Cavernous malformation of the trigeminal nerve

Cavernous Malformation From Cranial Nerves: A Systematic Review With a Novel Classification and Patient-Level Analysis

BACKGROUND AND OBJECTIVES

Cavernous malformations (CMs) occurring in the cranial nerve (CN) are extremely rare, and there is currently no comprehensive review on CN CMs, leading to a lack of sufficient understanding of CN CMs. We aimed to systematically review all published CN CM cases; summarize the epidemiology, clinical manifestations, treatment, and prognosis of CN CMs; and identify factors influencing the prognosis of CN CMs.

METHODS

This systematic review identified all cases potentially diagnosed with CN CM through a systematic search of PubMed, SCOPUS, Web of Science, and Cochrane databases. This represents the most comprehensive systematic review to date. We classified CN CMs based on their anatomic origins. Patient characteristics, disease manifestations, treatment approaches, and prognosis were summarized descriptively. Further analysis was conducted to identify factors influencing the prognosis of CN CMs.

RESULTS

The final analysis included 108 articles (127 individual patient cases). The optic nerve (49/128, 38.3%) is the most commonly affected nerve. Notably, CN CMs can be categorized into 3 types: Intraneural, Perineural, and Extraneural. Preoperative nerve function status and novel classification were associated with the prognosis of CN CMs (P = .001; P < .001). The postoperative neurological deterioration rate for the Intraneural type was 19/37 (51.4%); for the Extraneural type, it was 13/69 (18.8%); and for the Perineural type, it was 1/22 (4.5%) (P < .001).

CONCLUSION

We reviewed all the published CN CMs to date, offering a comprehensive description of CN CMs for the first time and identifying prognostic factors. The classification of CN CMs proposed in this study could serve as guidance for the selection of intraoperative treatment regimens. The findings of this systematic review are expected to provide a foundation for clinical decision-making in this crucial rare disease and lay the groundwork for developing relevant clinical guidelines.

Case Report: Recurrent pediatric cavernous malformation of the trigeminal nerve

Background

Most cavernous malformations (CM) usually involve the parenchyma and rarely occur in cranial nerves. Recurrence of CM associated with cranial nerves after surgical resection has not been previously reported.

Case description

This paper describes the case of an 11-year-old girl who presented with left otalgia and headache because of a left trigeminal cavernous malformation. She underwent radical resection via a left retrosigmoid approach while sparing the trigeminal nerve. Surveillance imaging at 18 months demonstrated recurrence along the length of the trigeminal nerve into Meckel's cave with significant extension into the middle cerebellar peduncle. Subsequent re-operation via an extended middle fossa approach with anterior petrosectomy enabled complete resection with division of the trigeminal nerve. Postoperatively, she had a transient left facial paresis, and right hemiparesis that resolved within 48 h.

Conclusion

This case highlights the importance of close postoperative surveillance in CM associated with cranial nerves as recurrence after nerve-sparing resection is possible. Surgical treatment due to the morphology of significant recurrence required the use of a complex skull base approach through a new corridor to achieve optimal clinical outcome.

Trigeminal neuralgia caused by cavernoma: A case report with literature review

Cavernoma is the second most common cerebrovascular lesion. Cavernoma involving the cranial nerves is very rare. Only 15 cases of cavernoma presenting with trigeminal neuralgia (TN) have been previously reported. Here, we report a rare case of cavernoma manifesting with TN. A young female patient with a 15-day history of right-sided lancinating pain in the face, difficulty in opening the mouth, and hearing dysesthesia. Magnetic resonance imaging (MRI) revealed a well-demarcated lesion in the cerebellopontine angle related closely to the root of the trigeminal nerve. The initial impression was that of a neurinoma. The lesion was surgically resected via the retrosigmoid approach, postoperative pathological analysis confirmed the diagnosis of cavernoma, and the patient's pain and difficulty in opening the mouth resolved completely. We presented the 16^th documented case of cavernoma with TN. Although cavernoma involving the trigeminal nerve is extremely rare, this diagnosis should be taken into consideration when a lesion in the cerebellopontine angle is detected on MRI, and the clinical manifestation is consistent with that of secondary TN. Specialized MRI sequences, such as susceptibility weighted imaging (SWI), gradient echo T2, and constructive interference in steady-state (CISS)-weighted imaging, aid in establishing the diagnosis. Resection via craniotomy may be the primary management strategy for cavernoma causing TN. In addition, gamma knife radiosurgery (GKRS) and percutaneous balloon compression (PBC) may ameliorate the pain to some extent.

Paediatric Cavernous Malformation of the Trigeminal Nerve: Case Report and Review of the Literature

INTRODUCTION

Intradural, extra-axial cerebral cavernous malformations (CCMs) are rare entities and are mostly reported in relation to the optic apparatus or the facial/vestibulocochlear complex. Cranial nerve CCMs tend to follow a clinically aggressive course, with a tendency to progressive neurological dysfunction following intra-lesional haemorrhage or less commonly due to the effects of subarachnoid haemorrhage.

