Teaching NeuroImages: Concurrent hemifacial spasm and trigeminal neuralgia due to vertebrobasilar dolichoectasia

A 64-year-old man reported a 2-week worsening of a 2-year history of paroxysmal, lancinating right facial pain and spasms. Head CT demonstrated a tortuous and ectatic vertebral-basilar system. MRI confirmed a dolichoectatic basilar artery that distorted the right trigeminal (figure 1) and facial nerve roots (figure 2). He failed conservative medical management including carbamazepine, oxcarbazepine, and levetiracetam. He underwent Gamma Knife radiosurgery with a few months of pain relief and was offered botulinum neurotoxin injection for spasms.

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Figure 1 Brain MRI, 3D magnetization-prepared rapid acquisition, axial view

MRI demonstrates dolichoectatic basilar artery distorting the right trigeminal nerve at the level of the mid pons (arrow). For reference, contralateral trigeminal nerve displayed with asterisk.

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Figure 2 Brain MRI, 3D magnetization-prepared rapid acquisition, axial view

MRI demonstrates dolichoectatic basilar artery distorting the right facial nerve at the cerebellopontine angle (arrow). For reference, contralateral facial nerve displayed with asterisk.

This case represents a rare presentation of concurrent hemifacial spasm and trigeminal neuralgia linked to an ectatic basilar artery.¹

• © 2013 American Academy of Neurology