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Halalmeh DR, Asad MY, Atallah OA, Sbeih AI, Alrashdan M, Richardson AM, Moisi MD, Sbeih IA. Predictors of Surgical Outcomes in Patients with Abducens Nerve Schwannoma: A Comprehensive Systematic Review and a Case Report. World Neurosurg 2023; 179:204-215.e4. [PMID: 37652133 DOI: 10.1016/j.wneu.2023.08.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Abducens nerve (AN) schwannomas are extremely rare tumors. Clinical characteristics and factors that influence postoperative outcomes are not well defined. OBJECTIVE To characterize clinical features of AN schwannomas and predictors of surgical outcomes. METHODS PRISMA-guided systematic review of the literature on AN schwannomas was performed. Subsequently, univariate and multivariate regression analyses were performed to identify the predictive value of variables that influence postoperative outcomes. RESULTS A total of 42 studies with 55 patients were evaluated. The mean age at presentation was 43.9 ± 14.6 years. The most common presenting symptom was cranial nerve VI palsy (69.1%). Cavernous sinus (49.1%) and prepontine cistern (36.3%) were the most commonly involved locations. Complete recovery after surgery was seen in 36.3% at a median follow-up of 28.4 ± 25.8 months. Preoperative AN palsy (P < 0.001), suboccipital approach (P = 0.007), and subtotal resection of tumor (P = 0.044) were significant protective factors for postoperative complications. Prepontine location and postoperative complications were poor prognostic indicators of AN recovery (odds ratio [OR], 0.10, P = 0.030 and OR, 0.10, P = 0.028, respectively). Subtotal resection was significantly correlated with higher odds of AN recovery (OR, 6.06; P = 0.040). CONCLUSIONS AN schwannomas are rare but serious tumors that can cause significant morbidity, with only approximately one third of patients showing complete recovery after surgery. The suboccipital approach was a protective factor for postoperative complications, especially when combined with subtotal resection. Knowledge of these factors along with tumor characteristics helps optimize surgical planning and preoperative counseling.
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Affiliation(s)
- Dia R Halalmeh
- Department of Neurosurgery, Hurley Medical Center, Flint, Michigan, USA.
| | - Mahmoud Y Asad
- Department of Neurosurgery, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Omar A Atallah
- Department of Neurosurgery, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | | | | | - Angela M Richardson
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marc D Moisi
- Department of Neurosurgery, Hurley Medical Center, Flint, Michigan, USA
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Bal J, Bruneau M, Berhouma M, Cornelius JF, Cavallo LM, Daniel RT, Froelich S, Jouanneau E, Meling TR, Messerer M, Roche PH, Schroeder HWS, Tatagiba M, Zazpe I, Paraskevopoulos D. Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section. Part I: oculomotor and other rare non-vestibular schwannomas (I, II, III, IV, VI). Acta Neurochir (Wien) 2022; 164:285-297. [PMID: 34755208 DOI: 10.1007/s00701-021-05048-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/29/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogeneous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear, and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations. METHODS A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the first of a three-part series describing non-vestibular schwannomas (I, II, III, IV, VI). RESULTS A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies and follow-up management. CONCLUSION This article represents the consensually derived opinion of the task force with respect to the treatment of non-vestibular schwannomas. For each of these tumours, the management of these patients is complex, and for those which are symptomatic tumours, the paradigm is shifting towards the compromise between function preservation and progression-free survival.
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Affiliation(s)
- Jarnail Bal
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK
| | - Michael Bruneau
- Department of Neurosurgery, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Moncef Berhouma
- Neuro-Oncologic and Vascular Department, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Luigi M Cavallo
- Department of Neurosurgery, University Hospital of Naples Federico II, Napoli, Italy
| | - Roy T Daniel
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, 42 rue du Bugnon, 1011, Lausanne, Switzerland
| | | | - Emmanuel Jouanneau
- Skull Base and Pituitary Neurosurgical Department, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | | | - Mahmoud Messerer
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, 42 rue du Bugnon, 1011, Lausanne, Switzerland
| | - Pierre-Hugues Roche
- Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Idoya Zazpe
- Department of Neurosurgery, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Dimitrios Paraskevopoulos
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK.
