Tentorial meningioma and painful tic convulsif. Case report

Flocculus Herniation and Hearing Disturbance Induced by Remote Tentorial Meningioma: A Case Report

Tentorial meningiomas, not involving the cerebellopontine angle cistern or cranial nerves, rarely cause symptoms of cranial nerve disturbance. We report a case of a patient with a paramedian tentorial meningioma who presented with hearing loss as a result of indirect compression of the vestibulocochlear nerve by the herniated cerebellar flocculus into the internal acoustic meatus. A 50-year-old woman had presented with hearing loss in her right ear. Magnetic resonance imaging (MRI) revealed a large tentorial meningioma in the right posterior cranial fossa. Constructive interference in steady-state (CISS) imaging demonstrated a non-enhanced solid structure at the ipsilateral cerebellopontine angle cistern and internal acoustic meatus. During surgery, after resection of the tumor, the herniated cerebellar flocculus into the internal auditory canal was observed at the ipsilateral cerebellopontine angle. MRI obtained following meningioma resection demonstrated the herniated flocculus regressing from the fundus of the internal acoustic meatus to the cerebellopontine angle cistern, and her hearing was improved as a result of decompression. This is a rare case report of flocculus herniation caused by remote tentorial meningioma. Patients with paramedian tentorial meningiomas rarely present with hearing loss. In these cases, the causes of the hearing loss (microvascular compression, transformed brainstem, and venous circulation disorders) have been described in the literature. In this report, a new mechanism became evident: a herniated flocculus into the internal acoustic meatus by a tumor can cause hearing loss. MRI, particularly CISS imaging, can clearly show the flocculus during the entire clinical course.

Microvascular decompression in patients with coexistent trigeminal neuralgia, hemifacial spasm and glossopharyngeal neuralgia

BACKGROUND

Trigeminal neuralgia(TN), hemifacial spasm (HFS) and glossopharyngeal neuralgia (GPN) were referred to hyperactive dysfunction syndromes (HDSs) of the cranial nerves. These symptoms may occur synchronously or metachronously, but the combination of three diseases is extremely rare.

METHODS

From 2007 through 2013, six patients with coexistent GPN-HFS-TN were treated in our department. The combined symptoms occurred on the same side in three and on both sides in three. These patients underwent nine microvascular decompression (MVD) procedures in total. The clinical data including operative findings were respectively analyzed, and the etiological factors as well as treatment strategies were discussed.

RESULTS

Intraoperatively, in all the cases a small posterior fossa was found, which was crowded with cranial nerve roots and cerbellar vesels. Postoperatively, spasm was stopped immediately in four and within 3 months in two; the symptom of TN disappeared immediately in four and within 2 weeks in two; the symptom of GPN was relieved immediately in four and improved with medication in two. During the up to 77 months' follow-up, no changes, recurrence or any dysfunctions of cranial nerves were observed in any of the patients.

CONCLUSIONS

The combination of HFS-TN-GPN is extremely rare and is often associated with a looped VBA and a smaller posterior fossa. However, MVD is still a good choice for treatment. To achieve a safe and effective outcome, dissection of the caudal cranial nerves and proximal transposition of the vertebral artery before decompression of the affected nerve roots are strongly recommended.

Aetiology and pathogenesis of trigeminal neuralgia: a comprehensive review

Objectives

The aim of present paper was to discuss issues related to trigeminal neuralgia with strong emphasis on the aetiology and pathogenesis of this problem.

Material and Methods

An electronic search of 5 databases (1965 - Oct 2012) and a hand search of peer-reviewed journals for relevant articles were performed. In addition, experience acquired from treating 3263 patients in the Department of Maxillofacial Surgery, Lithuanian University of Health Sciences, were also summarized.

