Targeting neurovascular conflict in atypical vagal-glossopharyngeal neuralgia: illustrative case

Background: Vagal-glossopharyngeal neuralgia (VGPN) represents a rare and often misdiagnosed condition. Compared to the more common trigeminal neuralgia, its clinical picture is more heterogeneous due to the multiple functions exerted by the rootlets involved; indeed, presentation may include dysphagia, dysphonia, syncope, bradycardia, and paroxysmal cough alongside the typical, sharp, unilateral pain. Neurovascular conflict at the root entry zone of the lower cranial nerves (CNs) is often considered the underlying cause. Observations: The authors present the case of a 50-year-old female with a 3-year history of recurrent dysphagia-associated pain on the right side of the throat and tongue as well as episodic wheezing and progressive dysphonia. MRI revealed a high-riding posterior inferior cerebellar artery (PICA), causing distortion of the lower CNs. Microvascular decompression was performed through a retrosigmoid approach. Intraoperative findings confirmed the anomalous course of the PICA between CNs IX and X. Lessons: At 6 months, the patient reported resolution of all symptoms. This case is presented along with a 2D operative video illustrating the surgical technique, followed by a comprehensive literature review discussing the diagnosis, treatment, and outcomes of VGPN. https://thejns.org/doi/10.3171/CASE25726.