Neurovascular compression in patients with stress-related somatic complaints

Abstract

This case series explores the complex interplay between stress-related somatic complaints and neurovascular compression, specifically focusing on anterior inferior cerebellar artery (AICA) vascular loops. Three female patients presented with diverse neurological symptoms, including facial discomfort, vertigo, tinnitus, and headache, often accompanied by anxiety and psychosocial stressors. Magnetic resonance imaging revealed AICA loops in all patients (unilateral in two, bilateral in one). While the AICA loops may contribute to the symptom complex, all patients experienced significant improvement with combined psychotropic (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, antipsychotics) and neuropharmacological (propranolol) treatment. This suggests a significant role of psychological factors and highlights the importance of a holistic approach. This series underscores the need for clinicians to consider neurovascular compression syndromes in patients with stress-related somatic complaints and emphasizes the potential benefit of a multidisciplinary approach involving both neurological and psychiatric perspectives. Further research is warranted to clarify the precise role of AICA loops in these presentations and optimize therapeutic strategies.

Patients with stress-related somatic complaints often present with diverse neurological symptoms, posing diagnostic challenges. Neurovascular compression syndromes, such as anterior inferior cerebellar artery (AICA) vascular loops, have been implicated as potential etiological factors, though they remain under-recognized in psychiatric settings. AICA loops, where a single vessel, typically the AICA, loops around the vestibulocochlear and facial nerves at the cerebellopontine angle, can extend into the internal auditory canal.[1] These structures are clearly depicted on 3D FIESTA/CISS magnetic resonance imaging (MRI), while time-of-flight magnetic resonance angiography visualizes the vascular loop’s course. AICA loops are classified based on their location: Type I (within the cerebellopontine angle), Type II (extending less than 50% into the internal auditory canal), and Type III (extending more than 50% into the canal).[2] This case series explores the presentation, diagnosis, and management of three patients with stress-related somatic complaints and AICA vascular loops.

CASE REPORTS

Case 1

A 35-year-old married woman, educated up to high school level, a homemaker by occupation, from a rural background, and belonging to a lower socio-economic status, presented to the psychiatry Outpatient Department (OPD) accompanied by her mother. She had been referred by a physician whom she had consulted for chronic multiple bodily complaints. Her physical examination and investigations were unremarkable.

She reported a five-year history of mild, diffuse pain involving the head, neck, hands, and limbs, which worsened with physical activity and improved with rest. She also reported heaviness in both cheeks, numbness around the mouth, vertigo, and right-sided facial weakness. She exhibited anxiety (“ghabrahat”) and reassurance-seeking behavior, despite normal routine investigations. Additionally, she described intermittent back pain, episodes of breathlessness, palpitations, and a burning sensation in the mid-chest region. She also complained of poor food tolerance, alternating constipation and diarrhea, and irregular menstrual cycles.

Over the years, she sought consultations from orthopedics, neurologists, and physicians. She had also pursued Ayurvedic and homeopathic treatments, which provided only transient relief in her symptoms. Her medical history included abdominal tuberculosis, intermittent cervical spondylitis, and recurrent miscarriages. On further exploration, she disclosed psychosocial stressors, including her husband’s alcohol use and lack of responsibility toward the family. This, coupled with an absence of support from her parents and in-laws, contributed to her distress. She denied experiencing a low mood or using any substance herself.

Mental status examination revealed a well-groomed woman who sat quietly, occasionally wincing while touching her body to describe her symptoms. She was detailed and elaborate in explaining her physical complaints. Her speech was normal, mood appeared euthymic, and her thought content was predominantly preoccupied with somatic concerns. Cognitive functions were intact, and she demonstrated good insight and preserved judgment. MRI revealed a left-sided AICA loop. She was diagnosed with somatic symptom disorder with underlying anxiety and started on tablet duloxetine 40 mg/day and aripiprazole 5 mg/day, after which her symptoms improved significantly over the next six months.

Case 2

A 25-year-old female presented with a two-year history of episodic restlessness, panic attacks, and somatic symptoms such as facial tingling, dizziness, and tinnitus that intensified under stress. One year ago, she was hospitalized and diagnosed with chronic benzodiazepine abuse but discontinued treatment after a 3-day stay, against medical advice. Ten days later, she returned with irritability, palpitations, agitation, and insomnia and was prescribed tablet chlordiazepoxide 25 mg, sertraline 25 mg, and pantoprazole 40 mg daily. She developed diarrhea after one day of this regimen and discontinued therapy at home. Now, she presented to the hospital with a week-long history of multiple somatic complaints, difficulty in initiating and maintaining sleep, increased fatigue, and headache. Clinically, somatoform disorder was diagnosed. Brain MRI revealed a left-sided AICA loop [Figure 1], while other investigations were unremarkable. She responded well to treatment with escitalopram, propranolol, and clonazepam.

Figure 1.

Magnetic resonance imaging showing anterior inferior cerebellar artery loops

Case 3

A 39-year-old female presented with a constellation of distressing symptoms which were acute in onset, characterized by a unilateral throbbing headache, associated with photophobia and phonophobia. This was accompanied was episodes of nausea and vomiting when the intensity of the headache was severe. She also had pain in her neck radiating to her left arm, which was gradual in onset and dull-aching type. She also experienced vertigo episodes 2–3 times per week, each lasting 20–30 minutes, accompanied by intermittent high-pitched tinnitus and occasional diplopia, which she found particularly distressing. The onset of these symptoms was temporally related to a depressive episode that occurred during the COVID-19 lockdown. There was no history of any past hospitalization or surgeries. A significant factor in the patient’s case was the substantial caregiver burden she faced after her son’s autism diagnosis, which acted as a major contributor to her elevated stress levels and potential onset or worsening of her symptoms.