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Langlois AM, Iorio-Morin C, Faramand A, Niranjan A, Lunsford LD, Mohammed N, Sheehan JP, Liščák R, Urgošík D, Kondziolka D, Lee CC, Yang HC, Atik AF, Mathieu D. Outcomes after stereotactic radiosurgery for schwannomas of the oculomotor, trochlear, and abducens nerves. J Neurosurg 2021; 135:1044-1050. [PMID: 33482633 DOI: 10.3171/2020.8.jns20887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cranial nerve (CN) schwannomas are intracranial tumors that are commonly managed by stereotactic radiosurgery (SRS). There is a large body of literature supporting the use of SRS for vestibular schwannomas. Schwannomas of the oculomotor nerves (CNs III, IV, and VI) are rare skull base tumors, occurring close to the brainstem and often involving the cavernous sinus. Resection can cause significant morbidity, including loss of nerve function. As for other schwannomas, SRS can be used to manage these tumors, but only a handful of cases have been published so far, often among reports of other uncommon schwannoma locations. METHODS The goal of this study was to collect retrospective multicenter data on tumor control, clinical evolution, and morbidity after SRS. This study was performed through the International Radiosurgery Research Foundation. Patients managed with single-session SRS for an oculomotor cranial nerve schwannoma (CN III, IV, or VI) were included. The diagnosis was based on diplopia or ptosis as the main presenting symptom and anatomical location on the trajectory of the presumed cranial nerve of origin, or prior resection confirming diagnosis. Demographic, SRS dose planning, clinical, and imaging data were collected from chart review of the treated patients. Chi-square and Kaplan-Meier analyses were performed. RESULTS Seven institutions submitted data for a total of 25 patients. The median follow-up time was 41 months. The median age at the time of treatment was 52 years. There were 11 CN III schwannomas, 11 CN IV schwannomas, and 3 CN VI schwannomas. The median target volume was 0.74 cm3, and the median marginal dose delivered was 12.5 Gy. After SRS, only 2 patients (including the only patient with neurofibromatosis type 2) had continued tumor growth. Crude local control was 92% (23/25), and the 10-year actuarial control was 86%. Diplopia improved in the majority of patients (11/21), and only 3 had worsening following SRS, 2 of whom also had worsened ptosis, both in the context of tumor progression. CONCLUSIONS SRS for schwannomas of the oculomotor, trochlear, and abducens nerves is effective and provides tumor control rates similar to those for other cranial nerve schwannomas. SRS allows improvement of diplopia in the majority of patients. SRS should therefore be considered as a first-line treatment option for oculomotor nerve schwannomas.
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Affiliation(s)
- Anne-Marie Langlois
- 1Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Québec, Canada
| | - Christian Iorio-Morin
- 1Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Québec, Canada
| | - Andrew Faramand
- 2Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Ajay Niranjan
- 2Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 2Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Nasser Mohammed
- 3Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- 3Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Roman Liščák
- 4Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Dušan Urgošík
- 4Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Douglas Kondziolka
- 5Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Cheng-Chia Lee
- 6Department of Radiation Oncology and Neurological Surgery, Taipei Veterans Hospital, Taipei, Taiwan; and
| | - Huai-Che Yang
- 6Department of Radiation Oncology and Neurological Surgery, Taipei Veterans Hospital, Taipei, Taiwan; and
| | - Ahmet F Atik
- 7Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David Mathieu
- 1Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Québec, Canada
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Alhussain ZM, Alharbi SK, Farrash F. Abducens nerve schwannoma of the cavernous sinus: A case report and literature review. Surg Neurol Int 2020; 11:402. [PMID: 33365165 PMCID: PMC7749956 DOI: 10.25259/sni_362_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/30/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Schwannomas of the abducens nerve are a rare pathology and are encountered less within the cavernous sinus. We describe a case of sixth cranial nerve schwannoma, in the cavernous sinus. Case Description: A 50-year-old lady, presented with 2 years history of double vision and left facial numbness that started 6 months before presentation, found to have hyperintense lobulated mass at the left cavernous sinus extending into Meckel’s cave with bony remodeling on magnetic resonance imaging. She underwent left frontotemporal craniotomy, combined extra-intradural approach, gross total resection. She had a gradual recovery of the sixth cranial nerve function. Conclusion: Abducens nerve schwannoma of the cavernous sinus is a rare and challenging tumor. However amenable to surgical intervention with favorable neurological outcome.