Results

Generally, aetiological factors can be classified into 3 most popular theories that were based on: 1) Related to other disease, 2) Direct injury to the trigeminal nerve, and 3) Propagates the polyetiologic origin of the disease. In addition, two pathogenesis mechanisms of trigeminal neuralgia were proposed. First: the peripheral pathogenetic mechanism that is often induced by progressive dystrophy around the peripheral branches of the trigeminal nerve. Second, central pathogenetic mechanism which often triggered by peripheral pathogen that causes long-lasting afferent impulsation and the formation of a stable pathologic paroxysmal type irritation focus on the central nerve system (CNS).

Conclusions

Patients with susceptive trigeminal neuralgia should be examined carefully by specialists who have expertise in assessing and diagnosing of possible pathological processes and be able to eliminate the contributing factors so the trigeminal neuralgia can be properly managed.

Four patients with painful tic convulsive and a brief review of surgical treatment

We present four patients with unusual painful tic convulsive: three were due to neurovascular compression; one was secondary to a cerebellopontine angle epidermoid cyst. We discuss these patients and those in the literature to determine the appropriate therapy for this rare disease.

Hemifacial spasm can be the presenting symptom of a fourth ventricle tumour. A short case-illustrated review and pathogenetic considerations

In this short case-illustrated review we aimed to analyse the possible nuances of hemifacial spasm (HFS) as the presenting symptom of a tumour of the fourth ventricle. The issue is remarkable since HFS can be secondary to a fourth ventricle tumour, even when no other neurological signs are reported. In addition, the possible presentation with only upper facial muscle involvement, as in the presented case, can be deceitful because this is characteristic of the benign and much more frequent "typical" form. Based on our intra-operative data and on the previously reported cases, we think that pathogenesis could be referable to the facial nerve nucleus involvement and that clinical nuances could be related to the specific somatotropy of the nucleus under the fourth ventricle floor that, as in our case, can be infiltrated by tumour. Resolution of the disorder can usually be obtained after the complete resection of the tumour that in the reported case resulted a subependymoma (WHO grade I), so far never described in literature associated with HFS.

Microvascular Decompressions in Patients With Coexistent Hemifacial Spasm and Trigeminal Neuralgia

BACKGROUND:

Although microvascular decompression (MVD) is widely accepted as the effective therapy for hemifacial spasm (HFS) or trigeminal neuralgia (TN), the surgical treatment of coexistent HFS and TN in an individual is seldom addressed.

OBJECTIVE:

To discuss the operative strategy of MVD for both the hemifacial and trigeminal nerves.

METHODS:

Nine consecutive cases of coexistent HFS and TN caused by neurovascular confliction in the same side were studied. Except for one, the patients suffered from HFS followed by ipsilateral TN. All patients underwent MVD and were followed up for 3 to 30 months. Each surgery was analyzed retrospectively.

RESULTS:

Intraoperatively, a looped vertebral artery (VA) shifted to the suffered side was found in 8 patients. The VA was regarded as the direct or indirect offending artery. After MVDs, the spasm ceased immediately in 6 patients; the other 3 patients had delayed relief within 3 months. The pain disappeared immediately in 7 of 9 patients. One patient felt relief after a week, and 1 had pain but improved slightly. No recurrence or complication was found.

CONCLUSION:

A shifted VA loop may account for this tic convulsif syndrome. MVD is a reasonable and effective therapy with a high cure rate for the disease. The key to the surgery is to move the VA proximally. The dissection should be performed rostrally starting from the caudal cranial nerves.

CEREBELLOPONTINE ANGLE ARACHNOID CYST: A CASE OF HEMIFACIAL SPASM CAUSED BY AN ORGANIC LESION OTHER THAN NEUROVASCULAR COMPRESSION

OBJECTIVE

A rare case of cerebellopontine angle arachnoid cyst manifesting as hemifacial spasm (HFS) is reported. The patient is a 42-year-old woman with 10-month history of left HFS. A preoperative magnetic resonance imaging scan showed a well-demarcated area, hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging, in the left cerebellopontine angle, without contrast enhancement, resembling an arachnoid cyst.

