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Muacevic A, Adler JR, Picão Fernandes A, Pinto A, Meireles L. Let Us Not Forget About Bleeding: A Case Report and Brief Literature Review on Hemorrhagic Vestibular Schwannoma. Cureus 2022; 14:e32269. [PMID: 36620834 PMCID: PMC9815954 DOI: 10.7759/cureus.32269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Hemorrhagic vestibular schwannoma (HVS) consisting of acute intratumoral and subarachnoid hemorrhage is a rare phenomenon. We present the case of a 31-year-old woman who attended the Otorhinolaryngology department with right-sided intense tinnitus, dizziness, imbalance, and headache. Brain computed tomography revealed a spontaneous hyperdensity in the posterior fossa with marked deformation of the brainstem, middle cerebral peduncle, and cerebellum, with the near collapse of the fourth ventricle. Ophthalmology evaluation confirmed bilateral papilledema. Brain magnetic resonance imaging confirmed a voluminous 33 x 28 x 29 mm extra-axial lesion centered on the right pontine-cerebellar angle cistern, extending from the plane of the trigeminal nerve/tent of the cerebellum. The acoustic pore was enlarged. The patient underwent retrosigmoid craniotomy and microscopic tumor resection showing significant improvement in the follow-up. Pathological findings confirmed HVS. Delayed treatment of HVS can increase morbidity or even be fatal. The objective of this work is to describe and revise HVS, in order to bring awareness to this uncommon entity.
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Ali NES, Sayyid ZN, Alyono JC. Natural History of Cystic Vestibular Schwannomas. Ann Otol Rhinol Laryngol 2022:34894221119613. [PMID: 35993287 DOI: 10.1177/00034894221119613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the natural history of cystic vestibular schwannomas (VS). STUDY DESIGN Retrospective cohort. SETTING Single tertiary academic hospital. PATIENTS Adults diagnosed with cystic VS who had at least 2 MRIs performed at least 6 months apart between 2008 and 2016 with no intervening treatment. MAIN OUTCOME MEASURES Volumetric growth rates of both the entire tumor and individual cystic and solid components were measured. Linear growth rate of the entire tumor was assessed using the largest diameter parallel to the petrous face at the cerebellopontine angle (CPA). RESULTS Twenty-one patients met inclusion criteria. The average volumetric growth rate of the tumor was 1.1 ± 2 (range: -1.2 to 7.8), while the average growth rate of the cystic component was 0.8 ± 1.6 (range: -0.5 to 5.3) cm3/year. The CPA diameter of the tumor demonstrated an average linear growth rate of was 1.2 ± 4.4 (range: -8to 13.5) mm/year. With regards to tumor diameter, 9/21 (42.9%) remained stable, 3/21 (14.2%) decreased in size, while 9/21 (42.9%) increased in size. CONCLUSIONS Cystic tumors demonstrate a wide variability in growth rate. Larger, multi-center studies will be required to further compare this relationship to solid tumors.
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Affiliation(s)
- Noor-E-Seher Ali
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University, Springfield, IL, USA
| | - Zahra N Sayyid
- Department of Otolaryngology-Head and Neck Surgery, John Hopkins University, Baltimore, MD, USA
| | - Jennifer C Alyono
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA, USA
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Avalos LN, Morshed RA, Goldschmidt E. Hemorrhagic vestibular schwannoma: a case example of vestibular apoplexy syndrome. Illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21722. [PMID: 36303506 PMCID: PMC9379692 DOI: 10.3171/case21722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/10/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute intratumoral hemorrhage within a vestibular schwannoma, or vestibular apoplexy, is a rare condition. Unlike the typical insidious vestibulopathy typically caused by vestibular schwannoma growth, patients with vestibular apoplexy have an acute and severe presentation with nausea and emesis in addition to severe vertigo and hearing loss. Here, the authors present an illustrative case demonstrating this rare clinical condition and an operative video detailing the surgical management. OBSERVATIONS A 76-year-old man presented to the emergency department with acute-onset dizziness, left-ear fullness, double vision, gait ataxia, emesis, and facial numbness. Imaging revealed a 2.8-cm hemorrhagic left cerebellopontine angle lesion extending into the left internal auditory canal, consistent with hemorrhagic vestibular schwannoma. The patient subsequently underwent a retrosigmoid craniotomy for resection of the hemorrhagic mass, and by 1 month after surgery, all his presenting symptoms had resolved, allowing his return to daily activities. LESSONS Vestibular schwannomas typically present with decreased hearing and chronic vestibulopathy. Acute presentation should raise the suspicion for an apoplectic event, and surgical debulking may lead to improvement in most vestibular symptoms.
