Isolated Palsy of the Cisternal Segment of the Hypoglossal Nerve Due to Arterial Dissection of the V4 Segment of the Vertebral Artery: A Case Report With a Side Note on Nerve Trunk Ischemia

Abstract

We describe the case of a 57-year-old woman who developed severe left-sided neck pain followed by difficulty chewing, oropharyngeal dysphagia, and dysarthria. Clinically, she developed an isolated left-sided deviation of the tongue with protrusion; an isolated cisternal hypoglossal nerve palsy. A magnetic resonance angiogram imaging study revealed a left V4 cisternal vertebral artery dissection with normal diffusion-weighted imaging of the lower medulla. We outline the anatomy, histology, and pathophysiology of ischemic injury of nerve trunks and briefly review the recent trials of vertebral and carotid artery dissections.

Hypoglossal Nerve Neuropathies—Analysis of Causes and Anatomical Background

“…The pseudoaneurysm is a serious complication of the injury to the arterial walls and in 12% to 17% of patients, it occurs within five years after the initial damage [46,47]. The damage to the nerve develops in two basic ways: direct compression or ischemia secondary to ligation or avulsion of the vasa nervorum [48]. Occlusive disease of the ICA can be caused by spasms, thrombosis, aneurysm, mural fibrosis, contusion, and, most frequently, intimal tear [49,50].…”

Isolated hypoglossal nerve neuropathy in vertebral dolichoectasia: Microvascular decompression by vessel transposition with Teflon cuff

“…[14] e literature describes cases of nerve damage at the medullary segment, when the vertebral artery causes compression of the medulla oblongata and, accordingly, the motor nuclei of the XII nerve. [14,20,26,28] In the cisternal segment, HN damage can be caused by contact with the V4 segment of the vertebral artery, [1,17,23,24] its dissection, [13,15,16] thrombosis, kinking [21] and abnormal course, [18] as well as a consequence of an infectious process. [10] Tumors are the most common cause of NHN and can affect every segment of the nerve, but most commonly the one passing through the canal of the HN at the base of the skull.…”

“…In the cisternal segment, HN damage can be caused by contact with the V4 segment of the vertebral artery,[ 1 , 17 , 23 , 24 ] its dissection,[ 13 , 15 , 16 ] thrombosis, kinking[ 21 ] and abnormal course,[ 18 ] as well as a consequence of an infectious process. [ 10 ]…”