Complete surgical excision of intramedullary schwannoma at the craniovertebral junction in neurofibromatosis type-2

Spinal intramedullary schwannomas-report of a case and extensive review of the literature

Intramedullary schwannomas (IMS) represent exceptional rare pathologies. They commonly present as solitary lesions; only five cases of multiple IMS have been described so far. Here, we report the sixth case of a woman with multiple IMS. Additionally, we performed the first complete systematic review of the literature for all cases reporting IMS. We performed a systematic review of the literature in PubMed, EMBASE and Cochrane Central Register of Controlled (CENTRAL) to retrieve all relevant studies and case reports on IMS. In a second step, we analysed all reported studies with respect to additional cases, which were not identified through the database search. Studies published in other languages than English were included. One hundred nineteen studies including 165 reported cases were included. In only five cases, the patients harboured more than one IMS. Gender ratio showed a ratio of nearly 3:2 (male:female); mean age of disease presentation was 40.2 years; 11 patients suffered from neurofibromatosis (NF) type 1 or 2 (6.6%). IMS are rare. Our first systematic review on this pathology revealed 166 cases, including the here reported case of multiple IMS. Our review offers a basis for further investigation on this disease.

Intramedullary schwannoma of cervicomedullary junction: A case report

BACKGROUND

Intramedullary schwannomas of brain stem and spinal cord are extremely rare. In almost all cases, homogeneous, asymmetrical or circular intensive gadolinium enhancement has been demonstrated. However, no cases reported previously with minimal contrast enhancement in cervicomedullary junction.

CASE DESCRIPTION

A 38-year old man presented with a one-month history of constant, radiative right shoulder and arm pain. There was no pathological finding in his neurological examination. Also, physical evidence or family history of neurofibromatosis was not found. Magnetic resonance imaging of brain and cervical spine showed intramedullary, solid-cystic lesion localized in the cervicomedullary junction with unobvious gadolinium enhancement. The mass was gross totally resected through a sub-occipital craniotomy via midline approach. Postoperative pathological examination confirmed diagnosis of schwannoma. No changes were detected in the neurological examination of the patient after the operation.

CONCLUSIONS

There are 3 previously reported intramedullary schwannomas of the cervicomedullary junction in the literature. To the best of our knowledge, this is the first case of unobvious contrast enhancing intramedullary schwannoma of the cervicomedullary junction. The possibility of schwannoma should not be excluded when a mass with slight contrast enhancement is detected in the intramedullary region of the cervicomedullary junction.

Neurofibromatosis type 2

Neurofibromatosis type 2 is an autosomal-dominant multiple neoplasia syndrome that results from mutations in the NF2 tumour suppressor gene located on chromosome 22q. It has a frequency of one in 25,000 livebirths and nearly 100% penetrance by 60 years of age. Half of patients inherit a germline mutation from an affected parent and the remainder acquire a de novo mutation for neurofibromatosis type 2. Patients develop nervous system tumours (schwannomas, meningiomas, ependymomas, astrocytomas, and neurofibromas), peripheral neuropathy, ophthalmological lesions (cataracts, epiretinal membranes, and retinal hamartomas), and cutaneous lesions (skin tumours). Optimum treatment is multidisciplinary because of the complexities associated with management of the multiple, progressive, and protean lesions associated with the disorder. We review the molecular pathogenesis, genetics, clinical findings, and management strategies for neurofibromatosis type 2.

Intramedullary tumours in patients with neurofibromatosis type 2: MRI features associated with a favourable prognosis

AIM

To assess the magnetic resonance imaging (MRI) features and natural history of intramedullary tumours in patients with neurofibromatosis type 2 (NF2).

MATERIALS AND METHODS

Eleven NF2 patients with intramedullary spinal cord tumours were identified from the database of the multidisciplinary NF2 clinic. All the imaging studies of these patients were individually reviewed by two neuroradiologists to evaluate the size, number, location, imaging characteristics, and interval growth of the intramedullary tumours.

RESULTS

Two of the 11 patients had lesions that required surgery. Both these lesions were in the cervical region, and extended over three and five segments respectively. Nine patients with a mean imaging follow-up period of 77 months had lesions that remained stable, apart from the development of small peritumoral cysts in three. The lesions were well circumscribed, often multiple, usually less than 1cm in diameter, and were most frequently found in the cervical cord.

CONCLUSION

The majority of intramedullary tumours in NF2 patients are very slow growing and share certain MRI features that differ from those of progressive or symptomatic lesions.