CASE PRESENTATION

We report the first case of a trigeminal CCM presenting in a child with otalgia and left-sided headaches. The patient was initially managed with radiological surveillance but required surgical management following deterioration. We describe the successful treatment of the lesion with microsurgical resection.

CONCLUSION

A CCM should be considered in the differential diagnosis of mass lesions arising in the region of the trigeminal nerve. Surgical resection is recommended to prevent neurological deterioration and may result in significant symptomatic improvement.

Simultaneous hemorrhage of multiple cerebral cavernous malformations of the insular lobe and Meckel's cave: a case report and literature review

We describe a case of sporadic cavernous malformation (CM) in a patient suffering from multiple hemorrhagic intracranial lesions, including one originating from the trigeminal nerve (TN). The patient presented with left side facial pain and disturbed right limb movement. The patient was pre-operatively diagnosed with multiple cerebral CMs. This diagnosis was confirmed by postoperative pathology.

Gamma Knife Radiosurgery for Trigeminal Neuralgia Caused by a Cavernous Malformation: Case Report and Literature Review

OBJECTIVE

Trigeminal neuralgia (TN) related to a brainstem cavernous malformation (CM) is a rare entity. We present the first radiosurgical management of a patient with TN secondary to a CM.

CLINICAL PRESENTATION

An 80-year-old female presented with a 33-year history of progressively severe TN refractory to medications. Imaging confirmed a solitary CM located at the pontine dorsal root entry zone of cranial nerve 5.

TREATMENT

Stereotactic radiosurgery of the trigeminal nerve was performed using the Leksell gamma knife. A single 4-mm isocenter of radiation was focused on the trigeminal nerve and a maximum dose of 80 Gy (40 Gy at the 50% isodose line) was delivered to the nerve.

RESULTS

At 1 year, the patient noted that the severe pain attacks had been reduced by 75%, although a background lingering discomfort persisted. Pain suppression medications had been significantly reduced to lamotrigine 100 mg twice daily. Her preoperative distribution of sensory dysfunction mildly increased.

CONCLUSION

For medically refractory TN related to a CM, radiosurgery of the afferent nerve may ameliorate pain without a major decrease in sensation. The more than 30-year history of pain in our patient may have reduced the chance of more significant pain relief.

Angiographically occult vascular malformation of the intracranial accessory nerve: case report

Angiographically occult cerebral vascular malformations (AOVMs) are usually found in the supratentorial brain parenchyma. Uncommonly, AOVMs can be found within the cavernous sinus or basal cisterns and can be associated with cranial nerves. AOVMs involving the intracranial segment of the spinal accessory nerve have not been described. A 46-year-old female patient presented with a history of episodic frontal headaches and episodes of nausea and dizziness, as well as gait instability progressing over 6 months prior to evaluation. Imaging revealed a well-circumscribed 3-cm extraaxial T1-weighted isointense and T2-weighted hyperintense contrast-enhancing mass centered in the region of the right lateral cerebellomedullary cistern. The patient underwent resection of the lesion. Although the intraoperative appearance was suggestive of a cavernous malformation, some histological findings were atypical, leading to the final diagnosis of vascular malformation, not otherwise specified. The patient's postoperative course was uneventful with complete resolution of symptoms. To the authors' knowledge, this is the first report of an AOVM involving the intracranial portion of the accessory nerve. For any AOVM located within the cerebellomedullary cistern or one suspected of involving a cranial nerve, the authors recommend including immunohistochemistry with primary antibody to neurofilament in the histopathology workup.

Cavernous Malformation in the Trigeminal Distribution: A Case Report of Aggressive Presentation and Management

BACKGROUND

Cavernous malformation (CM) is a vascular malformation found in the encephalic parenchyma, spinal cord, nerve roots, and extraneural tissue. CM in the trigeminal distribution is exquisitely uncommon and its biological behavior not completely understood. The clinical picture might be diverse, depending on the affected sector of the trigeminal architecture, and literature debating its pathobiology is scarce.

CASE DESCRIPTION

We describe a case of 56-year-old woman who presented with left trigeminal neuralgia and a rapidly growing cavernous malformation of the entire distribution of the fifth nerve. The clinical picture evolved to a progressive gait ataxia and follow-up neuroimaging showed a large intracranial mass leading to a brainstem compression. After microsurgical resection, the mass proved to be a typical CM of the trigeminal root.

CONCLUSION

We present an uncommonly aggressive progression of a CM of the trigeminal root, Gasserian ganglion, and cavernous sinus evolving to severe brainstem compression. The documentation of this unique case as well as its management is presented is discussed.

A review of cavernous malformations with trigeminal neuralgia

Cavernous malformation with trigeminal neuralgia is relatively rare; only 10 cases have been reported. In deciding treatment strategies, it is helpful to classify cavernous malformation according to its origin, as follows: in the Gasserian ganglion (Type G); between the cisternal and intra-axial portions of the trigeminal nerve root (Type C); in the intra-axial trigeminal nerve root in the pons (Type P); or in the spinal tract of the trigeminal nerve root (Type S). A 62-year-old male presented with left trigeminal neuralgia (V2 area) and left facial hypoesthesia. Imaging studies revealed a cerebellopontine angle mass lesion with characteristics of a cavernous malformation and evidence of hemorrhage. The lesion was completely removed via a left anterior transpetrosal approach. The mass was attached to the trigeminal nerve root; it was located between the cisternal and intra-axial portions of the nerve root, and feeding off microvessels from the trigeminal nerve vascular plexus. Histological examination confirmed a cavernous malformation. In this case, the cavernous malformation was Type C. We review cases of cavernous malformation with trigeminal neuralgia and discuss therapeutic strategies according to the area of origin.