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Affiliation(s)
- Zeyad M Alhussain
- Department of Neuroscience, Division of Neurological Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Shatha K Alharbi
- Department of Neuroscience, Division of Neurological Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Faisal Farrash
- Department of Neuroscience, Division of Neurological Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Mariniello G, de Divitiis O, Caranci F, Dones F, Maiuri F. Parasellar Schwannomas: Extradural vs Extra-Intradural Surgical Approach. Oper Neurosurg (Hagerstown) 2019; 14:627-638. [PMID: 28961901 DOI: 10.1093/ons/opx174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 07/12/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Schwannomas of the parasellar region may arise from the trigeminal, oculomotor, trochlear, and abducens nerves. OBJECTIVE To define the tumor origin, location, and dural relationship (extradural vs extra-intradural vs cisternal) on preoperative magnetic resonance imaging (MRI), in order to plan the best surgical approach (purely extradural vs extra-intradural). METHODS Twenty-four patients with parasellar schwannomas who underwent surgery were retrospectively analyzed. Twenty arose from the trigeminal nerve (7 intracavernous and 13 within the Meckel's cave), 3 from the oculomotor nerve, and 1 from the abducens nerve. The preoperative identification of the tumor location (extradural vs extra-intradural vs cisternal) and the nerve of origin was defined on MR sequences. All patients were operated on through a pterional approach (extradural or extra-intradural route). RESULTS The tumor location was correctly defined on MRI in 22 out of 24 cases (92%) and the nerve of origin in 22 (92%). An extradural approach without intradural exploration was performed in all 5 intracavernous trigeminal schwannomas, in 11 out of 13 of the Meckel's cave, and in 2 schwannomas of the oculomotor nerve. Two schwannomas of the Meckel's cave with transgression of the medial dural wall, 1 of the oculomotor nerve, and the abducens nerve schwannoma required an extra-intradural approach. Complete tumor resection was obtained in 19 out of 24 cases (80%). CONCLUSION The pterional extradural approach is sufficient for Dolenc type I and II trigeminal schwannomas, excepting for those transgressing the inner dural layer. Schwannomas of the oculomotor and abducens nerves with cisternal location require an extradural-intradural approach.
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Affiliation(s)
- Giuseppe Mariniello
- Department of Neurosciences, Reproductive, and Odontostomatologic Sciences, Neurosurgical Clinic, "Federico II" University School of Medicine, Naples, Italy
| | - Oreste de Divitiis
- Department of Neurosciences, Reproductive, and Odontostomatologic Sciences, Neurosurgical Clinic, "Federico II" University School of Medicine, Naples, Italy
| | - Ferdinando Caranci
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Flavia Dones
- Department of Neurosciences, Reproductive, and Odontostomatologic Sciences, Neurosurgical Clinic, "Federico II" University School of Medicine, Naples, Italy
| | - Francesco Maiuri
- Department of Neurosciences, Reproductive, and Odontostomatologic Sciences, Neurosurgical Clinic, "Federico II" University School of Medicine, Naples, Italy
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Nakamizo A, Matsuo S, Amano T. Abducens Nerve Schwannoma: A Case Report and Literature Review. World Neurosurg 2019; 125:49-54. [PMID: 30716483 DOI: 10.1016/j.wneu.2019.01.123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/11/2019] [Accepted: 01/14/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Abducens nerve function seldom shows complete recovery after removal of abducens nerve schwannoma. No cases with unclear course of the abducens nerve during surgery have been reported to achieve complete recovery of nerve function. CASE DESCRIPTION We report the case of a 44-year-old woman who presented with occasional dysgeusia without abducens nerve paresis. Magnetic resonance imaging showed a solid tumor about 2 cm in diameter at the left cerebellopontine cistern. Cranial nerves except the abducens nerve appeared intact. The tumor was removed via suboccipital craniotomy. The abducens nerve was totally invisible on the surface of the tumor throughout the procedure. Only short segments of abducens nerve were identifiable at around Dorello's canal and the root exit zone. The tumor was resected by subcapsular dissection, and part of the tumor capsule was preserved as a scaffold for nerve generation, although whether any abducens nerve was included remained uncertain. Histopathologic examination confirmed World Health Organization grade I schwannoma. Postoperatively, the patient presented with complete left abducens nerve paresis and diplopia, but abducens nerve function began to improve 3 months later and had completely recovered within 16 months after surgery. CONCLUSIONS This represents the first description of abducens nerve schwannoma in which the course of the abducens nerve was intraoperatively unclear but complete recovery was achieved. In such cases, intentional subcapsular dissection may potentiate functional recovery.
