Severe neurovascular hypertension in a 17-year-old girl cured by microvascular decompression

Abstract

We report a rare case of centrally caused hypertension in a 17-year-old adolescent due to neurovascular compression of the root entry/exit zone of the ninth/tenth cranial nerves of the rostral ventrolateral medulla oblongata on the left side. The patient underwent a comprehensive diagnostic workup to exclude other causes of secondary hypertension. A cranial magnetic resonance imaging (cMRI) indicated a neurovascular compression. The patient underwent microvascular decompression (MVD) twice. After the first MVD, blood pressure values significantly decreased to normotensive levels without any antihypertensive medication. After one year without clinical symptoms, the patient experienced recurrent hypertension and underwent a second MVD. Again, the blood pressure normalized without any medication or clinical symptoms within six-month follow-up. This case report highlights neurovascular compression at brainstem level as an important differential diagnosis of centrally caused hypertension, even in the absence of specific cranial nerve deficits. MVD is an effective treatment option.

FIGURE 1

BP values before and after MVDs. From September 2022 to June 2024, noninvasive and invasive BP measurement was regularly taken multiple times per day with a maximum of four measurements per day which went into analysis. In case of invasive BP measurement, mean values of morning, noon, evening and night were used. (a) After 1st MVD, preop mean systolic 156.2 mmHg and mean diastolic 96.9 mmHg BP values (measured from initial presentation in September 2022 until the 1st MVD) significantly decreased to postop mean systolic 126.9 mmHg and mean diastolic 71.4 mmHg (n = 476 for preop values and n = 74 postop values; mean systolic difference −29.3 ± SEM 2.2 and 95% confidence interval −33.6 to −25.0, mean diastolic difference −25.4 ± SEM 2.1 and 95% confidence interval −29.6 to −21.2). (b) After 2nd MVD, mean systolic 165.3 mmHg and mean diastolic 108.5 mmHg BP values (measured from February 2024 until the 2nd MVD) significantly decreased to postop mean systolic 112.9 mmHg and mean diastolic 62.8 mmHg (n = 11 for preop values and n = 112 postop values; mean systolic difference −52.3 ± SEM 2.9 and 95% confidence interval −58.0 to −46.6, mean diastolic difference −45.7 ± SEM 3.2 and 95% confidence interval −52.1 to −39.3). Unpaired Student's t-test ∗∗∗∗P value < 0.0001. Column bar graph shows mean with standard deviation. x-axis shows systolic and diastolic state preop and postop, y-axis shows BP values in mmHg. preop = preoperative. postop = postoperative. SEM = standard error of the mean.

FIGURE 2

Intraoperative anatomy of 1st and 2nd MVD. Intraoperative anatomy in both operations showing a vessel-nerve contact of the left vagal nerve at the REZ of the RVLM and a vertebral artery (VA) branch and (a) anatomy before first MVD, (b) anatomy before and after second MVD.