Cranial nerve cavernous malformations causing trigeminal neuralgia and chiasmal apoplexy: Report of 2 cases and review of the literature

BACKGROUND

Cavernous malformations (CMs) confined to the cranial nerves (CN) are extremely rare lesions.

CASE DESCRIPTION

The authors report 2 cases of CMs, one involving the trigeminal nerve presenting with a 3 years history of a refractory right trigeminal neuralgia that was microsurgically resected by a retromastoid approach with resolution of the neuralgia; and another CM involving the chiasma with an abrupt onset of vision loss with acute intralesional bleeding that was removed through a right pterional approach with vision improvement.

CONCLUSION

Surgical resection is recommended in the context of progressive significant neurological deficit, emergency decompression as a result of recent hemorrhage for symptomatic relief or increase in size on serial magnetic resonance imaging (MRI).

Cavernous Malformation of the Trochlear Nerve: Case Report and Review of the Literature on Cranial Nerve Cavernomas

BACKGROUND AND IMPORTANCE:

Cavernous malformations (CMs) arising intrinsically to the cisternal segment of the trochlear nerve are extremely rare. This case of a trochlear nerve cavernous angioma is the third to be reported in the neurosurgical literature and the first to be resected by a middle fossa approach.

CLINICAL PRESENTATION:

The authors present a case of a 31-year-old woman with progressive left-sided headache and left hemisensory symptoms, whose magnetic resonance imaging showed a solid enhancing tumor in the left ambient cistern at the level of the midbrain-pontine junction causing significant brainstem compression. Intraoperatively, a left trochlear nerve cavernous angioma circumferentially enveloping the nerve was visualized. The angioma was microsurgically resected by a middle fossa approach under frameless stereotactic guidance. Gross total resection of the intrinsic trochlear nerve lesion was achieved, although the trochlear nerve could not be preserved intact.

CONCLUSION:

CMs should be considered in a possible differential diagnosis of cisternal trochlear nerve tumors. Surgical resection remains the standard of care, and is indicated for relief of compressive symptoms and prevention of future bleeds. Postoperative diplopia often persists; however, resolution of diplopia reported in the literature can be attributed to either regeneration after direct surgical repair of the sacrificed nerve or a spontaneous adaptation over time.

Cavernous malformation of the cisternal trigeminal nerve

Intradural extraaxial cavernous malformations (CM) are very rare. We report a case of CM originating from the cisternal portion of trigeminal nerve in a 20-year old male. Surgery produced favourable outcome in this case.

Spinal accessory nerve cavernous malformation

We present the first reported case of a spinal accessory nerve cavernous malformation. A 54-year-old Caucasian male presented with a several-year history of progressive, vague bilateral upper and lower extremity paresthesias and pain. MRI of the spine revealed a heterogenously enhancing mass in the dorsal aspect of the spinal canal at the level of the atlas with mild spinal cord compression. The lesion was resected and upon gross and histologic examination it was a cavernous malformation embedded within a branch of the spinal accessory nerve. Post-operatively, the patient had no complications and some improvement in his symptoms. To our knowledge, this is the first report of a patient with a spinal accessory nerve cavernous malformation, and this should be considered in the differential of lesions in the craniocervical region.

Removal of cavernous malformation of the Meckel's cave by extradural pterional approach using Heros muscle dissection technique

BACKGROUND

We report on a patient with trigeminal neuralgia caused by an extraaxial cavernous malformation (CM) located within Meckel's cave. The lesion was removed via a pterional extradural approach with a modified temporalis muscle dissection technique, which was first described by Heros and Lee. Cadaveric dissections were performed to demonstrate the wider exposure gained by this approach.

METHODS

A 56-year-old man presented with a history of episodic shocklike, right-sided facial pain for 10 years. Neurologic examination revealed diminished sensation in the mandibular division of the right trigeminal nerve. Magnetic resonance imaging showed an ipsilateral enhancing lesion in Meckel's cave.

RESULTS

After placement of a lumbar drain, a right extradural pterional approach was undertaken. By reflecting the temporalis muscle posterolaterally, the craniotomy was extended so that the line of sight was level with the floor of the middle fossa. This allowed access to the lesion without needing to remove the zygoma. The lesion was resected with microsurgical technique. The patient's pain improved significantly after resection, and histopathologic examination confirmed the diagnosis of CM.

CONCLUSIONS

Extraaxial middle fossa CMs arising solely from Meckel's cave are rare. These lesions are safely and simply approached by posteriorly deflecting the temporalis muscle during a pterional craniotomy, avoiding excessive elevation of the anterior temporal lobe or further bony removal.