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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01054-X
10.1016/j.ijscr.2024.110273
110273
Case Report
Facial nerve decompression of a PICA vessel loop: A case report
Msheik Ali dr.alimsheik@gmail.com
⁎
Yazbeck Mohamad
Neurological Surgery, Lebanese University, Lebanon
⁎ Corresponding author. dr.alimsheik@gmail.com
11 9 2024
10 2024
11 9 2024
123 11027315 7 2024
3 9 2024
6 9 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Facial nerve palsy is a common condition with various etiologies. However, compression due to a vessel loop is an exceptionally rare cause. This case report highlights the unusual presentation and management of facial nerve palsy caused by vascular compression, emphasizing the importance of considering rare etiologies in persistent cases.

Case presentation

We describe the case of a young female patient who presented with a history of right blepharospasm and facial muscle twitching for several years. Cranial magnetic resonance imaging (MRI) revealed a posterior inferior cerebellar artery (PICA) vessel loop compressing the exit of the acoustofacial bundle at the level of the brainstem.

Clinical discussion

The patient's condition necessitated a microscopic surgical decompression to relieve the compression on the facial nerve. During the procedure, the facial nerve was freed and cushioned using Teflon. This intervention highlights the potential for surgical resolution in cases of facial nerve palsy caused by vascular compression, despite its rarity.

Conclusion

Postoperatively, the patient was free from blepharospasm and showed significant clinical improvement in facial muscle control. This case underscores the importance of considering vascular compression in the differential diagnosis of persistent facial nerve palsy and demonstrates the efficacy of surgical decompression in such cases.

Highlights

• Case of facial nerve compression treatment by surgical decompression

• Video record of the surgical intervention and the result after the intervention

Keywords

Facial nerve compression
Microsurgical decompression
PICA vessel loop
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pmc1 Introduction

Facial nerve palsy is a medical disorder that is frequently observed and has multiple probable causes. It is characterized by the malfunctioning of the facial nerve. A variety of symptoms, such as weakening, twitching or paralysis of the muscles on one side of the face, drooping of the mouth or eyelid, and trouble closing the eye or grinning, can result from this neurological dysfunction [[1], [2], [3], [4]]. Healthcare practitioners must take into account less prevalent aetiologies in certain situations, even if viral infections, trauma, tumours, and Bell's palsy are among the more common causes of facial nerve palsy. One remarkable but atypical cause is compression brought on by a vascular loop [1,2].

In this report, we present the case of a young female patient who had a PICA vessel loop compressing the facial nerve and leading to hemifacial twitching.

2 Case presentation

The case involves a 32-year-old female patient who presented with a history of right blepharospasm and facial muscle twitching persisting for a few years. Previously, the condition was considered psychogenic and the patient was kept on carbamazepine. Physical exam revealed non-stop right facial twitching and weakness of House-Brackmann grade IV when the patient was instructed to execute facial muscle movements.

A cranial magnetic resonance imaging (MRI) revealed a unique finding: a posterior inferior cerebellar artery (PICA) vessel loop compressing the exit of the acoustofacial bundle at the level of the brain stem. Previously, the patient was seen by multiple neurologists who misdiagnosed the condition and failed to observe this finding on the MRI. The previous physicians have only read the report as stated by the patient.

This intricate discovery highlighted the rare connection between the vascular anatomy and the neurological symptoms experienced by the patient. The PICA vessel loop, an aberration in the blood vessels supplying the brain, was identified as the culprit for the compression of the acoustofacial bundle at the site of exit from the brainstem. The acoustofacial bundle is a crucial structure that houses the facial nerve and plays a pivotal role in the control of facial muscles.

In order to address this complex issue, the neurosurgical team opted for a microscopic surgical decompression procedure. The goal of the surgery was to meticulously free the facial nerve from the compression caused by the PICA vessel loop. Additionally, to provide a protective buffer and prevent further compression, a Teflon cushioning technique was employed during the surgical intervention.

