PMC9986834_01
Operative microscope view of left lower cranial nerves. a A loop of the PICA (arrow) can be seen distorting the upper rootlets of the Xth nerve, with the IXth nerve more rostral and the XIth nerve more caudal. b The individual rootlets of the vagus nerve have been exposed, with the most rostral rootlet, XA, being stimulated. c The more caudal rootlets of the vagus are exposed, with the most caudal rootlet, XE, being stimulated. d The PICA (arrow) has been displaced anterocaudally.
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F1
At the beginning of the exposure, the patient had a loop of the PICA compressing the IXth and most rostral rootlets of the Xth cranial nerve (Fig. 1a). The patient had five vagus nerve rootlets on her left side (Fig. 1b, c). PICA was mobilized anteroinferiorly, allowing complete decompression of the lower cranial nerves without the need to sacrifice any nerve rootlets (Fig. 1d). Post-operatively, the patient had temporary dysphagia (7 days), temporary hoarseness (1 month), and complete resolution of her glossopharyngeal neuralgia and hemi-layngopharyngeal spasm.
Video of the anaesthetic monitor during stimulation of the most caudal rootlet of the left vagus nerve, XE. The upper trace, ECG, demonstrates profound bradycardia when the stimulation (2.0 mA, 100 mus, 50 Hz) is turned "on."
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F2
When the stimulation was increased to 0.2 mA at 50 Hz, there was a profound bradycardia when vagus rootlet E was stimulated (Fig. 2) but no similar response from any of the other rootlets.