Mental status examination revealed a well-groomed woman who sat quietly, occasionally wincing while touching her body to describe her symptoms. She was detailed and elaborate in explaining her physical complaints. Her speech was normal, mood appeared euthymic, and thought content was predominantly preoccupied with somatic concerns. Cognitive functions were intact, and she demonstrated good insight and preserved judgment. Her neurological examination and routine investigations were normal. MRI brain revealed bilateral AICA loops, Type II on the right and Type I on the left side. She showed marked improvement over six months with tablet sertraline (up to 50 mg daily) and tablet propranolol (20 mg daily). Concurrently, both family therapy and behavior therapy for her son were initiated to support the pharmacological management.

DISCUSSION

This case series highlights the intricate relationship between stress-related somatic complaints and neurovascular compression, particularly involving AICA vascular loops. While these loops are sometimes observed in asymptomatic individuals, their presence in these patients with diverse neurological symptoms raises the question of their clinical significance. The cases presented demonstrate a complex interplay of neurological, psychological, and social factors, suggesting that AICA loops may contribute to, but are unlikely to be the sole cause of, the patients’ symptoms.

The pathophysiology of neurovascular compression, as seen in conditions like trigeminal neuralgia and hemifacial spasm, involves a pulsating vessel compressing a nerve, potentially leading to demyelination and dysfunction. In the case of AICA loops impinging on the vestibulocochlear nerve, this neurovascular compression is thought to trigger vestibular paroxysmia (VP), characterized by brief episodes of vertigo due to demyelination at the nerve’s entry zone.[3,4]

However, the symptoms observed in the above cases, such as facial discomfort, tinnitus, headache, and other neurological complaints, extend far beyond classic VP.[5] Such a broad symptom profile suggests that an AICA loop may predispose individuals to more extensive neural dysfunction. Potential mechanisms include central sensitization, where repeated peripheral nerve irritation enhances central neuronal responsiveness and altered neuronal excitability arising from ongoing demyelination or vascular pulsatility.[6,7] While imaging often reveals AICA loops in many asymptomatic individuals, the fact that some patients experience multifaceted symptoms indicates a possible pathophysiological spectrum. Further investigation is warranted to clarify whether central sensitization or other neural network changes contribute to this expanded clinical presentation.

The significant improvement observed with psychotropic medications (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, antipsychotics) and anxiolytics in all three patients points toward a crucial role of psychological factors in their presentations. Stress, anxiety, and psychosocial stressors, such as recurrent miscarriages and caregiver burden, appear to exacerbate symptoms. This implies that while an AICA loop may contribute to neurological issues, it more likely serves as a trigger or amplifier in those with existing psychological vulnerability. This aligns with the “vulnerable brain” model, in which preexisting anxiety, depression, or chronic stress lowers the threshold for symptoms when neurovascular conflict occurs.[8]

It is also important to consider the possibility of a functional component to the patients’ symptoms. Somatic symptom disorder is a prevalent condition in psychiatric practice, marked by distressing physical symptoms accompanied by excessive and persistent thoughts, emotions, or behaviors in response to those symptoms. The patients in this series exhibited some features consistent with this diagnosis, such as reassurance-seeking behavior and a focus on physical sensations.[9] Unlike purely functional somatic syndromes, our cases were distinguished by objective MRI evidence of AICA loops. This raises the possibility of a combined pathology presentation, where structural vascular anatomy interacts with psychological factors to create a complex clinical picture.

The differential diagnosis for these presentations is broad, encompassing various neurological and psychiatric conditions. It is essential to distinguish VP from other causes of vertigo, such as vestibular migraine, benign paroxysmal positional vertigo, and Ménière’s disease. Additionally, central neurological conditions like multiple sclerosis, brainstem tumors, and stroke must be considered, particularly when neurological signs are atypical.[4] From a psychiatric perspective, it is important to distinguish somatic symptom disorder from other anxiety disorders, such as panic disorder and generalized anxiety disorder. A thorough clinical evaluation, including a detailed neurological examination, neuroimaging studies, and a comprehensive psychiatric assessment, is essential for accurate diagnosis and treatment planning.

The management of these complex cases requires a multidisciplinary approach involving both neurologists and psychiatrists. While medications targeting neurovascular compression, such as carbamazepine or oxcarbazepine,[10] might be considered in some cases, the significant response to psychotropic medications in our patients suggests that addressing the psychological component is crucial. Cognitive behavioral therapy and other forms of psychotherapy can be helpful in managing anxiety, stress, and somatic symptoms. Additionally, addressing psychosocial stressors such as caregiver burden, via family counseling or participation in support groups, can significantly enhance overall well-being and help alleviate symptoms.

CONCLUSION

MRI scans in all three patients revealed an AICA vascular loop, supporting neurovascular compression as a potential contributing factor. Treatment with psychotropic and neuropharmacological agents resulted in significant symptom relief across all cases, demonstrating the efficacy of a combined approach. These cases highlight the importance of considering neurovascular compression syndromes, such as AICA vascular loops, in patients with stress-related somatic complaints. A multidisciplinary treatment strategy integrating psychotropic and neuropharmacological therapies can effectively manage such presentations, emphasizing the need for collaboration between psychiatry and neurology. Further research is needed to clarify the precise role of AICA loops in these complex presentations and to optimize treatment strategies.

Authors’ contributions

All authors contributed equally to compilation of clinical case details, manuscript, critical analysis of literature and discussion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Data availability statement

Not applicable.

Funding Statement

Nil.