Microvascular Decompression (MVD) of the 8th Nerve

R

rtwombly

Member
Author
Apr 23, 2014
369
Southeast USA
Tinnitus Since
01/2014
Cause of Tinnitus
Unknown
#1
Hiya! Been lurking for awhile. After three months of aggressively seeking treatment for my tinnitus, I am currently undergoing some therapy that will take time to show results. Meanwhile I've been reading about microvascular decompression of the 8th nerve and the success some patients have had in relieving their symptoms after this surgery. Some cases are discussed here: https://www.tinnitustalk.com/thread...-cures-some-peoples-tinnitus.1792/#post-15300. From what I've read, the "controversial" nature of applying MVD to tinnitus is that some studies have shown non-symptomatic patients with similar vascular compression to symptomatic patients. In fact, vascular compression has appeared in the asymptomatic ears of patients affected unilaterally.

Some years ago I did some reading about male pattern baldness. Basically, some men go bald due to a genetically predisposed sensitivity to a by-product of testosterone. Men who don't go bald may not have that predisposition, or they may have insufficient levels of testosterone to produce the by-product in toxic amounts. Thus, it's a combination of genetic and other factors that create the condition.

Could something similar be responsible for tinnitus in individuals with vascular compression of the 8th nerve? Could the compression be the basic cause, but depend on a genetic-or-environmental predisposition to produce its symptoms? That would explain why some people with vascular compression are asymptomatic. The genetic argument is harder to make regarding asymptomatic ears of unilateral sufferers; however, this does not rule out environmental factors. For that matter, might there not be a genetic difference between the two ears?

I hope someone is pursuing this avenue of medical research. I've recently been reviewing the results of my MRI (it's not a tuumah) and am impressed by the amount of data that can be gleaned from this technology. Unfortunately, I have no idea how to spot abnormalities myself. The consulting neurologist gave me a clean bill of cranial health, but we didn't speak in person. I have no way of knowing if vascular compression is a diagnosis s/he would have considered, and I am weighing up the pros and cons of seeking a second opinion.

Anybody know of ongoing MVD-VIII research? Any advice on getting a neurootologist to walk me through my MRI?
 
#2
No I don't know of any research but I do know a TN sufferer who had hyperacusis( many do actually along with t) not sure about t and while she had her mvd they also fixed the 8th nerve and her h was MUCH BETTER afterwards. Anyways I suspect it be hard to find a surgeon perform this for just t. It is brain surgery after all.
 
#4
Hope to get some more interest in this thread. For all of us with unknown cause of T a nerve compression might be the problem, might also be in combination with cochlear damage. Dose anybody knew whats characteristic for a nerve caused T? I've heard that if you have tics around your eyes in combination with T that could be an indicator. Also that it doesn't have to be synchronized with your pulse.

Here is a quite recent report of a surgical approach to solve the problem. It seams to be quite promising.

http://www.neurologyindia.com/artic...e=60;issue=5;spage=495;epage=497;aulast=Zhang

Also here is a very recent studies how to better determinate if you might benefit for a operation.

http://petit.lib.yamaguchi-u.ac.jp/G0000006y2j2/file/23007/20140221170135/A050060000105.pdf

Did any of you T fellows consider this route?
 
#6
What kind of doctor is capable of performing this operation? (MVD)
My MRI show I have in vascular compression on the 7th and 8th nerve of the right ear. This is where my tinnitus comes from, although I thought it was due to acoustic trauma. I also have hyperacusis.

My ENT gave me Neurontin (Gabapentin) for this condition, but I read there is a 3 years window for Microvascular Decompression operation. Actually they say the sooner the better. Perhaps the damage to the nerve becomes irreparable after some time of vascular compression.
 
#7
Im going to bump this old thread.
I think that micro vascular compression is a topic not well enough explored.
I'd like to hear from any member that has had an mvd either for a neuralgia or T, H.

