), ptosis (7%), and various other mild side effects were seen less frequently

Botulinum toxin appears to be an effective and safe method of therapy for hemifacial spasm !!

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Randomized controlBlindedPlacebo-control trialSmall populationSingle center

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Botulinum Toxin A Treatment for Primary Hemifacial Spasm : A 10-Year Multicenter Study

Background: Botulinum toxin A (BTX) is the currently preferred symptomatic treatment for primary hemifacial spasm (HFS), but its long-term efficacy and safety are not known.

Objective: To assess the long-term effectiveness and safety of BTX in the treatment of primary HFS.

Design: Retrospective review of medical records of the 1st and 10th years of treatment.

Setting: Outpatient clinics of 4 Italian university centers in the Italian Movement Disorders Study Group.

Participants: A series of 65 patients with primary HFS who had received BTX injections regularly for at least 10 years.

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Results: 95% response rate and an overall mean duration of improvement of 12.6 weeks during year 1.

The effectiveness of BTX remained unchanged in the 1st and 10th years. Patients needed statistically similar BTX doses in the 1st and 10th years. The rate of local adverse effects (including upper lid ptosis, facial weakness, and diplopia) diminished significantly in the 10th year of treatment.

Conclusion: Treatment with BTX effectively induces sustained relief from symptoms of HFS in the long term, with only minimal and transient adverse reactions!!!

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RetrospectiveMulticenterStandard methodLong-term follow up(1~10 years)Population

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Conclusion

Botulinum toxin appears to be an effective and safe method of therapy for hemifacial spasm !!

Treatment with BTX effectively induces sustained relief from symptoms of HFS in the long term

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Comment by Dr.李宜恭

報告History宜用time sequence可讓聽眾就有印象。

Laboratory Data可稍微整理一下，如果是強調Normal就直接寫出來。善於利用EBM

Case PresentationGeneral DataRight hand numbness in this morning Social Hx, Past HxPhysical ExaminationLaboratoryClinical CourseChapter 355. Trigeminal Neuralgia, Bell's Palsy, and Other Cranial Nerve Disorders…Harrison’s IM 16EProblemStructure of PICOProcess of Searching EvidenceTreatment of hemifacial spasm with botulinum toxinBotulinum Toxin A Treatment for Primary Hemifacial Spasm : A 10-Year Multicenter Study�ConclusionComment by Dr.李宜恭