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Affiliation(s)
- Akira Nakamizo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan.
| | - Satoshi Matsuo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | - Toshiyuki Amano
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
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Radiosurgery in trochlear and abducens nerve schwannomas: case series and systematic review. Acta Neurochir (Wien) 2017; 159:2409-2418. [PMID: 29022157 DOI: 10.1007/s00701-017-3348-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 09/29/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Schwannomas involving the occulomotor cranial nerves (CNs; III, IV and VI), can be disabling, due to the associated diplopia and decreased quality of life and are extremely rare. We evaluated the role of Gamma Knife surgery (GKS) in these cases. METHODS Five patients with CN IV and VI schwannomas (three and two, respectively) were treated in Lausanne University Hospital between 2010 and 2015. Four benefitted from upfront GKS and one from a combined approach (planned subtotal resection followed by GKS), due to a large preoperative tumour volume (size, 3 × 2 × 2.5 cm; volume, 7.9 ml), with symptomatic mass effect and oedema, as well as an entrapement cyst at the brainstem interface, in a young patient. Neuro-ophtalmological evaluation was performed at baseline and during each follow-up time-point. A systematic literature review is presented and compared to the present report. RESULTS The mean follow-up was 44.4 months (12-54). Initial clinical presentation was diplopia in four cases and cavernous sinus syndrome in one. The marginal dose was 12 Gy in all cases. The mean target volume was 1.51 cm3 (0.086-5.8). The mean prescription isodose volume (PIV) was 1.71 cm3 (0.131-6.7). At last follow-up, all patients presented with disappearance of the baseline symptoms. Tumour control was achieved in 100%, with decrease in volume in all cases. The systematic review analysed 11 peer-reviewed studies, with a total of 35 patients. For uniformly reported CN VI, the mean marginal radiation dose ranged between 12 and 12.5 Gy, with disappearance of symptoms in 12.5%, improvement in 31.25%, stabilisation in 6.25%, worsening in 12.5%. Tumour volume decreased in all cases. CONCLUSIONS Our data suggest that first intention GKS is a safe and effective option for patients with small to medium size oculomotor schwannomas, providing a high rate of clinical alleviation and tumour control. When the initial tumour volume is too large for first intention GKS, a combined approach with planned subtotal resection followed by GKS can be performed, with favourable and comparable outcomes as in upfront GKS.
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Factors Associated with Abducens Nerve Recovery in Patients Undergoing Surgical Resection of Sixth Nerve Schwannoma: A Systematic Review and Case Illustration. World Neurosurg 2017; 104:883-899. [PMID: 28465275 DOI: 10.1016/j.wneu.2017.04.146] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 04/21/2017] [Accepted: 04/22/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Limited or no literature exists identifying factors associated with functional nerve recovery in patients undergoing resection of sixth cranial nerve (CN VI) schwannomas. METHODS A systematic review of literature was performed on CN VI schwannomas that were treated surgically. Synthesizing the findings pooled from the literature, we investigated associations of patient demographics and clinical characteristics with postsurgical CN VI functional recovery in multivariable regression models. In addition, we present the findings of an adolescent woman surgically managed for intracavernous CN VI schwannoma. Complete encasement of the cavernous segment of the internal carotid artery is unique to our case. RESULTS We synthesized data of 32 patients from 29 studies, and our index case. Overall, the mean age of the patients was 44.0 ± 16.5 years, and approximately 52% (n = 17) were female. Most tumors were left-sided (n = 18; 54.5%), with an average size of 3.46 ± 1.71 cm. The most common location was cisternal (n = 11; 33%), followed by cavernous sinus (CS) proper (n = 9; 27%), cisterocavernous (n = 8; 24%), orbital (n = 4; 12%) and caverno-orbital (n = 1; 3%). CN VI recovery was reported in less than half the cohort (n = 14; 45%). Tumor extension in the CS was significantly associated with lesser likelihood (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01-0.98; P = 0.048) of postsurgical CN VI recovery. Although female gender (OR, 0.86; 95% CI, 0.07-10.09; P = 0.906), large tumor size (>2.5 cm) (OR, 0.45; 95% CI, 0.07-2.89; P = 0.397), and solid consistency (OR, 0.37; 95% CI, 0.03-4.19; P = 0.421) were associated with lesser odds for recovery, these were not statistically significant. Likewise, although gross total resection (OR, 6.28; 95% CI, 0.33-118.25; P = 0.220) was associated with higher odds of nerve recovery, the estimates were statistically insignificant. CONCLUSIONS CS involvement is associated with lesser odds for functional nerve recovery in patients undergoing surgical resection for CN VI schwannoma.