I have been having bizzare and excruciating ear, face pain T and H over the past year. Diagnosed, misdiagnosed, doctors that just threw their hands up and say that they havn't a clue try a cocktail of anticonvulsants and hope for relief..
I had a my 4th mri in a year's time, this time ordered by a neurosurgeon who suspected mvc.
An MR with the 'fiesta' sequence is need calling special attn to the cranial nerves. A normal MR will not visualize the nerves nor any attached small blood vessals.
Sure enough my MR report showed a few compressions on the 7th, '7-8 complex' (nerve bundle to the ear) and a suspect compression on the glossopharyngeal nerve.
All findings were unilateral located on the side with all if the pains.
Findings have been confirmed by 6 neuologists and surgeons from NY, Pittsburg, to Ca.

I did want to revive this discussion as it could shed light for some members suffering with ear and facial pain. I had to go to lengths, and visited some very prodominent ent's and I have to add, do not care or pethaps do not understand basic ear innervation. I know that is a neuro's job, but ent's do not wish to even explore that realm in the most basic context which is a bit of a diservice to many as the ear is jam packed with nerves. (4 cn's to be exact?). I cannot help to add that the effort that i received from ents (approx 10) was pitiful. Likely the reason why the understanding of T and H remains in the dark ages. It took a cross boundry approach lead by neurology to address my ear issues.

I'm sharing my information in hopes to find others that have explored this territory or might have something to add.

James
 
#8
maz1 said:
Findings have been confirmed by 6 neuologists and surgeons from NY, Pittsburg, to Ca.
Click to expand...
You have the lucky to have the opinions of the biggest neurosurgial school about nerve compression (moller & jannetta in pittsburgh) and ask for an opinion on internet? sorry i'm confused. Here there aren't surgeons. I have trigeminal nevralgia and tinnitus due to vascular compression. i deal using anticonvulsant oxcarbazepine and clonazepam with some effects even on tinnitus. Surgery will be my last chance for a lot of reason. Follow your prescription. Don't trust internet opinion. Good Luck
 
#9
ReyKalinic said:
You have the lucky to have the opinions of the biggest neurosurgial school about nerve compression (moller & jannetta in pittsburgh) and ask for an opinion on internet? sorry i'm confused. Here there aren't surgeons. I have trigeminal nevralgia and tinnitus due to vascular compression. i deal using anticonvulsant oxcarbazepine and clonazepam with some effects even on tinnitus. Surgery will be my last chance for a lot of reason. Follow your prescription. Don't trust internet opinion. Good Luck
Click to expand...

I certainly appreciate your input, especially from a fellow TN sufferer. You obviously know the pain.

I have been told that MVD would be my next best (only) move however have been given lousy odds on MVD success due to the my 'complex and atypical symptoms'.
The reason for my inquiry to the 'internet' is to survey other's experiences and other possibilities. I am not soliciting for information on where or who should I go to. Neurosurgeons aren't Otologists, and diagnosis of a nerve compression is a clinical one, there is grey area. You have to agree that information gathering is a major responsibility while contemplating brain surgery.

I would like to know more about your symptoms and the location of your compression. Do you have typical, atypical, Geniculate, GPN? I'd like to hear about your symptoms in detail if you cared to share? Please contact me via PM if you are more comfortable. I would greatly appreciate it.
 
#10
maz1 said:
I'd like to hear about your symptoms in detail if you cared to share? Please contact me via PM if you are more comfortable. I would greatly appreciate it.
Click to expand...


the administrators of this site are afraid of my sincerity and not allow me to send private messages on my part. I am a person "uncomfortable."

Back to us; My first symptoms was the pain in the face, like electric shocks intermittant. It happened after a trivial but violent basketball rebound on my left cheekbone. In the previous days i had a dental surgery.
The pain initially was intermittant. Not costant but one night (it still happen if i don't use the full medications dosages) it was starting to be excruciating and with a mild tinnitus that was triggered by the pain (now is costant). So i went to the er and after to a private clinic in Marseille for an mri.
The diagnosys was of nerovascular compression of the 7 and 8 nerve but... the most important question is; is possible that a basketball in face is able to trasnform the nerve and vessel position? Maybe they were already in those position. and in fact... read here; "
Our findings showed that anterior inferior cerebellar artery (AICA) loops in CPA (type I) were found to be present in 65% of patients with tinnitus (44/68), in 72% of controls (62/86), and in 83% of patients (35/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus (Table 2). AICA loops lying in the IAC but not extending >50% of its depth (type II) were detected in 26% of patients with tinnitus (18/68), in 17% of controls (15/86), and in 7% of patients (3/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus (Table 2). AICA loops extending >50% of the length of IAC (type III) were found to be present in 9% of patients with tinnitus (6/68), in 11% of controls (9/86), and in 10% of patients (4/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus (Table 2). However, these results did not show a statistically significant difference for the presence of all types of vascular loops (P > .05).

