Objective: To describe a case of recurrent intractable hiccups (diaphragmatic spasms) developed following microvascular decompression for right hemifacial spasms.

Background: A 59-year-old male was seen by us in the neurology clinic 1 year back with complaints of very frequent and severe left hemifacial spasms. Brain imaging was suggestive of vertebra-basilar dolichoectasia with anterior inferior cerebellar artery (AICA) vascular loop around root entry zone of the left facial nerve. The patient was given options for medical management, botulinum toxin injection, and surgical microvascular decompression for the management of Hemifacial spasms. The patient started medical management but refused botulinum toxin therapy and lost to follow-up. In view of increasing symptoms patient finally underwent microvascular decompression through retro-mastoid craniotomy. During decompression surgery, AICA was found to be forming a stiff loop with severe compression of the root entry zone of the facial nerve and later dividing vagal nerve bundles into two halves. His right AICA was carefully decompressed with Teflon pledgets. The procedure went uneventful and his hemifacial spasms were completely relieved following the procedure but on the 3^rd day of the procedure, the patient developed intractable hiccups suggestive of recurrent severe and very frequent diaphragmatic spasm, not relieved by proton pump inhibitors, metoclopramide, or ondansetron.

Method: Unfortunately, in this patient spasms were shifted from facial muscles to diaphragmatic muscles but his misery persisted.
Possibly, some displacement of AICA over vagal nerves causing its irritation or post-operative edema in and around the brainstem (medullary hiccups center) led to diaphragmatic spasms.

Results: The patient was started on oral baclofen 10 mg twice daily and tab lorazepam 0.25 mg twice daily. Within 4-5 days patient, started showing improvement. Baclofen was further increased to 20 mg twice daily, and his symptoms got completely improved in the next 5-7 days.

Conclusion: Intractable hiccups due to diaphragmatic spasms can be seen following decompressive surgery for vascular loops. But they can be treated with proper medical management.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/facial-to-diaphragmatic-spasms-a-tale-of-misfortune/