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Affiliation(s)
- Lauro N. Avalos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ramin A. Morshed
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Saigal G, Pisani L, Allakhverdieva E, Aristizabal J, Lehmkuhl D, Contreras F, Bhatia R, Sidani C, Quencer R. Utility of Microhemorrhage as a Diagnostic Tool in Distinguishing Vestibular Schwannomas from other Cerebellopontine Angle (CPA) Tumors. Indian J Otolaryngol Head Neck Surg 2021; 73:321-326. [PMID: 34471620 DOI: 10.1007/s12070-021-02372-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022] Open
Abstract
Although a majority of tumors in the Cerebellopontine Angle (CPA) are vestibular schwannomas (VS), other masses can also be seen in the region and differentiation of various CPA tumors, particularly meningiomas can be difficult on imaging alone. Treatment options may vary based on specific pathology of the CPA tumor. In this study, the presence of microhemorrhage (MH) and other imaging features such as size of lesion, cystic features and pattern of IAC extension, were evaluated as a tool in distinguishing VS from other CPA masses. A review of CPA masses in the last 11 years at our institution was performed. All the pathology proven tumors with at least 1 pre-operative MRI were considered for analysis. A T2* GRE or SWI sequence was used to assess presence of MH within the lesion. Pattern of IAC extension ('centric' versus 'eccentric') of tumor was also evaluated. A total of 147 patients were reviewed out of which 102 patients (with T2* GRE or SWI) were included for analysis of MH. 57 patients (56%) had VS as the final histopathological diagnosis and 45 patients (44%) had other types of tumor. A sensitivity of 82% and a specificity of 98% was noted for the presence of MH favoring the diagnosis of VS from other tumors (p < 0.001). All meningiomas with IAC extension (25/31) showed an 'eccentric' pattern of extension into the canal. Visualization of MH and pattern of IAC extension is useful in the differentiation of schwannomas from other CPA masses, particularly meningiomas.
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Affiliation(s)
- G Saigal
- Department of Radiology, WW279, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136 USA
| | - L Pisani
- Emory University, 1364 Clifton Road Northeast, Atlanta, GA 30322 USA
| | - E Allakhverdieva
- Department of Radiology, WW279, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136 USA.,Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL 33136 USA
| | - J Aristizabal
- University of Antioquia, Cl. 67 ##53-108, Medellín, Antioquia, , CO USA
| | - D Lehmkuhl
- Department of Radiology, WW279, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136 USA.,Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL 33136 USA
| | - F Contreras
- Department of Radiology, WW279, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136 USA.,Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL 33136 USA
| | - R Bhatia
- Department of Radiology, WW279, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136 USA
| | - C Sidani
- Department of Radiology, WW279, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136 USA
| | - R Quencer
- Department of Radiology, WW279, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Miami, FL 33136 USA
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Woo PYM, Lam PL, Ip YHK, Chan TSK, Ng OKS, Kwan MCL, Wong HT, Wong AKS, Chan KY. "When the Benign Bleed" Vestibular Schwannomas with Clinically Significant Intratumoral Hemorrhage: A Case Series and Review of the Literature. Asian J Neurosurg 2021; 16:221-227. [PMID: 34211900 PMCID: PMC8202378 DOI: 10.4103/ajns.ajns_287_20] [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: 06/10/2020] [Revised: 06/24/2020] [Accepted: 07/29/2020] [Indexed: 02/02/2023] Open
Abstract
Vestibular schwannomas (VSs) are slow-growing benign neoplasms commonly located at the cerebellopontine angle. Although clinically significant hemorrhagic VSs are rarely encountered with only 75 patients previously reported, they could be life threatening. We discuss the presentation and outcomes of three patients with hemorrhagic VS as well as review the literature for this phenomenon. Consecutive adult patients with a histologically proven diagnosis of VS over a 9-year period were retrospectively reviewed. Fifty adult patients were identified with three (6%) having clinically significant intratumoral hemorrhage. This was defined as patients having acute to subacute symptoms with frank radiological evidence of hemorrhage. The mean age of diagnosis was 62 ± 9 years and the male-to female ratio was 2:1. The mean duration of symptoms, namely headache, vertigo, and sensorineural hearing impairment, was 26 ± 4 days with one patient presenting with acute coma. Retrosigmoid craniotomy for tumor resection was performed for all patients. Histopathological examination revealed extensive areas of microhemorrhage with considerable macrophage infiltration. All three patients were discharged with no additional neurological deficit and good functional performance. Clinically significant hemorrhagic VSs are rare, and patients may present with acute to subacute (i.e., within a month) symptoms of hearing loss headache, facial, or trigeminal nerve palsy. Macrophage infiltration is frequently encountered in tumor specimens and reflects the pivotal role of chronic inflammation in their pathophysiology. Surgical resection can lead to good outcomes with timely intervention.