Vascular contact with the eighth CN was depicted in 53% of patients with tinnitus (36/68), in 41% of controls (35/86), and in 40% of patients (17/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus. The angulation of the eighth CN was found to be present in 15% of patients with tinnitus (10/68), in 13% of controls (11/86), and in 14% of patients (6/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus. Again, there was no statistically significant difference between the groups for vascular contact and the angulation of the eighth CN (P> .05)"

Vascular or not.... is difficult! http://www.ajnr.org/content/29/9/1746.full

image1.jpg
image2.jpg





Maybe our mri are similar. On the right you can see the left side with a clear cut crossover conflict between 7 and 8 nerve (facial and cochlear) with artery AICA inside....but....

we have an huge problem; for trigeminal nevralgia, the decompression (as soon is possible) guarantee a good relief but it can come back in the future.

For tinnitus, not. With high risk of bias and worsening. Even with others diagnostics tool like ABR, Nistagmography, and simptoms expecially the motion intolerance.

Forgive me if i say; american doctor are too much aggressive. But it 's real. They do too "easy" on surgery. I hope that if you have a diagnosys of vascular conflict, Your neurologists will try all the medications available before go for surgery. You have a window of time; 4 years. You could spend this time tryng anticonvulsant like tegretol or trileptal and doing this you coul take double results. Therapeutic and diagnostics. If the medication work, the diagnosys is confirmed. Another possible exam is the stellate ganglion blocking. If it work, the diagnosys is confirmed. Now i'm curious about what the surgeons have suggested for you. I hope not surgery. Expecially if your tinnitus is not pulsatile.

I invite you to read with attention this document that end; as the previous article quote;
Conclusion
Findings of this study showed that the presence of a vascular loop either in contact with the eighth CN and causing angulation of the cisternal component of the nerve or its penetration into the IAC does not correlate with reports of unexplained tinnitus by the patient. Therefore, we think that the diagnosis of the eighth CN vascular compression syndrome should not be based solely on imaging findings, and this recommendation may prevent considering unnecessary surgery.

http://www.ajnr.org/content/29/9/1746.full

Take care.

hold on
 
#12
CONCLUSION: Microvascular decompression of the cochlear nerve can improve tinnitus intensity in selected patients if decompression is performed early, before the end of the 4th year. Tinnitus distress does not seem to change

Better don't open the skull!

I'm trying a new antidepressant by 3 months very low dosage. Massive improvement after 15 days. If it continues I will update
 
#14
Fabrikat said:
What is the name of the drug you are taking?
Click to expand...
Brintellix 5mg. I started with drops because l'm oversensitive to this class of drugs. Hate SSRI and psychotropic medication in general. Too many disgraceful past experience but indeed i need help so my psych suggest to replace efexor (awful).
My psychiatrist with a holy patience offered me to start with one drop for a week and then to raise at least 5.

Finally, I succeeded. I've always seen "evil" in antidepressants then I met people with fibromyalgia problems who are forced to use these drugs. A good number of them responds well. Others need further pharmacological approaches. I did as if it were a vaccine. I gave the body the time to get used to the "poison" and now finally, after so long, the therapy seems to work. I hope it will always be so special because the side effects are tolerable. Hopes
 
#16
skoupidis said:
What kind of doctor is capable of performing this operation? (MVD)
My MRI show I have in vascular compression on the 7th and 8th nerve of the right ear. This is where my tinnitus comes from, although I thought it was due to acoustic trauma. I also have hyperacusis.

My ENT gave me Neurontin (Gabapentin) for this condition, but I read there is a 3 years window for Microvascular Decompression operation. Actually they say the sooner the better. Perhaps the damage to the nerve becomes irreparable after some time of vascular compression.
Click to expand...

How is this seen on an MRI?
 
