Magnetic resonance imaging of vertebrobasilar ectasia in tic convulsif

Case report

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✓ A patient with trigeminal neuralgia and hemifacial spasm was evaluated using multiplanar magnetic resonance (MR) imaging with gadolinium enhancement. Preoperative images demonstrated massively ectatic vertebral and basilar arteries and their distortion of the brain stem and the trigeminal and facial nerves. Surgical manipulation included selective trigeminal rhizotomy, cushioning of the residual nerve at the point of maximal distortion by the underlying basilar artery, and microvascular decompression of the seventh nerve from the anterior inferior cerebellar artery which was being pushed dorsomedially by the vertebral artery. Postoperatively, the patient had neither trigeminal neuralgia nor facial spasm. Gadolinium-enhanced MR imaging not only excludes other etiologies such as tumor or arteriovenous malformation, but also demonstrates cranial nerve compression by ectatic vertebral and basilar arteries. The choice of preoperative imaging modality is discussed and the literature concerning the etiology of tic convulsif is reviewed.

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Address reprint requests to: Griffith R. Harsh IV, M.D., Department of Neurological Surgery, c/o The Editorial Office, 1360 Ninth Avenue, Suite 210, San Francisco, California 94122.

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    Left vertebral angiogram, anteroposterior projection, of the posterior circulation showing a dilated elongated right vertebral artery passing horizontally to join the left vertebral artery to the left of midline. The basilar artery is dilated, laterally displaced, and rotated.

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    Magnetic resonance images. A: T1-weighted (TR 600 msec, TE 20 msec, first echo) sagittal image depicting a vessel indenting and posteriorly displacing the pontomedullary junction. B: Gadolinium-enhanced T1-weighted (TR 400 msec, TE 20 msec, first echo) axial image confirming the horizontal course of this vessel and depicting its acute turn in the left cerebellopontine angle. C: Gadolinium-enhanced T1-weighted coronal image showing compression of the caudal pons at the left facial nerve root exit zone. D: Gadolinium-enhanced T1-weighted axial image demonstrating compression of the rostral pons at the left trigeminal nerve root entry zone.

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    Intraoperative drawing of the left cerebellopontine angle. The massively dilated loop of the elongated vertebro-basilar arterial complex (V-B) displaces a loop of the anterior inferior cerebellar artery (AICA) into the root exit zone of the facial nerve (VII) and displaces the trigeminal nerve (V) dorsally. Pet. = petrous temporal bone; Tent. = tentorium cere-belli; roman numerals denote cranial nerves.

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