The patient came to the clinic 06-May-2014 complaining of agonizing right trigeminal neuralgia for more than 3 years, involving the three divisions of the trigeminal nerve. The patient is a known diabetic for 6 years under treatment. He underwent radiofrequency ablation 27-August-2013 without improvement elsewhere and he has reports as having AVM. The patient is receiving Tegretol CR 600 three times a day, Lyrica 75 mg  three times a day and Liorezal 10 mg three times a day without any benefit. MRI of the brain done 06-February-2012 of bad quality without proper information.

On examination; the patient has congenital macular deformity disabling him to see directly. The right VI VII and VIII are affected in the process. Otherwise the patient is neurologically free. The patient was sent for new MRI of the brain with contrast with MRA, MRV of the brain with special protocol for the posterior fossa. No AVM was found and it was possible to see the right PICA pushing up the right trigeminal nerve.

Right retromastoid approach in the setting position. Craniotomy of the right side with bone defect abutting the transverse sinus and the right sigmoid. The dura was opened parallel to this sinuous angle. Supra-right infratentorial approach to the right trigeminal nerve. There was very small Dandy vein, which was coagulated. The arachnoid membrane surrounding the trigeminal nerve was thick. It was sharply opened. The PICA was severely adherent to the brainstem, trigeminal nerve and the facial nerve. It was necessary to make dissection of the artery along all these structures to obtain its release from under the trigeminal nerve. The nerve was split by the artery into 2 parts and the motor branch was preserved. The trigeminal nerve after release from the arterial loop became lax and the cavity under the nerve was filled by Teflon piece and Gelfoam. No arterial bleeding from PICA was seen during the procedure. Hemostasis with water-tight closure of the dura and the bone was returned to its place and routine closure of the wound.

Smooth postoperative recovery. The patient showed dense left side plegia which started to resolve over the next hours. The neuralgia disappeared.

This case was complicated with some regional inflammatory process, which led to massive adherence of the PICA to the brainstem, trigeminal nerve and even the facial nerve.

The vigorous dissection of the PICA resulted in spasm of this artery, which resolved over the next postoperative period.

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