Painful tic convulsif: Dual neurovascular compression within the spectrum of cranial nerve hyperactive dysfunction syndromes

Background: Concurrent trigeminal neuralgia (TN) and hemifacial spasm (HFS), historically termed painful tic convulsif, is a rare manifestation of cranial nerve hyperactive dysfunction associated with neurovascular compression. The operative anatomy may involve independent conflicts affecting cranial nerves V and VII or shared compression, particularly in vertebrobasilar dolichoectasia. Methods: We report a case of medication-refractory TN with ipsilateral HFS treated by microvascular decompression (MVD) and integrate the findings with a focused review of 23 studies addressing combined cranial nerve hyperactive dysfunction and dual neurovascular compression. Results: A 35-year-old male presented with TN in the V2-V3 distribution followed by progressive ipsilateral HFS. High-resolution MRI showed neurovascular contact of the trigeminal nerve by the superior cerebellar artery and facial nerve compression by a separate posterior inferior cerebellar artery loop. Retrosigmoid MVD confirmed independent dual conflicts. Decompression of both nerves produced immediate resolution of pain and spasms, with sustained symptom-free status at two-year follow-up. Published reports support neurovascular compression as the principal surgically treatable mechanism in painful tic convulsif, with independent dual conflicts and shared ectatic vertebrobasilar compression both described. Conclusions: Painful tic convulsif is best considered within the spectrum of cranial nerve hyperactive dysfunction. Comprehensive inspection of both the trigeminal and facial nerves during MVD is essential, because missed offending vessels may lead to persistent or recurrent symptoms. When all responsible conflicts are identified and decompressed, single-session MVD can provide durable relief in appropriately selected patients.