#17
ReyKalinic said:
the administrators of this site are afraid of my sincerity and not allow me to send private messages on my part. I am a person "uncomfortable."

Back to us; My first symptoms was the pain in the face, like electric shocks intermittant. It happened after a trivial but violent basketball rebound on my left cheekbone. In the previous days i had a dental surgery.
The pain initially was intermittant. Not costant but one night (it still happen if i don't use the full medications dosages) it was starting to be excruciating and with a mild tinnitus that was triggered by the pain (now is costant). So i went to the er and after to a private clinic in Marseille for an mri.
The diagnosys was of nerovascular compression of the 7 and 8 nerve but... the most important question is; is possible that a basketball in face is able to trasnform the nerve and vessel position? Maybe they were already in those position. and in fact... read here; "
Our findings showed that anterior inferior cerebellar artery (AICA) loops in CPA (type I) were found to be present in 65% of patients with tinnitus (44/68), in 72% of controls (62/86), and in 83% of patients (35/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus (Table 2). AICA loops lying in the IAC but not extending >50% of its depth (type II) were detected in 26% of patients with tinnitus (18/68), in 17% of controls (15/86), and in 7% of patients (3/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus (Table 2). AICA loops extending >50% of the length of IAC (type III) were found to be present in 9% of patients with tinnitus (6/68), in 11% of controls (9/86), and in 10% of patients (4/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus (Table 2). However, these results did not show a statistically significant difference for the presence of all types of vascular loops (P > .05).

Vascular contact with the eighth CN was depicted in 53% of patients with tinnitus (36/68), in 41% of controls (35/86), and in 40% of patients (17/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus. The angulation of the eighth CN was found to be present in 15% of patients with tinnitus (10/68), in 13% of controls (11/86), and in 14% of patients (6/42) in the group formed by asymptomatic sides of patients with unilateral tinnitus. Again, there was no statistically significant difference between the groups for vascular contact and the angulation of the eighth CN (P> .05)"

Vascular or not.... is difficult! http://www.ajnr.org/content/29/9/1746.full

View attachment 11535 View attachment 11536




Maybe our mri are similar. On the right you can see the left side with a clear cut crossover conflict between 7 and 8 nerve (facial and cochlear) with artery AICA inside....but....

we have an huge problem; for trigeminal nevralgia, the decompression (as soon is possible) guarantee a good relief but it can come back in the future.

For tinnitus, not. With high risk of bias and worsening. Even with others diagnostics tool like ABR, Nistagmography, and simptoms expecially the motion intolerance.

Forgive me if i say; american doctor are too much aggressive. But it 's real. They do too "easy" on surgery. I hope that if you have a diagnosys of vascular conflict, Your neurologists will try all the medications available before go for surgery. You have a window of time; 4 years. You could spend this time tryng anticonvulsant like tegretol or trileptal and doing this you coul take double results. Therapeutic and diagnostics. If the medication work, the diagnosys is confirmed. Another possible exam is the stellate ganglion blocking. If it work, the diagnosys is confirmed. Now i'm curious about what the surgeons have suggested for you. I hope not surgery. Expecially if your tinnitus is not pulsatile.

I invite you to read with attention this document that end; as the previous article quote;
Conclusion
Findings of this study showed that the presence of a vascular loop either in contact with the eighth CN and causing angulation of the cisternal component of the nerve or its penetration into the IAC does not correlate with reports of unexplained tinnitus by the patient. Therefore, we think that the diagnosis of the eighth CN vascular compression syndrome should not be based solely on imaging findings, and this recommendation may prevent considering unnecessary surgery.

http://www.ajnr.org/content/29/9/1746.full

Take care.

hold on
Click to expand...

What am I supposed to see on this picture. I don't understand what you highlited / circled.
 
#18
Grey Dawn said:
Anyone try decompression and severing the nervous intermedius?
Click to expand...

I know someone who underwent something similar. Instead of severing the nerve they numbded it (i didnt ask how they did it). According to the docotrs most patients get relieve, but it didn't work for him. Instead he has a tingling feeling on several places on his head. But i guess his t has another etiology and they were just trying something.
 
#21
Codaz said:
How is this seen on an MRI?
Click to expand...
Hi.
It has been too long since I visited here. No need to anymore, my T is gone!

