Neurinoma of the third, fourth, and sixth cranial nerves: A survey and report of a new fourth nerve case

doi:10.1016/0090-3019(92)90172-J

Surgical Neurology

Volume 38, Issue 3, September 1992, Pages 216-224

https://doi.org/10.1016/0090-3019(92)90172-J Get rights and content

Abstract

A rare case of trochlear nerve neurinoma is described. Including this case, the number of reported intracranial tumors arising from the sheaths of the third, fourth, and sixth cranial nerves is 38. By site and relationship to the nerve segment, they fall into three groups: cisternal, cisternocavernous, and cavernous. In cisternal tumors of the third and sixth nerves, paresis of the nerve hosting the tumor is the unique nerve deficit; by contrast, in those of the fourth nerve, paresis of the trochlear nerve can be absent and that of the third nerve present. In the latter tumors, a peculiar ataxic hemiparesis syndrome is produced by midbrain compression. Cisternocavernous neurinomas often cause symptoms of intracranial hypertension, while cavernous neurinomas bring about two clinical features: paresis of one or more nerves of the cavernous sinus and a clinicoradiological orbital apex syndrome. At surgery, generally cisternal neurinomas are totally removed and the nerve source of the tumor identified; in cisterno-cavernous and cavernous neurinomas, total removal of tumor and identification of the parent nerve have been reported in only half of the cases. In the majority of parasellar neurinomas, clinical differences can be found between those arising from the nerves governing eye movement and those arising from the gasserian ganglion.

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Predictors of Surgical Outcomes in Patients with Abducens Nerve Schwannoma: A Comprehensive Systematic Review and a Case Report
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Abducens nerve (AN) schwannomas are extremely rare tumors. Clinical characteristics and factors that influence postoperative outcomes are not well defined.
To characterize clinical features of AN schwannomas and predictors of surgical outcomes.
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.
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).
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.
The Trochlear Nerve: Anatomy and Pathology
2022, Seminars in Ultrasound, CT and MRI
Citation Excerpt :
Trochlear nerve schwannomas without being related to type 2 neurofibromatosis (NF2) are rare, with only a few cases reported.8 Three types of trochlear schwannomas were described and have been classified according to the location of the predominant mass as cisternal, cisterno-cavernosus and cavernous types, being the cisternal type the most frequent.8,9 Rarely the trochlear nerve can be involved by metastatic disease (leptomeningeal carcinomatosis) and MRI with 3-dimensional T1W postcontrast images shows abnormal contrast enhancement of the cisternal portion of the nerve (Fig. 2).
Surgical Treatment of Trochlear Nerve Schwannomas: Case Series and Systematic Review
2022, World Neurosurgery
Citation Excerpt :
Forty-one studies were included in the review. There were 11 articles from the United States5,6,12,13,25,30,33,37,39,41,44; 8 articles from Japan8,10,15,18,21,27,29,34; 3 articles from Italy14,31,40 and England11,16,24; 2 articles from Australia,9,19 India,20,26 Turkey,23,43 Germany,28,32 and Iran36,42; and 1 article from Spain,7 France,17 Israel,22 China,38 and Taiwan.45 By combining these studies and our experience, the data of 45 patients in total were obtained.
Cranial nerve schwannomas almost always arise from sensory or mixed nerves. Motor cranial nerves, such as the trochlear nerve, are rarely associated with schwannomas. No consensus has yet been made for surgical intervention because of the low number of reported cases of trochlear nerve schwannomas. This study comprises a systematic review of the literature and our experience for surgically treated trochlear nerve schwannomas.
Three databases (Web of Science, PubMed, and Cochrane Library) were searched without date restrictions. Studies were included if they were published in the English literature and presented patients of any age who underwent surgical treatment for trochlear schwannoma. Data extracted from the included studies were combined with our experience.
Forty-one studies, presenting 43 patients, met the inclusion criteria. The total number of patients was 45 after our experience was added. The most common symptoms were diplopia (62.2%), headache (46.7%), and motor weakness (37.8%). Mean age during the diagnosis was 45.1 years. Although the subtemporal transtentorial approach (n = 14) is the most preferred method, its application has decreased in recent years. In the last decade, the lateral suboccipital approach (n = 11) has gained popularity. Residual postoperative trochlear nerve deficit was detected in 81% of patients. The probability of neurologic deficit was not statistically associated with tumor volume (P = 0.914), location (P = 0.669), or resection rate (P = 0.554).
Although trochlear schwannomas are rare and their treatment involves challenges, total resection with the proper approach provides the most desirable results.
Surgical Technique and Nuances of Resection of a Trochlear Schwannoma: Operative Video
2022, World Neurosurgery
Cranial nerve schwannomas accounts for around 8% of all benign intracranial tumors, arising most commonly from the vestibular nerve, followed by the trigeminal nerve and other lower cranial nerves. However, trochlear schwannoma in a patient without neurofibromatosis-2 are extremely rare and to date, fewer than 100 cases have been reported in the literature. They are either asymptomatic or present with ophthalmologic or neurologic symptoms. Diplopia is the most common initial symptom. As the tumor grows, it can compress the surrounding brainstem and other cranial nerves, causing neurologic symptoms. Asymptomatic lesions are detected incidentally following imaging for some other reason. There are no clear guidelines for the management of these tumors. In general, small asymptomatic tumors are closely observed by serial imaging and symptomatic or larger tumors are managed by surgical excision and/or stereotactic radiosurgery.1, 2, 3, 4, 5, 6, 7
Here we present a 41-year-old female patient with incidentally detected left trochlear schwannoma during the follow-up magnetic resonance imaging (MRI) scans. She was followed up regularly with multiple repeat MRI. Recently she started complaining of occasional headaches, and MRI showed a left peimesencephalic cistern tumor causing mass effect on the ipsilateral midbrain. There was also significant brainstem edema. Hence she underwent left retromastoid suboccipital craniectomy, lateral supracerbellar approach, and complete excision of the tumor. Postoperatively the patient had an uneventful recovery without any new neurologic deficits. At 6 months’ follow-up the patient is doing well.
Neoplasms of the cranial nerves
2022, Handbook of Neuro-Oncology Neuroimaging
Schwannomas, optic pathway gliomas (OPGs) and primary central nervous system lymphomas (PCNSLs) are the three main types of tumours that affect the cranial nerves. Schwannomas are the most common and they affect the vestibular nerve most often. They have characteristic findings on computed tomography (CT) and magnetic resonance imaging (MRI) compared to meningiomas. Gliomas of the cranial nerves are far less common; however, gliomas of the optic nerve/chiasm (OPGs) have a higher incidence and are associated with neurofibromatosis type 1. MRI with gadolinium will demonstrate enhancement of the involved segment of the nerve. PCNSL is typically a disease associated with immunocompromised patients. These tumours rarely involve a single cranial nerve without extension from the parenchyma, though PCNSL of the cranial nerves alone has been reported. This tumour is best imaged using MRI and newer imaging modalities such as MR single-photon-emission CT and [18F]fluorodeoxyglucose positron emission tomography scans.
Trochlear Schwannoma Arising from Transition Zone of Nerve Sheath in the Pineal Region: Case Report and Review of the Literature
2020, World Neurosurgery
This report presents the third case of trochlear schwannoma arising from the pineal region and the first case to be resected using a paramedian infratentorial supracerebellar approach. Schwannomas of cranial nerves have traditionally been thought to arise from the transitional point where the axonal envelopment switches from glial cells to Schwann cells; however, recent temporal bone histopathologic evidence from vestibular schwannomas challenges this view. Of the 38 cases of pathology-confirmed trochlear schwannoma in the literature, there are only 2 cases arising from the pineal region, where the nerve sheath transition zone is located. Here, we discuss an unusual case of trochlear schwannoma arising from this transition zone.
A 65-year-old man was admitted to our institute after a traffic accident. He complained of headache and dizziness, and a computed tomography scan revealed an isodense mass in the pineal region with obstructive hydrocephalus. Magnetic resonance imaging with contrast showed an enhancing mass in the pineal region. The tumor was subtotally resected using a paramedian infratentorial supracerebellar approach, and pathology confirmed the diagnosis of trochlear schwannoma.
Trochlear schwannoma should be considered when a mass is identified in the pineal region. This diagnosis should still be entertained for mass lesions along the free tentorial edge because the tumor may arise distant from the glial-Schwann transition zone located by the dorsal midbrain. We propose a treatment algorithm for this rare tumor that seeks to maximize functional outcome.

