Introduction We report a case of unilateral mydriasis following microvascular decompression for hemifacial spasm complicated by pneumocephalus through the operative incision. Case report A 50-year-old gentleman with a past medical history of hypertension presented with a left hemifacial spasm. He received left-side microvascular decompression under general anaesthesia. After operation, the patient's right pupil was found to be markedly dilated (6 mm), with diminishing direct or consensual light reflex. The left pupil was 2 mm and also nonreactive to light. Emergent head CT revealed pneumocephalus and no intracranial haemorrhage or any other abnormalities. We concluded that the right oculomotor must have been distorted by pneumocephalus. The patient was extubated in the operation room. The right pupil returned to normality within the next 6 h. Postoperative course was uneventful other than insomnia in the first 24 h. Conclusion We think that pneumocephalus leads to brainstem shift and distorted the right oculomotor nerve. Unilateral mydriasis is alarming after neurosurgery and must be interpreted with caution.
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