Trigeminal neuralgia plus hemifacial spasm caused by a dilated artery: a case of painful tic convulsif syndrome

A 61-year-old woman came to our neurosurgery clinic complaining of spasms and episodic pain on the left side of her face; the spasms had been present for 20 years and the pain for 5 years. She said that initially the facial spasms affected only the corner of her left eye but over the years progressed to involve most of the muscles of the lower left side of her face. For the past 7 years, she had been given botulinum toxin injections twice per year, which had provided some relief. The pain, which developed alongside the spasms, was characterised by frequent episodes of excruciating, lancinating pain—rated by the patient as very severe using a visual analogue pain scale—along the ophthalmic and maxillary branches of the trigeminal nerve. The woman described several things—including chewing, touching her face, and brushing her gums—that clearly triggered the pain. Taking carbamazepine lessened the pain, but she stopped the drug because she could not tolerate the associated drowsiness. She never had any problems affecting the right side of her face. A neurological examination was normal, including intact corneal reflexes. She had no medical history of a stroke, transient ischaemic attack, or demyelinating disease.