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Affiliation(s)
| | - Pak-Lun Lam
- Diagnostic and Interventional Radiology, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
| | - Yuki Hoi-Kei Ip
- Department of Neurosurgery, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
| | | | | | | | - Hoi-Tung Wong
- Department of Neurosurgery, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
| | | | - Kwong-Yau Chan
- Department of Neurosurgery, Kwong Wah Hospital, Yau Ma Tei, Hong Kong
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An unusual cause of superficial siderosis of central nervous system: A case report of a vestibular schwannoma. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.649652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kocharyan AH, Briggs S, Cosetti MK, Heman-Ackah SM, Golfinos JG, Roland JT. Atypical Schwannoma: A 10-year experience. Am J Otolaryngol 2020; 41:102309. [PMID: 31727334 DOI: 10.1016/j.amjoto.2019.102309] [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: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The goal of this study was to describe the clinical presentation associated with atypical schwannoma of the cerebellopontine angle, characterize the pathologic findings and describe the long-term outcome. MATERIALS AND METHODS The study design was retrospective case review of patients with the histopathologic diagnosis of atypical and benign schwannoma of the cerebellopontine angle diagnosed at the study institution over a 10-year period. SETTING Tertiary referral center. MAIN OUTCOMES MEASURE Demographic data of the cohort were recorded. Findings on pathology were evaluated. Initial treatment and post-operative course was recorded. Main outcome measures were clinical presentation, including cranial nerve deficits at the time of presentation, complication and recurrence rates. RESULTS At presentation, a somewhat accelerated course of cranial nerve deficit was noted among patients with atypical schwannoma as compared to benign schwannoma. In the immediate post-operative period, there were no differences noted in the complication rate. Atypical schwannomas appear to have higher recurrence rate compared to benign schwannomas. CONCLUSIONS Atypical schwannoma is an intermediate disease process with an accelerated clinical course and higher recurrence rate as compared to vestibular schwannoma. Traditional operative approaches may be employed without increased concern for post-operative complications. Thorough counseling and close follow-up should be offered to these patients given the higher recurrence rate. Larger studies are required to determine if these patients need more frequent MRIs for long-term surveillance.
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Affiliation(s)
- Armine H Kocharyan
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Selena Briggs
- Department of Otolaryngology, MedStar Georgetown University Medical Center, Washington, DC, USA; Department of Otolaryngology, MedStar Washington Hospital Center, Washington, DC, USA; Department of Otolaryngology, New York University School of Medicine, New York, NY, USA.
| | - Maura K Cosetti
- Department of Otolaryngology, Eye and Ear Infirmary of Mount Sinai, The Mount Sinai Hospital, Mount Sinai Beth Israel, New York, NY, USA
| | - Sabrina M Heman-Ackah
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - John G Golfinos
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - J Thomas Roland
- Department of Otolaryngology, New York University School of Medicine, New York, NY, USA; Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
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Dandinarasaiah M, Grinblat G, Prasad SC, Taibah A, Sanna M. Rapidly growing cystic vestibular schwannoma with sudden onset facial palsy, ten years after subtotal excision. Laryngoscope 2017; 128:1649-1652. [PMID: 28722232 DOI: 10.1002/lary.26768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/05/2017] [Indexed: 02/01/2023]
Abstract
An elderly male patient diagnosed with a right-sided cystic vestibular schwannoma (CVS) at our center underwent a translabyrinthine approach with a subtotal excision to preserve the facial nerve (FN). The tumor grew slowly for the first 9 years but in the subsequent 2 years grew rapidly, with the patient developing a FN paralysis. Using the previous approach, a second surgery was done and the tumor was excised, leaving behind a sheath of tumor on the facial and lower cranial nerves. This case demonstrates that CVSs show unpredictable growth patterns and need to be followed up for a longer period of time. Laryngoscope, 128:1649-1652, 2018.
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Affiliation(s)
| | - Golda Grinblat
- Department of Otology and Skull Base Surgery, Gruppo Otologico , Piacenza, Rome, Italy
| | | | - Abdelkader Taibah
- Department of Otology and Skull Base Surgery, Gruppo Otologico , Piacenza, Rome, Italy
| | - Mario Sanna
- Department of Otology and Skull Base Surgery, Gruppo Otologico , Piacenza, Rome, Italy
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Li P, Bi Z, Hao S, Zhang J. Multicystic vestibular schwannomas with fluid-fluid levels: A report of three cases. Oncol Lett 2015; 10:206-210. [PMID: 26171000 DOI: 10.3892/ol.2015.3211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 04/14/2015] [Indexed: 12/21/2022] Open
Abstract
The present study reported three rare cases of multicystic vestibular schwannoma with fluid-fluid levels. These three tumors exhibited apparent fluid-fluid levels that demonstrated a radiological appearance of two fluid levels in the cystic area. Two cases had an acute history, whereas one case presented with a chronic progression. A suboccipital retrosigmoid approach was used for access to the tumors and gross total resection was achieved in all the cases. During the surgical procedures, unclotted blood was observed, and the tumors were adhered to the facial nerve, other cranial nerves or the brain stem. In each case, the facial nerve function of the patients was impaired following surgery. The present study discussed the possible mechanism of the formation of the fluid-fluid levels, the effect of the fluid-fluid levels and the therapeutic strategy employed.
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Affiliation(s)
- Puxian Li
- Department of Neurosurgery, Laiwu Hospital, Taishan Medical University, Laiwu, Shandong 271100, P.R. China ; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Zhiyong Bi
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Shuyu Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Junting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, P.R. China
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