The use of microscopic surgical techniques allowed for precise and targeted decompression, minimizing the risk of damage to adjacent structures and optimizing the chances of a successful outcome. The Teflon cushioning served as a safeguard, ensuring that the facial nerve could function without hindrance once liberated from the vascular compression. The surgical details are illustrated in the video article and as below:1. Position: Park-bench position, head turned to left shoulder

2. Incision: Retro-auricular

3. Craniotomy: Retro-sigmoid craniotomy at J-point

4. Dissection: Below J-point Dural incision, lower cranial nerve exposure and CSF drainage, retraction of cerebellum till exposure of the acousticofacial bundle

5. Vessel Loop identification

6. Vessel Loop dissection

Postoperatively, the patient experienced a remarkable improvement in her symptoms. The blepharospasm, which had been a persistent issue for several years, was completely alleviated. The patient was off carbamazepine. Furthermore, there was evident clinical improvement in the control of facial muscles, indicating the restoration of normal neurological function.

3 Discussion

This case underscores the significance of a comprehensive diagnostic approach, combining advanced imaging modalities with meticulous surgical techniques. Diagnosis of this condition required the careful revision of the head MRI FIESTA (Fast Imaging Employing Steady-state Acquisition) sequences. The successful outcome not only relieved the patient from her distressing symptoms but also contributed valuable insights to the medical community regarding the association between vascular anomalies and facial nerve disorders. The utilization of microsurgical methods and Teflon exemplifies the evolving landscape of neurosurgical interventions aimed at providing tailored solutions for intricate neurological conditions.

Facial nerve compression caused by a vascular loop is an extremely uncommon medical anomaly. This phenomenon is caused by a loop of blood vessels, usually veins or arteries, compressing the facial nerve. The vascular loop's pressure can obstruct the face nerve's normal function, which can result in facial nerve palsy's distinctive symptoms [[1], [2], [3]].

To determine the precise site and kind of compression, a comprehensive clinical examination, imaging tests, and neurophysiological evaluations may be part of the diagnostic process in these circumstances. The fine intricacies of the facial nerve and the surrounding vasculature can be seen with the aid of magnetic resonance imaging (MRI) and angiography. Neurologists, neurosurgeons, and vascular experts may need to work together to manage facial nerve palsy brought on by vessel loop compression. In order to relieve the pressure on the facial nerve, treatment options may include surgical procedures to reduce the compression, such as microvascular decompression [4].

The uncommon nature of vascular loop compression-induced facial nerve palsy highlights the significance of a thorough assessment when dealing with individuals who appear atypically. In order to better understand facial nerve problems and help healthcare practitioners diagnose and treat affected persons, more study and clinical awareness of these rare aetiologies are needed [3,4].

4 Conclusion

This case study presents a patient with facial nerve compression caused by a PICA vessel loop, a rare condition often misdiagnosed. Through careful MRI analysis and a tailored surgical approach, the patient's symptoms were successfully alleviated. The case underscores the importance of a comprehensive diagnostic evaluation and the effectiveness of advanced surgical techniques in managing complex neurological disorders. By raising awareness of this rare condition, healthcare providers can better diagnose and treat patients with similar symptoms.

The following is the supplementary data related to this article.Video 1

PICA vessel LOOP VIDEO anonymous.

Video 1

Disclaimer

This care was reported according to the SCARE criteria [5].

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval for this study (Ethical Committee at ZHUMC) was provided by the Ethical Committee of ZHUMC, Beirut, Lebanon on 12 May 2024.

Funding

No funding sources.

Author contribution

Ali Msheik: Study concept, design, data collection, writing the paper.

Mohamad Yazbeck: Study concept, surgical intervention, design, data collection, writing the paper.

Guarantor

Ali Msheik is the guarantor.

Research registration number

n/a.

Declaration of competing interest

No conflict of interest.
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