Venous vascular malformation of the facial nerve

Last revised by Doron Goldman Baum on 23 Jul 2020

Venous vascular malformations of the facial nerve, previously known as facial nerve hemangiomas, are rare benign vascular malformations of the facial nerve usually presenting as a facial nerve palsy, which can be rapid in onset mimicking a Bell palsy

As they do not appear to have the clinical course or histological features of hemangiomas, the nomenclature was changed 5

These lesions typically affect middle aged patients and are very slow growing.

At presentation, they are usually ~1 cm in size, and typically cause significant symptoms despite their small size. This is another distinguishing feature from schwannomas which despite larger size often have few symptoms. Typically they present with facial nerve palsy which can be of rapid onset mimicking a Bell palsy. Sensorineural hearing loss and tinnitus can also be presentations.

It has a predilection for the region around the geniculate ganglion (although even more rarely seen in the internal auditory canal), compared to schwannomas which can occur anywhere along the nerve. 

The bony margins are indistinct, as although the malformation is localized it is unencapsulated, enabling them to be distinguished from schwannomas, which like schwannomas elsewhere (think jugular foramen lesions) have well defined remodeled margins.

Both capillary and cavernous subtypes are identified histologically and both types can be seen within the one tumor. A variant is the ossifying hemangioma of the facial nerve, which has a distinctive appearance; radiating outwards from its center is a 'spoke wheel' or 'honeycomb' arrangement of ossification.

There is an osteolytic lesion centered in the facial nerve canal with irregular and amorphous margins. The presence of internal honeycomb ossific matrix, present in half of cases, is pathognomonic 6.

Reported signal characteristics of the region include:

  • T1: iso or slightly hypointense
  • T2: hyperintense
  • T1 C+ (Gd): intense contrast enhancement

Definitive treatment requires surgical resection.

Imaging differential considerations include:

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Cases and figures

  • Figure 1: gross pathology
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  • Case 1
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  • Case 2: CT
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  • Case 2: MRI
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  • Case 3
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