METHODS

The cyst was excised with microneurosurgical technique and the facial, vestibular, and acoustic nerves were completely decompressed from the arachnoid wall.

RESULTS

The postoperative course was uneventful, and the left HFS disappeared immediately. Histologically, the cyst wall was a typical arachnoidal membrane. Ten months after surgery, the patient is symptom free.

CONCLUSION

It is well-known that in approximately 10% of cases, trigeminal neuralgia can be caused by a space-occupying mass. However, the fact that HFS can also be caused by organic lesions as well as neurovascular compression is less well-known. Although the occurrence of tumor compression causing HFS has been previously recognized, cerebellopontine angle cysts have very rarely been described. The observation of a patient with a cerebellopontine angle arachnoid cyst causing HFS prompted us to review the literature relative to HFS caused by an organic lesion rather than neurovascular compression.

Hemifacial spasm caused by a huge tentorial meningioma

A rare case of hemifacial spasm caused by an ipsilateral tentorial meningioma is described. Magnetic resonance imaging showed a huge tumor in the right cerebellar hemisphere, distant to the cerebello-pontine cistern. The facial-vestibulocochlear nerve complex was stretched by the shift of the brainstem and the right cerebello-pontine cistern was effaced. After removing the tumor, the hemifacial spasm resolved completely. We review our case with the pertinent literature regarding the etiological mechanism.

Remote tentorium meningioma causing sudden sensorineural deafness

BACKGROUND

Sudden sensorineural deafness is a well-known symptom mostly of unknown etiology.

CASE DESCRIPTION

A case of sudden sensorineural deafness is reported to be caused by a small, remote, ipsilateral tentorial meningioma not compressing the vestibulocochlear nerve or auditory tract. Surgical resection of the meningioma immediately restored the patient's hearing.

CONCLUSION

The authors hypothesize that the sudden sensorineural deafness resulted from a growing meningioma inducing a neurovascular compression of the vestibulocochlear nerve, the vertebral artery already being in close relationship with the vestibulocochlear nerve in the premorbid phase. Resection of the meningioma allows for an autodecompression of this vascular conflict resulting in hearing restoration.

Facial pain: clinical differential diagnosis

Differential diagnosis of pain in the face as the presenting complaint can be difficult. We propose an approach based on history and neurological examination, which allows a working diagnosis to be made at the bedside, including aetiological hypotheses, leading to a choice of investigations. Neuralgias are characterised by stabs of short lasting, lancinating pain, and, although neuralgias are often primary, imaging may be needed to exclude symptomatic forms. Facial pain with cranial nerve symptoms and signs is almost exclusively of secondary origin and requires urgent examination. Facial pain with focal autonomic signs is mostly primary and belongs to the group of the idiopathic trigeminal autonomic cephalalgias, but can occasionally be secondary. Pure facial pain is most often due to sinusitis and the chewing apparatus, but also a multitude of other causes. The pain can also be idiopathic. Imaging as well as non-neurological specialist assessment is often necessary in these cases.

[Tentorial meningiomas. Report of our series]

PURPOSE

The main objectives of this report are to describe the clinical and radiological features, surgical management, complications, and final outcome of patients with a tentorial meningioma.

METHODS

This is a retrospective study of 25 patients operated on for tentorial meningiomas at our department since december 1975 to may 2002. All the patients, except the first, were diagnosed by computed tomography; in 13 of them a magnetic resonance imaging was performed too; in 14 patients, diagnosis was completed with cerebral arteriography. The preoperative clinical condition, the interval between the first symptoms and the date of the operation, the postoperative morbidity and the recurrence are analysed.

RESULTS

There were 20 women and 5 men of ages ranging from 35 to 79 years (average of 54.6). Surgical removal was considered radical (Simpson I-II) in 22 patients. Of them one had a recurrence 25 years after the operation, another had three recurrences, in two years, that were reoperated, and a third one had recurrence at five years who did not require surgery. The postoperative mortality was 8%. The mean follow-up period was of 5.3 years. The final outcome was good recovery in 19 patients, moderate disability in 1 and death in 4.

