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NEUROIMAGE
Year : 2010  |  Volume : 58  |  Issue : 1  |  Page : 163-165

Simultaneous involvement of fifth and seventh nerves by vertebrobasilar dolichoectasia presenting as painful tic convulsif - Demonstrated by MR imaging


Department of Radiodiagnosis, C.S.M.M.U. (KGMU), Lucknow, UP, India

Date of Acceptance02-Nov-2009
Date of Web Publication8-Mar-2010

Correspondence Address:
Pallavi Aga
Type 4/87 SGPGI campus, Raebareli Road, Lucknow, U.P - 226 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.60394

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How to cite this article:
Aga P, Parashari U, Parihar A, Yadav R, Singh R, Kohli N. Simultaneous involvement of fifth and seventh nerves by vertebrobasilar dolichoectasia presenting as painful tic convulsif - Demonstrated by MR imaging. Neurol India 2010;58:163-5

How to cite this URL:
Aga P, Parashari U, Parihar A, Yadav R, Singh R, Kohli N. Simultaneous involvement of fifth and seventh nerves by vertebrobasilar dolichoectasia presenting as painful tic convulsif - Demonstrated by MR imaging. Neurol India [serial online] 2010 [cited 2023 Sep 24];58:163-5. Available from: https://www.neurologyindia.com/text.asp?2010/58/1/163/60394


Painful tic convulsif (PTC) a rare entity, characterized by the coexistence of trigeminal neuralgia with hemifacial spasm was first described in 1920 by Cushing. [1] Since then only a few cases have been reported. Vascular compression by superior cerebellar artery (SCA) and vertebral artery or its branches is the commonest cause. [2] Simultaneous compression of both the nerves caused by dolichoectatic vertebrobasilar artery is uncommon and could easily be missed preoperatively. However, pre-operative diagnosis can be done by an appropriate magnetic resonance imaging (MRI) sequences. [3],[4] We describe a patient with PTC in whom compression of both trigeminal and facial nerves by vertebrobasilar dolichoectasia (VBD) has been demonstrated by MRI and magnetic resonance angiography (MRA).

A 70-year-old hypertensive male was referred for MRI with two month history of left side trigeminal neuralgia and hemifacial spasm. MRI showed an ectatic vascular structure coursing anterolateral to the pons on the left side compressing and deforming the pons. [Figure 1] and MRA showed an elongated and dilated right vertebral artery causing compression over the anterolateral pons and coursing to the left of midline to join the left ectatic vertebral artery. The elongated basilar artery, laying lateral to the plane of the clivus showed a high bifurcation; just above the plane of the suprasellar cistern. The diameter of the ectatic vertebral arteries was 6 mm and the basilar artery being 7 mm. [Figure 2]. To better delineate the vascular structure, a unique sequence of 3D fast spoiled gradient recalled acquisition in the steady state (FSPGR) images, after administration of IV gadolinium, were obtained for mutiplanar reconstruction. The data acquired by 3D SPGR was reconstructed as 0.5 mm axial and coronal 3D reformations by the multi planar reformation (MPR) method at the MR workstation. The resulting images depicted the trigeminal nerve stretched, compressed and elongated at the root entry zone by the dolichoectatic left vertebral artery, however, no compression was noted in the cisternal course. Additional compression, stretching and deviation of the exit zone of left facial nerve by the same ectatic vertebral artery were also seen. [Figure 3]a and b, [Figure 4]. The pontine deformity was also better delineated in this sequence [Figure 5].The complete MR imaging with the above mentioned sequences helped in clinching the diagnosis of VBD being the cause of trigeminal as well as facial nerve compression.