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Takase H, Araki K, Seki S, Takase K, Murata H, Kawahara N. Unique Diagnostic Features and Surgical Strategy for Intracranial Carotid Sympathetic Plexus Schwannoma: Case Report and Literature Review. World Neurosurg 2017; 98:876.e1-876.e8. [DOI: 10.1016/j.wneu.2016.11.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/18/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
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Prasad GL, Sharma MS, Kale SS, Agrawal D, Singh M, Sharma BS. Gamma Knife radiosurgery in the treatment of abducens nerve schwannomas: a retrospective study. J Neurosurg 2016; 125:832-837. [PMID: 26824380 DOI: 10.3171/2015.8.jns151140] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Of the intracranial schwannomas, those arising from the vestibular nerves are the most common. Abducens nerve (AN) schwannomas are very rare, and there is limited literature on their optimal management. Therapeutic options include surgery and/or stereotactic radiosurgery. The aim of this study was to evaluate the role of Gamma Knife radiosurgery (GKRS) in these sixth cranial nerve (CN) schwannomas. METHODS The authors performed a retrospective analysis of patients who had undergone GKRS for intracranial tumors at their institute in the period from 2003 to 2010. Inclusion criteria were as follows: isolated AN paresis on presentation, a lesion along the course of the sixth CN, and imaging features characteristic of a schwannoma. Patients with other CN deficits and neurofibromatosis Type 2 were excluded. Symptomatic improvement was defined as the resolution of or an improvement in diplopia noted on a subjective basis or as an improvement in lateral eyeball excursion noted objectively on follow-up. A reduction in tumor volume by at least 20%, as noted by comparing the pre- and post-GKRS images, was deemed significant. RESULTS Six patients with a mean age of 37.1 years (range 17-55 years) underwent primary GKRS. There were 2 prepontine cistern, 3 cavernous sinus, and 1 cisterno-cavernous tumor. The mean duration of symptoms was 6.1 months (range 3-12 months). The mean tumor volume was 3.3 cm3 (range 1.5-4.8 cm3). The mean tumor margin radiation dose was 12.5 Gy (range 12-14 Gy), while the median margin dose was 12 Gy (50% isodose line). The median number of isocenters used was 5 (range 4-8). The brainstem received an average 8.35-Gy radiation dosage (range 5.5-11 Gy). The mean follow-up duration was 44.3 months (range 24-78 months). Symptoms remained stable in 1 patient, improved in 3, and resolved in 2 (total improvement 83%). Magnetic resonance imaging at the last follow-up showed a stable tumor size in 3 patients (50%) and a reduction in the other 3. Thus, the tumor control rate achieved was 100%. No new CN deficits were noted. CONCLUSIONS Abducens nerve schwannomas are rare intracranial tumors. They can be cavernous, cisternal, or cisterno-cavernous in location. Excellent tumor control rates and symptomatic improvement can be achieved with GKRS, which appears to be a safe and effective, minimally invasive modality for the treatment of such lesions. Therefore, it is reasonable to consider GKRS as the initial treatment of choice for this rare pathology. Long-term follow-up will be essential for further recommendations.
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Affiliation(s)
| | - Manish Singh Sharma
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank S Kale
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Bhawani Shankar Sharma
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
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Abstract
The abducens nerve schwannoma is one kind of rare intracranial tumor. We report an interesting case of abducens nerve schwannoma in the right cerebellopontine angle in a 68-year-old male patient presenting only vertigo and headache, without any symptom of abducens nerve palsy. This is the oldest patient with abducens nerve schwannoma to date. The patient received a craniectomy via suboccipital retrosigmoid approach and had total surgical excision.