CONCLUSIONS

Despite the advances in Neuroradiology and Microsurgery, these tumors represent a challenge for the neurosurgeon, due in some cases to a large tumor size and extension to critical areas. A removal as complete as possible allows minimizing the recurrence risk.

Trigeminal neuralgia associated with tentorial agenesis and temporal lobe herniation--case report

A 22-year-old female presented with an extremely rare case of trigeminal neuralgia associated with tentorial agenesis. The pulsating pain in her left maxillary region persisted for an abnormally long time and had no trigger zone. The pain later spread to the periorbital region. Coronal magnetic resonance imaging revealed left medial temporal lobe herniation caused by tentorial agenesis. The herniated temporal lobe, which had distorted the superior cerebellar artery, was causing compression of the trigeminal nerve. Her condition improved following microvascular decompression surgery. Tentorial agenesis should be considered as a cause of atypical pulsating facial pain, especially in younger patients.

Combined hyperactive dysfunction syndrome of the cranial nerves: trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia: 11-year experience and review

OBJECTIVE

A pathological condition caused by vascular compression at the root entry/exit zone of the cranial nerves is designated hyperactive dysfunction syndrome (HDS) of the cranial nerves. Patients with HDS who exhibited a combination of trigeminal neuralgia (TN), hemifacial spasm (HFS), and/or glossopharyngeal neuralgia were retrospectively reviewed, to study the incidence, etiological factors, and demographic characteristics for this combined HDS group.

METHODS

Medical and surgical records were analyzed for 41 patients with combined HDS, of 1472 consecutive patients with HDS who were treated between 1984 and 1994.

RESULTS

The combined HDS group accounted for 2.8% of all patients with HDS; 19 patients (1.3%) exhibited bilateral symptoms, i.e., 14 cases of TN, 3 of combined TN and HFS, and 2 of HFS. Twenty-two patients (1.5%) exhibited ipsilateral symptoms, i.e., 19 cases of TN and HFS and 3 of TN and glossopharyngeal neuralgia. Excluding three patients whose symptoms were associated with brain tumors or arteriovenous malformations, this patient group was older (63.2 versus 55.3 yr, P = 0.0009) and exhibited an increased percentage of associated hypertension (47.4 versus 17.5%, P = 0.000008), with a female predominance (86.8 versus 71.3%, P = 0.07), compared with the single HDS group. Thirty-six of these patients underwent a total of 61 microvascular decompression procedures, with favorable outcomes. The offending vessels were similar to those in single HDS, which were usually conventional and multiple.

CONCLUSION

The associated etiological factors for vascular compression syndromes were more evident in the combined HDS group than in the single HDS group. Progressive arteriosclerotic vasculoarchitectural changes of the vertebrobasilar system, accelerated by aging and hypertension, bring about the development of combined HDS, with a remarkable female predominance.

Long-term outcome after operation for trigeminal neuralgia in patients with posterior fossa tumors

During a 20-year period, 26 patients with typical symptoms of trigeminal neuralgia were found to have posterior fossa tumors at operation. These cases included 14 meningiomas, eight acoustic neurinomas, two epidermoid tumors, one angiolipoma, and one ependymoma. The median patient age was 60 years and 69% of the patients were women. Sixty-five percent of the symptoms were left sided. The median preoperative duration of symptoms was 5 years. The distribution of pain among the three divisions of the trigeminal nerve was similar to that found in patients with trigeminal neuralgia who did not have tumors; however, more divisions tended to be involved in the tumor patients. The mean postoperative follow-up period was 9 years. At operation, the root entry zone of the trigeminal nerve was examined for vascular cross-compression in 21 patients. Vessels compressing the nerve at the root entry zone were observed in all patients examined. Postoperative pain relief was frequent and long lasting. Using Kaplan-Meier methods the authors estimated excellent relief in 81% of the patients 10 years postoperatively, with partial relief in an additional 4%.