The trigeminal nerve arises from a motor nucleus and three sensory nuclei and exits from the anterolateral aspect of the pons as a large sensory and a smaller motor root and then traverses through the pre-pontine cistern . [5] The facial nerve has its nuclei in the pons and the nerve fibers exit the brain at the inferior border of the pons. The root entry or exit zone is the point of change from central to peripheral myelin, varying between 10- 15 mm of length and is the most predisposed segment for vascular compression. [5]

Increase in length and diameter of the intracranial arteries termed as dolichoectasia is the most common cause of vascular compression. Vertebrobasilar system is considered elongated if the basilar artery lies lateral to the margin of the clivus or dorsum sellae or if it bifurcates above the plane of the suprasellar cistern. Ectasia is considered to be present if the basilar artery has a diameter greater than 4-5 mm. [6] Patients with VBD manifestations are often hypertensive, older in age, and male with predominantly left-sided involvement. The postulated pathogenesis is severe atherosclerotic changes associated with hypertension. [7] However, sometimes VBD could also manifest at a younger age due to a congenital vascular anomaly. [8]

Demonstration of simultaneous compression of both trigeminal and facial nerves utilizing various MR sequences like spoiled gradient recalled acquisition in the steady state (SPGR) sequences, fast imaging in steady precession (FISP) or constructive imaging in steady state (CISS) sequences together with MR angiography and 3-D imaging reconstructions from the data of SPGR MR imaging has been described. [9],[10],[11] In our patient, routine T1, T2, FLAIR and DWI sequences depicted an ectatic vessel to be the cause of the compression of brain stem and the nerves. MR imaging using post gadolinium SPGR sequences exquisitely demonstrated that the left trigeminal nerve was compressed, stretched and elongated due to ectatic left vertebral artery at the root entry zone, however the cisternal course appeared normal. The facial nerve was also stretched and compressed at the root entry zone by the ipsilateral ectatic vertebral artery. Probably this is the first pre-operative MRI demonstration of simultaneous seventh and fifth nerve compression by the same dolichoectatic vertebral artery.

 
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1.Cushing H. The major trigeminal neuralgias and their surgical treatment based on experiences with 332 Gasserian operations. Am J Med Sci 1920;160:157-84.  Back to cited text no. 1      
2.Jannetta PJ. Neurovascular compression in cranial nerve and systemic diseases Ann Surg 1980;192:518-25.  Back to cited text no. 2      
3.Linskey ME, Jho HD, Jannetta PJ. Microvascular decompression for trigeminal neuralgia caused by vertebrobasilar compression. J Neurosurg 1994;81:1-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Nomura T, Ikezaki K, Matsushima T, Fukui M. Trigeminal neuralgia: Differentiation between intracranial mass lesions and ordinary vascular compression as causative lesions. Neurosurg Rev 1994;17:51-7.  Back to cited text no. 4  [PUBMED]    
5.Woolfall P, Coulthard A. Pictorial review Trigeminal nerve anatomy. Br J Radiol 2001;74:458-67.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Singla V, Modi M, Singh P, Khandelwal NK. Dolichoectasia of vertebrobasilar system: A rare cause of tic douloureux. Indian J Med Sci 2007;61:30-1.  Back to cited text no. 6  [PUBMED]  Medknow Journal  
7.Linskey ME, Jho HD, Jannetta PJ. Microvascular decompression for trigeminal neuralgia caused by vertebrobasilar compression. J Neurosurg 1994;81:1-9.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Hegedus K. Ectasia of basilar artery with special reference to possible pathogenesis. Surg Neurol 1985;24:463-9.   Back to cited text no. 8      
9.Kumon Y, Sakaki S, Kohno K, Ohta S, Ohue S, Miki H. Three dimensional imaging for presentation of the caustaive vessels in patients of the causative vessels in patients with hemifacial spasm and trigeminal neuralgia. Surg Neurol 1997;47:178-86.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Yamakami I, Kobayashi E, Hirai S, Yamaura A. Pre-operative assessment of trigeminal neuralgia and hemifacial spasm using constructive inteference in steady state 3-dimensional Fourier transformation magnetic resonance imaging. Neurol Med Chir (Tokyo) 2000;40:545-56.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Juan CJ, Chen CY, Hsueh CJ, Hsu HH, Chin SC, Lee KW, et al. Imaging studies of two cases of trigeminal neuralgia caused by dolichoectatic vertebrobasilar system. Chin J Radiol 1999;24:41-5.  Back to cited text no. 11      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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