A case of trigeminal neuralgia (TGN) associated with hemifacial spasm (HFS) caused by a tortuous vertebro-basilar (V-B) artery is reported. Computed tomographic (CT) scan with contrast enhancement (CE) was significantly useful in the diagnosis of the tortuous V-B artery. A 72-yearold man, complaining of intermittent facial pain and twitching of the left facial muscles, had been unsuccessfully treated with carbamazepine and nerve block. On admission, muscle twitch was seen in the left orbicularis oculi, cheek, and platysma muscles. Sensory disturbance was noted in the territory of the left trigeminal nerve. Corneal reflex was decreased in the left side. CT with CE revealed a linear structure in the prepontine cistern, suggesting a tortuous V-B artery. Left vertebral angiogram showed a markedly enlarged and tortuous V-B artery, protruding into the left cerebellopontine cistern. It was suggested that the tortuous V-B artery was the cause of both symptoms of TGN and HFS. Neurovascular decompression was then successfully performed. Immediately after the operation, the facial pain and the twitch completely disappeared. Eleven such cases have been reported in the literature, but this is the first report of a successfully treated case by neurovascular decompression.