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Neurinoma of the third, fourth, and sixth cranial nerves: A survey and report of a new fourth nerve case

Abstract

J Neurol Neurosurg Psychiatry

J Neurosurg

Cryptogenic oculomotor nerve palsy

Neurinomas of the trigeminal nerve

Surg Neurol

Neurinome du nerf oculomoteur

Ataxic hemiparesis from a midbrain mass

Ann Neurol

Tumours of the fifth cranial nerve

Acta Neurochir (Wien)

I neurinomi del trigemino

Chirurgia

Neurilemmoma of the fourth cranial nerve

Value of serial stereotactic biopsies and impedance monitoring in the treatment of deep brain tumours

J Neurol Neurosurg Psychiatry

Neurinoma of the abducens nerve

Neurosurgery

Tumours involving the Gasserian ganglion

J Nerv Ment Dis

Correlative anatomy of the nervous system

Neurinome du ganglion de Gasser à développement temporal

Neurochirurgie

Récupération partielle du nerf moteur oculaire commun après section puis réparation au cours de l'exérèse d'une tumeur

Neurochirurgie

Ataxic hemiparesis

Homolateral ataxia and crural paresis: a vascular syndrome

J Neurol Neurosurg Psychiatry

Mesencephalic syndromes

Cystic schwannoma of the trochlear nerve mimicking a brain-stem tumor

Sixth nerve schwannoma: MR and CT demonstration

J Comput Assist Tomogr

Return of function after intra-cranial suture of the trochlear nerve

Sixth nerve neuroma in the cavernous sinus: CT features

Catecholamine-secreting malignant schwannoma in a patient with multiple intracranial aneurysms

Ataxic hemiparesis: three different locations of lesions studied by MRI

Neurology

Isolated midbrain lesion resulting from closed head injury: a unique presentation of ataxic hemiparesis

Neurology

An unusual presentation of neurofibroma of the oculomotor nerve

J Neurosurg

Trigeminal neuri-lemmoma presenting as a sphenoid sinus mass

Surg Neurol

Schwannoma of the trochlear nerve

Hémiparésie ataxique par lacune thalamique

Rev Neurol (Paris)

Das Okulomotoriusneurinom

Klin Monatsbl Augenheilkd

Capsular ataxic hemiparesis

Arch Neurol

Neurinoma with intrasellar extension: a case report

No Shinkei Geka

Oculomotor nerve anastomosis

Neurosurgery

Trigeminal neurinomas with some remarks on malignant invasion of the Gasserian ganglion

Ataxic hemiparesis

Arch Neurol

Neurinoma of the oculomotor nerve

Neurinoma of the oculomotor nerve: CT and MR features

Neurinoma of the oculomotor nerve

Trigeminal neurinoma presenting abducens nerve palsy as initial symptom: a report of two cases

No Shinkei Geka

Neurinoma of the oculomotor nerve: CT and MR features

Trochlear nerve sheath tumor