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Li X, Li J, Li J, Wu Z. Schwannoma of the 6th nerve: case report and review of the literature. Chin Neurosurg J 2015. [DOI: 10.1186/s41016-015-0004-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Chowdhury FH, Haque MR, Kawsar KA, Sarker MH, Hasan M, Goel AH. Intracranial nonvestibular neurinomas: Young neurosurgeons' experience. J Neurosci Rural Pract 2014; 5:231-43. [PMID: 25002761 PMCID: PMC4078606 DOI: 10.4103/0976-3147.133566] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Neurinoma arising from other than nonvestibular cranial nerves is less prevalent. Here we present our experiences regarding the clinical profile, investigations, microneurosurgical management, and the outcome of nonvestibular cranial nerve neurinomas. MATERIALS AND METHODS From January 2005 to December 2011, the recorded documents of operated nonvestibular intracranial neurinomas were retrospectively studied for clinical profile, investigations, microneurosurgical management, complications, follow-up, and outcomes. RESULTS The average follow-up was 24.5 months. Total number of cases was 30, with age ranging from 9 to 60 years. Sixteen cases were males and 14 were females. Nonvestibular cranial nerve schwannomas most commonly originated from trigeminal nerve followed by glossopharyngeal+/vagus nerve. There were three abducent nerve schwannomas that are very rare. There was no trochlear nerve schwannoma. Two glossopharyngeal+/vagus nerve schwannomas extended into the neck through jugular foramen and one extended into the upper cervical spinal canal. Involved nerve dysfunction was a common clinical feature except in trigeminal neurinomas where facial pain was a common feature. Aiming for no new neurodeficit, total resection of the tumor was done in 24 cases, and near-total resection or gross total resection or subtotal resection was done in 6 cases. Preoperative symptoms improved or disappeared in 25 cases. New persistent deficit occurred in 3 cases. Two patients died postoperatively. There was no recurrence of tumor till the last follow-up. CONCLUSION Nonvestibular schwannomas are far less common, but curable benign lesions. Surgical approach to the skull base and craniovertebral junction is a often complex and lengthy procedure associated with chances of significant morbidity. But early diagnosis, proper investigations, and evaluation, along with appropriate decision making and surgical planning with microsurgical techniques are the essential factors that can result in optimum outcome.
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Affiliation(s)
| | - Mohammod R Haque
- Department of Neurosurgery, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Khandkar A Kawsar
- Department of Neurosurgery, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Mainul H Sarker
- Department of Neurosurgery, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Mahmudul Hasan
- Department of ENT and Head Neck Surgery, Shohid Shawrowardi Medical College and Hospital, Dhaka, Bangladesh
| | - Atul H Goel
- Department of Neurosurgery, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Friedman DI, Digre KB. Headache medicine meets neuro-ophthalmology: exam techniques and challenging cases. Headache 2013; 53:703-16. [PMID: 23557163 DOI: 10.1111/head.12058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2013] [Indexed: 11/30/2022]
Abstract
The neuro-ophthalmology examination is critical to anyone who sees patients with the common symptom of headache. By examining the visual acuity, pupils, visual fields, motility, and fundus, clues to both secondary causes of headache and primary headaches exist. In this review, we discuss how to do the neuro-ophthalmology examination and we review cases of primary and secondary headache where key features of the examination assisted in making the correct diagnosis.
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Affiliation(s)
- Deborah I Friedman
- Department of Neurology & Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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16
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Abstract
Schwannomas of the abducens nerve are uncommon. Nineteen cases have been reported in the literature and are classified into two types: Type 1, in the cavernous sinus, and Type 2, in the prepontine area. However, a dumbbell-shaped type has not yet been reported. Here we report the first case of a dumbbell-shaped abducens schwannoma and classify this type into a new category (Type 3). A 36-year-old woman presented with left hearing disturbance for 4 years, dizziness for 2 years, and dysphagia for 6 months. Neurological examination showed left sensorineural hearing impairment, hypesthesia in the distribution of the left first and second branches of the trigeminal nerve, left curtain sign, and gait disturbance. Computed tomography and magnetic resonance imaging revealed a dumbbell-shaped tumor located in the cavernous sinus that extended to the right cerebellopontine angle. She underwent a two-staged operation; the first operation was via ananterior transpetrosal approach for the lesion in the middle fossa and the upper part in the posterior fossa, and the second surgery was via alateral suboccipital approach for the lower part in the posterior fossa. In the first operation, the abducens nerve was sacrificed. Histological examination confirmed schwannoma. Postoperatively, hearing disturbance and ataxia were improved and complete abducens nerve paresis appeared. The dumbbell-shaped abducens schwannoma has novel clinical features, difficulty of sixth nerve preservation, and unique surgical approach.
