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- hemifacial spasm
- magnetic resonance imaging
- neurovascular compression
- vertebral artery
A 42 year old woman with a history of an incompletely remitted peripheral left facial nerve palsy that was followed by clusters of hemifacial spasm and paroxysms of lancinating pain located behind the left ear and radiating to the ipsilateral eye, the neck, or shoulder, was admitted for re-evaluation due to additionally manifested short lasting syncope-like episodes of increasing frequency. Beneath a mild residual facial nerve palsy no further focal findings were documented. Extensive cardiologic workup revealed only a positive tilt table test, indicating an intense vagovasal reaction.
Re-evaluation of previously performed imaging examinations focused on an already angiographically described tortuous course of the vetrebrobasilar arteries (panel A), which compressed the left lateral surface of the medulla, pons, and pontomedullar junction, as also demonstrated on MRI (panel B). Based on the documented vagovasal reaction we assumed an affection of the lower cranial nerves and additionally performed ultra thin MRI. In this way we could impressively demonstrate a severe compression of the proximal stem of the cranial nerves IX and X (panel D), and the root entry zone of the facial nerve on the left (panel C). Owing to the escalation of symptoms the patient underwent microvascular decompressive surgery with interposition of a muscle graft. Two years later she remains asymptomatic. A repeated tilt table test was this time negative.
This is an uncommon case of neurovascular compression,1 characterised by known, however previously not in this combination, described features such as hemifacial spasms, variant glossopharyngeal neuralgia, and syncope,2–5 which all ceased after surgery.
Competing interests: none declared