Intraoperative neurophysiological monitoring (facial nerve electromyography and brainstem auditory evoked potential ) monitoring was conducted. The patient was taken to MVD surgery through a retrosigmoid approach. Magnetic resonance imaging angiography revealed a neurovascular compression of the left trigeminal nerve and facial nerve by the SCA and the PICA, respectively ( Fig. KEY WORDS: Trigeminal neuralgia, Hemifacial spasm, Tinnitus, Microvascular decompression surgery The patient’s hemifacial spasm, pulsatile tinnitus, and hemifacial pain improved immediately after microvascular decompression. Microvascular decompression via a retrosigmoid approach for separate offenders, including the superior cerebellar artery, anterior inferior cerebellar artery, and posterior inferior cerebellar artery was performed using Teflon sponges. Trigeminal neuralgia and hemifacial spasm were diagnosed after a neurological examination, imaging study, and electromyography. A 53-year-old female presented with lancinating pain in the left face, left hemifacial spasm, and ipsilateral pulsatile tinnitus for 2 years. We report a case with a simultaneous manifestation of trigeminal neuralgia, hemifacial spasm, and pulsatile tinnitus as neurovascular compression syndrome with separate offending vessels. Combined manifestations of neurovascular compression symptoms are very rare. Despite ongoing debate in the literature, pulsatile tinnitus is also known to be a neurovascular compression syndrome resulting from vascular compression of the vestibulocochlear nerve. Trigeminal neuralgia is the most frequent syndrome, followed by hemifacial spasm. Zixiao Yang and Jianping Song are the first two authors contributed equally to this work.Neurovascular compression syndrome is generally caused by vascular compression at the root entry or exit zone of the corresponding cranial nerve. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. A Doppler probe, intraoperative indocyanine green, and even angiography should be applied to assess the aneurysm obliteration and bypass patency. Considering the thickness of the VA intima, interrupted sutures should be used to sew up both the intima and adventitia to avoid artery dissection formation.ġ0. Then, an opposite anchor suture was placed. We first placed an anchor suture at the distal corner of the anastomotic stoma. During the bypass, we used Prolene 10-0 sutures. Meticulous and skilled deep bypass techniques are critical for safe bypass surgery.Ĩ. Dentate ligament transection is essential to decrease the interference of the lower cranial nerves in aneurysm access.ħ. Intraoperative electrophysiological monitoring is essential for brainstem ischemia warning.Ħ. PICA-V4 reimplantation was appropriate for proximal PICA aneurysm with PICA originating high from the VA superior and inferior to the hypoglossal nerves.ĥ. The far lateral approach was appropriate for proximal PICA aneurysms.Ĥ. IC-IC bypass was the first choice because remote donor artery or graft harvesting is unnecessary, and IC-IC bypass provides better dural closure.ģ. Preoperative cerebral angiography should be carefully analyzed for PICA aneurysm angioarchitecture evaluation and surgical planningĢ. Sanai N, Zador Z, Lawton MT (2009) Bypass surgery for complex brain aneurysms: an assessment of intracranial-intracranial bypass. Rodriguez-Hernandez A, Lawton MT (2011) Anatomical triangles defining surgical routes to posterior inferior cerebellar artery aneurysms. Lawton MT, Quinones-Hinojosa A, Jun P (2006) The supratonsillar approach to the inferior cerebellar peduncle: anatomy, surgical technique, and clinical application to cavernous malformations. Neurol Med Chir (Tokyo) 57:284–291Ībla AA, McDougall CM, Breshears JD, Lawton MT (2016) Intracranial-to-intracranial bypass for posterior inferior cerebellar artery aneurysms: options, technical challenges, and results in 35 patients. Abe H, Miki K, Kobayashi H, Ogata T, Iwaasa M, Matsushima T, Inoue T (2017) Unilateral trans-cerebellomedullary fissure approach for occipital artery to posterior inferior cerebellar artery bypass during aneurysmal surgery.

Pica artery nerves