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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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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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Thatcher J, Chang YM, Chapman MN, Hovis K, Fujita A, Sobel R, Sakai O. Clinical-Radiologic Correlation of Extraocular Eye Movement Disorders: Seeing beneath the Surface. Radiographics 2016; 36:2123-2139. [PMID: 27831838 DOI: 10.1148/rg.2016150227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Extraocular eye movement disorders are relatively common and may be a significant source of discomfort and morbidity for patients. The presence of restricted eye movement can be detected clinically with quick, easily performed, noninvasive maneuvers that assess medial, lateral, upward, and downward gaze. However, detecting the presence of ocular dysmotility may not be sufficient to pinpoint the exact cause of eye restriction. Imaging plays an important role in excluding, in some cases, and detecting, in others, a specific cause responsible for the clinical presentation. However, the radiologist should be aware that the imaging findings in many of these conditions when taken in isolation from the clinical history and symptoms are often nonspecific. Normal eye movements are directly controlled by the ocular motor cranial nerves (CN III, IV, and VI) in coordination with indirect input or sensory stimuli derived from other cranial nerves. Specific causes of ocular dysmotility can be localized to the cranial nerve nuclei in the brainstem, the cranial nerve pathways in the peripheral nervous system, and the extraocular muscles in the orbit, with disease at any of these sites manifesting clinically as an eye movement disorder. A thorough understanding of central nervous system anatomy, cranial nerve pathways, and orbital anatomy, as well as familiarity with patterns of eye movement restriction, are necessary for accurate detection of radiologic abnormalities that support a diagnostic source of the suspected extraocular movement disorder. ©RSNA, 2016.
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Affiliation(s)
- Joshua Thatcher
- From the Departments of Radiology (J.T., Y.M.C., M.N.C., K.H., A.F., O.S.), Ophthalmology (R.S.), Otolaryngology-Head and Neck Surgery (O.S.), and Radiation Oncology (O.S.), Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, 3rd Floor, Boston, MA 02118; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (Y.M.C.); Department of Radiology, Veterans Administration Boston Healthcare System, Boston, Mass (M.N.C.); and Department of Radiology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan (A.F.)
| | - Yu-Ming Chang
- From the Departments of Radiology (J.T., Y.M.C., M.N.C., K.H., A.F., O.S.), Ophthalmology (R.S.), Otolaryngology-Head and Neck Surgery (O.S.), and Radiation Oncology (O.S.), Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, 3rd Floor, Boston, MA 02118; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (Y.M.C.); Department of Radiology, Veterans Administration Boston Healthcare System, Boston, Mass (M.N.C.); and Department of Radiology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan (A.F.)
| | - Margaret N Chapman
- From the Departments of Radiology (J.T., Y.M.C., M.N.C., K.H., A.F., O.S.), Ophthalmology (R.S.), Otolaryngology-Head and Neck Surgery (O.S.), and Radiation Oncology (O.S.), Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, 3rd Floor, Boston, MA 02118; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (Y.M.C.); Department of Radiology, Veterans Administration Boston Healthcare System, Boston, Mass (M.N.C.); and Department of Radiology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan (A.F.)
| | - Keegan Hovis
- From the Departments of Radiology (J.T., Y.M.C., M.N.C., K.H., A.F., O.S.), Ophthalmology (R.S.), Otolaryngology-Head and Neck Surgery (O.S.), and Radiation Oncology (O.S.), Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, 3rd Floor, Boston, MA 02118; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (Y.M.C.); Department of Radiology, Veterans Administration Boston Healthcare System, Boston, Mass (M.N.C.); and Department of Radiology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan (A.F.)
| | - Akifumi Fujita
- From the Departments of Radiology (J.T., Y.M.C., M.N.C., K.H., A.F., O.S.), Ophthalmology (R.S.), Otolaryngology-Head and Neck Surgery (O.S.), and Radiation Oncology (O.S.), Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, 3rd Floor, Boston, MA 02118; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (Y.M.C.); Department of Radiology, Veterans Administration Boston Healthcare System, Boston, Mass (M.N.C.); and Department of Radiology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan (A.F.)
| | - Rachel Sobel
- From the Departments of Radiology (J.T., Y.M.C., M.N.C., K.H., A.F., O.S.), Ophthalmology (R.S.), Otolaryngology-Head and Neck Surgery (O.S.), and Radiation Oncology (O.S.), Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, 3rd Floor, Boston, MA 02118; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (Y.M.C.); Department of Radiology, Veterans Administration Boston Healthcare System, Boston, Mass (M.N.C.); and Department of Radiology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan (A.F.)
| | - Osamu Sakai
- From the Departments of Radiology (J.T., Y.M.C., M.N.C., K.H., A.F., O.S.), Ophthalmology (R.S.), Otolaryngology-Head and Neck Surgery (O.S.), and Radiation Oncology (O.S.), Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, 3rd Floor, Boston, MA 02118; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (Y.M.C.); Department of Radiology, Veterans Administration Boston Healthcare System, Boston, Mass (M.N.C.); and Department of Radiology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan (A.F.)
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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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McLaughlin N, Dye J, Khanlou N, Yong WH, Martin NA. A 26-year-old female with a millimetric prepontine lesion. Brain Pathol 2014; 24:421-2. [PMID: 25083538 DOI: 10.1111/bpa.12156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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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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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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Lee SK, Moon KS, Lee KH, Jung S. Cystic Abducens Schwannoma without Abducens Paresis : Possible Role of Cisternal Structures in Clinical Manifestation. J Korean Neurosurg Soc 2013; 53:374-6. [PMID: 24003375 PMCID: PMC3756133 DOI: 10.3340/jkns.2013.53.6.374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 04/03/2013] [Accepted: 06/19/2013] [Indexed: 11/27/2022] Open
Abstract
The abducens nerve paresis generally can aid in the presumptive diagnosis of abducens schwannoma along with the typical radiological features of schwannomas. The authors present a case of a 76-year-old male patient with a abducens schwannoma without abducens nerve paresis. Peroperatively, abducens nerve located in the cerebellopontine cistern had normal in contour and diameter, despite the mass originated from this nerve. We hypothesize that anatomic location of abducens nerve may affect the vector of tumor growth to prevent destruction of its origin, the abducens nerve.
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Affiliation(s)
- Seul-Kee Lee
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital and Medical School, Gwangju, Korea
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