Routine biochemical tests and cell blood count were normal. Magnetic Resonance Imaging showed the neurovascular conflict between the right facial nerve and right dolichoectasia of the vertebral artery (Figure 1) . The neurosurgical team recommended microvascular decompression surgery of the facial nerve as a definitive treatment.

Figure 1 (composed): Left and middle inset : axial MRI images, plain and contrast-phase (angio) showing the dilated, ectatic right vertebral artery in close contact with brainstem structures. Right inset: angio-MRI imaging of the vessel tortuosity, right vertebral artery.

The patient refused it and preferred pharmacological treatment. We decided to start the treatment with Clonazepam 2 mg per day. The patient came after several months without any clinical improvement. During these follow-up visits, the neurological examination remained unchanged. Treatment with Baclofen 40 mg per day was started, without any improvement. The patient decided to undergo surgery after unsuccessful pharmacological treatment. The spasms resolved the next postoperative day, without recurrence after a one-year follow-up.

Dolichoectasia of the vertebro-basilar system is a normal anatomic variant, where the arteries are enlarged and tortuous. It is usually not associated with neurological complications. Some cases have reported manifestations of dolichoectasia of vertebro-basilar system with hydrocephaly, bulbar compression, and vestibulocochlear symptoms [3]. In most cases, primary hemifacial spasms and blepharospasm relate to a neurovascular conflict of the anterior inferior cerebellar artery and posterior inferior cerebellar artery, while our patient’s symptoms were caused by dolichoectasia of the vertebral artery. Herewith we emphasize the importance of surgical treatment as a permanent solution to this condition.