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Affiliation(s)
- Shunsuke Shibao
- Department of Neurosurgery, Keio University School of Medicine
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17
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18
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Vachata P, Sames M. Abducens nerve schwannoma mimicking intrinsic brainstem tumor. Acta Neurochir (Wien) 2009; 151:1281-7. [PMID: 19357806 DOI: 10.1007/s00701-009-0302-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2008] [Accepted: 03/10/2009] [Indexed: 11/29/2022]
Abstract
Schwannomas of the abducens nerve are extremely rare tumors affecting cavernous, cisternal or both segments of sixth cranial nerve. Clinical features and neuroradiological imagery are frequently insufficient to reach an accurate pre-operative diagnosis. We report a patient with a cystic tumor with ring-like contrast enhancement at the right anterior pontomesencephalic junction. Radical excision was performed via anterior transpetrosal approach and showed an extrinsic tumor originating from the sixth nerve. A postoperative sixth nerve palsy had disappeared completely 9 months after the surgery. The correct diagnosis of an abducens nerve schwannoma is established by the intraoperative finding of a tumor attachment to the sixth nerve and by histopathological analysis. The various differential diagnoses, the clinical and radiological features of this diagnosis and management are issues discussed in this illustrated review.
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Affiliation(s)
- Petr Vachata
- Department of Neurosurgery, Masaryk Hospital, J. E. Purkinje University, Usti nad Labem, Czech Republic.
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19
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Cellular schwannoma of the abducens nerve: Case report and review of the literature. Clin Neurol Neurosurg 2009; 111:467-71. [DOI: 10.1016/j.clineuro.2009.01.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2008] [Revised: 12/26/2008] [Accepted: 01/02/2009] [Indexed: 11/24/2022]
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20
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Park JH, Cho YH, Kim JH, Lee JK, Kim CJ. Abducens nerve schwannoma: case report and review of the literature. Neurosurg Rev 2009; 32:375-8; discussion 378. [DOI: 10.1007/s10143-009-0203-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Revised: 02/20/2009] [Accepted: 03/24/2009] [Indexed: 11/28/2022]
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21
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Kim IY, Kondziolka D, Niranjan A, Flickinger JC, Lunsford LD. Gamma Knife surgery for schwannomas originating from cranial nerves III, IV, and VI. J Neurosurg 2009; 109 Suppl:149-53. [PMID: 19123902 DOI: 10.3171/jns/2008/109/12/s23] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Schwannomas from the motor cranial nerves controlling eye movement are rare. The authors evaluated the role of Gamma Knife surgery (GKS) in the management of schwannomas originating from cranial nerves III, IV, and VI. METHODS Over a 7-year period, 8 patients with schwannomas originating from the oculomotor (2 patients), trochlear (5 patients), or abducent (1) nerve underwent GKS. The mean patient age was 46.1 years (range 19-59 years). The presenting symptoms included diplopia in 5 patients, ptosis in 1 patient, ophthalmoplegia in 1 patient, and headache in 1 patient. Two patients had a history of neurofibromatosis Type 2. Gamma Knife surgery was performed as primary management in 7 patients and after prior resection in 1 patient. The median and mean tumor volumes were 0.22 and 1.32 cm(3) (range 0.03-7.4 cm(3)). A median margin dose of 12.5 Gy (range 11.0-13.0 Gy) was prescribed to the tumor margin. Clinical and imaging follow-up data were available for all 8 patients. RESULTS Magnetic resonance imaging showed tumor regression in all patients. The progression-free period varied from 4 to 42 months, with a mean of 21 months. Over a mean of 23 months, 4 of the 5 patients with a trochlear schwannoma and symptoms of diplopia noted symptomatic improvement. No improvement was noted in the 2 patients with oculomotor nerve palsies. Headache was improved in the 1 patient with an abducent neuroma. CONCLUSIONS Gamma Knife surgery is an effective and minimally invasive approach capable of inactivating schwannomas originating from the oculomotor, trochlear, and abducent nerves. Accompanying trochlear function may improve. Longer follow-up and larger patient samples are needed to confirm the authors' initial observations.
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Affiliation(s)
- In-Young Kim
- Department of Neurological Surgery, University of Pittsburgh, Center for Image-Guided Neurosurgery, Pittsburgh, Pennsylvania 15213, USA
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23
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Abstract
We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.
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Affiliation(s)
- A Vighetto
- Service de Neurologie D, Hôpital neurologique Pierre-Wertheimer et Université Claude-Bernard Lyon I, Lyon.
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