I dont remember how the mvc shows on MRI. A vein or artery is too close to the nerve, overlapping or surrounding it, if I am not mistaken. Do not even care any more.

If you want my advice regarding mvc, stop reading about it. There is no proven relation with T. Even if there was, it wouldnt explain my getting better by time passing by, would it?

I only took gingko 6000mg, vitamine E eviol and avoided loud and tiresome noises. Waited 2 years, then the T subsided. Now, 3 years after the onset, I don't even check this forum.

For the record, I had extremeily bad right ear Tinnitus, Hyperacusis, distortion of high frequency sounds. Listening to songs became a bad experience for me, they sounded like a "broken" record, even my wife's voice that is thin became scrambled.

Now all that is gone. I do not kid anybody, you can check my older posts. I used to haunt this forum like a ghost.
Just came back here after the news about the new machine they invented. I do not really beleive it works, whatever that means to me now...

Hope you get better. Do not despair, it can go away. Be patience, be careful. You never know ;)
 
#22
skoupidis said:
Hi.
It has been too long since I visited here. No need to anymore, my T is gone!

I dont remember how the mvc shows on MRI. A vein or artery is too close to the nerve, overlapping or surrounding it, if I am not mistaken. Do not even care any more.

If you want my advice regarding mvc, stop reading about it. There is no proven relation with T. Even if there was, it wouldnt explain my getting better by time passing by, would it?

I only took gingko 6000mg, vitamine E eviol and avoided loud and tiresome noises. Waited 2 years, then the T subsided. Now, 3 years after the onset, I don't even check this forum.

For the record, I had extremeily bad right ear Tinnitus, Hyperacusis, distortion of high frequency sounds. Listening to songs became a bad experience for me, they sounded like a "broken" record, even my wife's voice that is thin became scrambled.

Now all that is gone. I do not kid anybody, you can check my older posts. I used to haunt this forum like a ghost.
Just came back here after the news about the new machine they invented. I do not really beleive it works, whatever that means to me now...

Hope you get better. Do not despair, it can go away. Be patience, be careful. You never know ;)
Click to expand...

Thanks, but I'm worried about my newly hearing loss.
 
#23
Surgical treatment of paediatric unilateral tinnitus due to cochleovestibular nerve compression by intrameatal anterior inferior cerebellar artery (AICA) loop

SajjadMuhammadMD., PhD1RokuyaTanikawaMD.2MikaNiemeläMD., PhD1
1Department of Neurosurgery, Helsinki University and Helsinki University Hospital, Helsinki, Finland
2Sapporo Teishinkai Hospital, Sapporo, Japan
Received 7 October 2018, Revised 25 December 2018, Accepted 26 December 2018, Available online 10 January 2019.

https://doi.org/10.1016/j.wneu.2018.12.154Get rights and content

Abstract
Objectives
Cochleovestibular nerve compression syndrome due to intrameatal anterior inferior cerebellar artery (AICA) that causes tinnitus is an extremely rare condition with special therapeutic challenges and implications. Here we present the first surgically treated paediatric case of tinnitus showing microvascular conflict of cochleovestibular nerve and intrameatal AICA loop.

Methods
A paediatric case of tinnitus is described and a surgical technique is elaborated with video material. A Pubmed literature search was performed to identify surgically treated paediatric cases of intrameatal compression of eighth nerve with AICA loop.

Results
Tinnitus was completely resolved and hearing was intact immediately after surgical decompression. The patient was free from further symptoms after a short follow up of 12 weeks. Microsurgical decompression, including opening of IAC and transposition of AICA, was an effective treatment option in this case.

Conclusion
Decompression of the cochleovestibular nerve including opening of IAC and transposition of AICA appears to be an effective treatment option for cases with radiologically confirmed intrameatal vascular compression of eighth nerve causing unilateral pulsatile tinnitus.

Key words
Cochleovestibular nerve
intrameatal anterior inferior cerebellar artery (AICA)
Tinnitus
Pediatrics
Surgery
https://www.sciencedirect.com/science/article/pii/S1878875019300221
 
#24
I am so glad my life no longer revolves around searching for obscure tinnitus treatments, clinical trials, or reading this forum. I had MVD surgery for left-sided tinnitus and hyperacusis in December 2023, and I now consider myself healed from the torture of these horrible conditions.

I went from feeling suicidal to thriving again. From being locked in a dark room waiting to die, I am now working full time, enjoying the sound of my children's laughter, going on dates with my wife, riding motorcycles, and even rock climbing. My life is my own again.

To those who say this surgery cannot improve tinnitus or that vascular compression cannot cause tinnitus, I am living proof that you are wrong.
 
#27
Justwaitinchilin said:
I am so glad my life no longer revolves around searching for obscure tinnitus treatments, clinical trials, or reading this forum. I had MVD surgery for left-sided tinnitus and hyperacusis in December 2023, and I now consider myself healed from the torture of these horrible conditions.

I went from feeling suicidal to thriving again. From being locked in a dark room waiting to die, I am now working full time, enjoying the sound of my children's laughter, going on dates with my wife, riding motorcycles, and even rock climbing. My life is my own again.

To those who say this surgery cannot improve tinnitus or that vascular compression cannot cause tinnitus, I am living proof that you are w
Click to expand...
I'm so happy for you!

I also have a looped nerve, and my symptoms are getting worse. I experience massive spasms that can last for days, sometimes sounding like a distorted speaker and even radiating into my upper teeth. I tried taking Carbamazepine for three weeks, but it provided no relief. Right now, I'm barely managing with Valium and Endep.

I'm seriously considering surgery and am waiting to try a muscle relaxant called Cyclobenzaprine, which I ordered from Canada. Unfortunately, my good ear is now also experiencing spasms, though at a slower rate. There are also signs of a possible looped nerve issue on that side as well.

How are you recovering? Were you in much pain?
 
#28
Justwaitinchilin said:
OU Neurosurgery.
Click to expand...
OU Neurosurgery? Is that Ontario University Neurosurgery? Oregon United Neurosurgery? Or maybe Oogadoojoo Neurosurgery?

I'm delighted to hear that you've found an escape route for yourself. Meanwhile, we poor sufferers have to wait for the statistics and success rates before we can "all pile in!"
 
#30
Justwaitinchilin said:
I am so glad my life no longer revolves around searching for obscure tinnitus treatments, clinical trials, or reading this forum. I had MVD surgery for left-sided tinnitus and hyperacusis in December 2023, and I now consider myself healed from the torture of these horrible conditions.

I went from feeling suicidal to thriving again. From being locked in a dark room waiting to die, I am now working full time, enjoying the sound of my children's laughter, going on dates with my wife, riding motorcycles, and even rock climbing. My life is my own again.

To those who say this surgery cannot improve tinnitus or that vascular compression cannot cause tinnitus, I am living proof that you are wrong.
Click to expand...
Hi @Justwaitinchilin,

I hope you are still doing well.

I'm all cried out, now dealing with 24/7 tapping Morse code in my head. My neurologist is about to order a more extensive MRI. Apparently, I have a compressed nerve, inferior anterior, in conflict with a vein… something like that.

I'm struggling. I have now developed hyperacusis. I wonder if Baclofen caused that. My symptoms are getting worse. I'm waiting on cyclobenzaprine. My tinnitus spasms are not sound induced. They are constant and getting unbearable, so loud and fast. Both ears now.

This morning I am trying to stay calm to show my husband it is not just a nervous reaction. Lately my family has been suggesting I see a psychologist, but they do understand there could be a physical cause. I just do not understand how my normal tinnitus morphed into this monster.

Yes, I am an anxious and hyper vigilant person trying to stop negative and self sabotaging thoughts. Many years ago, after the birth of my first child, I suffered from panic attacks. They eventually faded as I started to relax and reengage with life. Is this related? Am I making things worse by constantly searching forums for answers?

I feel hopeless and alone. I am a Christian and I seek God's strength and direction. I am sorry. I am just writing and thinking about what to do next, dreading the prospect of dealing with these symptoms for months even if the surgical team agrees to operate.

I am in Australia and I believe only one surgeon here has experience with this procedure. I would be willing to travel to America if needed. You probably will not see this post, but I just needed to write things down to distract myself.

I wonder how many people have had success with MVD surgery. Did your surgeon see many cases?
 

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