Combined open maxillectomy and endoscopic endonasal resection of a giant V2 trigeminal schwannoma.

BACKGROUND: Trigeminal schwannoma is a rare type of tumor that arises from the Schwann cells of the trigeminal nerve. METHOD: We present a case of a patient with a giant V2 trigeminal schwannoma with painful swelling in the left maxilla. A complete resection using a combined open maxillectomy and endoscopic endonasal approach was performed. CONCLUSION: This case highlights the importance of a multidisciplinary approach to perform a combined open and endoscopic approach for safe resection while preserving adequate speech and swallowing.

Microsurgical Resection of Trigeminal Schwannoma via Anterior Petrosal Approach: 2-Dimensional Operative Video.

Trigeminal schwannomas are complex lesions that may be related to many critical neurovascular structures. We present the case of a 59-year-old male presenting a history of left-sided trigeminal neuralgia. Preoperative imaging demonstrated a mass highly suggestive of a trigeminal schwannoma, and microsurgical resection was indicated considering the progressive symptomatology and important mass effect (Video 1). A middle fossa route including an anterior petrosectomy was chosen. The patient was placed supine with the head rotated to the contralateral side, and an arcuate incision was performed. A V-shaped zygomatic osteotomy was done to mobilize the temporalis muscle more inferiorly and better expose the middle fossa floor. Following craniotomy, peeling of the dura propria from the lateral wall of cavernous sinus was carried out starting by coagulation of middle meningeal artery. Some tumor was already identified and removed, and then the anterior petrosectomy was performed until we exposed the posterior fossa dura. The middle fossa dural incision was connected with the other one at the posterior fossa dura, by coagulation of the superior petrosal sinus. The tentorium was completely cut toward the incisura. After lesion debulking, the tumor was progressively removed by peeling the arachnoid from the lesion to maintain arachnoid planes and preserve the nerves and their blood supply. Postoperative imaging demonstrated complete tumor resection. The patient's symptoms improved, and there were no neurologic deficits on follow-up. Extensive laboratory training is fundamental to be familiarized with the normal anatomic nuances and prepared to face the anatomy distorted by lesion. Informed consent was obtained from the patient for the procedure and publication of this operative video.

Trigeminal Ophthalmic Branch Schwannoma: Case Report and Literature Review

Schwannomas are the fourth most common primary neoplasms affecting the brain and cranial nerves. Central lesions commonly arise from sensory nerve roots, and a common intracranial site is the vestibular branch of the 8th nerve (>85%). We present the case report of a patient who has a schwannoma extending from the pterygopalatine fossa to the orbit, complaining about facial pain in the trajectory of the trigeminal ophthalmic branch. Schwannomas represent 1 to 2% of all neoplasms of the orbit, and trigeminal schwannomas are extremely rare, accounting for less than 0.5% of all intracranial tumors.

Treatment of severe trigeminal headache in patients with pituitary adenomas.

BACKGROUND: The incidence of headache in patients with pituitary adenomas is high, and the underlying pathological mechanisms are not completely understood. OBJECTIVE: We tested the efficacy of percutaneous ganglion block and trigeminal rhizotomy in the treatment of severe trigeminal/autonomic headache associated with pituitary tumors. METHODS: Eleven patients treated surgically for pituitary adenomas in whom intractable trigeminal headaches developed were enrolled in the study and underwent ictal cerebral single-photon emission computed tomography before starting treatment. Initially, all patients underwent a 6-month medical treatment trial. Patients who did not experience improvement in headache severity, addressed by the Headache Impact Test-6 scale, underwent trigeminal percutaneous ganglion blockade. Two patients subsequently underwent trigeminal balloon rhizotomy. RESULTS: Among the 11 patients, 6 did not have improved Headache Impact Test-6 scale scores after 6 months of treatment with medications and underwent trigeminal ganglion blockade. Significant improvement in headache severity was noted in 3 of them. Long-term response was obtained in 1 patient, and the other 2, in whom the response was transient, were then successfully treated with trigeminal rhizotomy. Cerebral single-photon emission computed tomography showed increased uptake in the thalamus/hypothalamus region in patients who responded well to manipulation of the trigeminal-hypothalamic system. CONCLUSION: Percutaneous ganglion blockade and trigeminal rhizotomy may be promising alternative options for the treatment of severe headache in selected patients with pituitary adenomas.

Surgical management of trigeminal schwannomas.

OBJECT: The authors provide a detailed review of the surgical management of trigeminal schwannomas (TSs) and also discuss the best surgical approach based on the surgical anatomy and tumor extension. METHODS: A series of 17 patients with TSs who were surgically treated between 1987 and 2008 at the authors' institution is reported. The lesions were small (< 3 cm) in 2, medium (between 3 and 4 cm) in 5, large (> 4 cm) in 6, and giant (> 5 cm) in 4 cases. Preoperative symptoms included trigeminal hypesthesia (53%), facial pain (53%), headaches (35.3%), hearing impairment (17.6%), seizures (17.6%), diplopia (11.8%), ataxia (11.8%), and hemiparesis and increased intracranial pressure with papilledema (5.9%). The mean follow-up duration was 10.5 years (121.6 months), with an average of 0.8 patients per year. RESULTS: Total tumor excision was possible in 16 patients, with no surgery-related deaths. Postoperative trigeminal anesthesia was observed in 7; trigeminal motor function was preserved in 7. Two developed cerebrospinal fluid leakage, 2 presented with mild facial palsy, and 1 patient with neurofibromatosis Type 2 had recurrence of the tumor, which was uneventfully removed. Of the 9 who reported facial pain, only 1 remained symptomatic postoperatively. CONCLUSIONS: The best treatment for TSs is complete microsurgical removal. Postoperative preservation of trigeminal nerve function is possible when resection of the lesion is performed at well-established skull base neurosurgical centers. Although good results have been reported with radiosurgery, no cure can be obtained with this therapeutic modality. Instead, this treatment should be reserved only for nonresectable and residual tumors within the cavernous sinus.

Endoscopic assisted microneurosurgery for gasserian portion of trigeminal neuroma: two cases.

We report two cases of trigeminal neuroma that were operated on by the neurosurgery team at Felício Rocho Hospital, Belo Horizonte, Minas Gerais State, Brazil. Endoscopic assisted microsurgery was the technique used to approach the gasserian region tumor with good results.

Endoscopic assisted microneurosurgery for gasserian portion of trigeminal neuroma: two cases / Microneurocirurgia assistida por endoscópio para abordagem da porção gasseriana do neurinoma do trigêmeo: relato de dois casos

We report two cases of trigeminal neuroma that were operated on by the neurosurgery team at Felício Rocho Hospital, Belo Horizonte, Minas Gerais State, Brazil. Endoscopic assisted microsurgery was the technique used to approach the gasserian region tumor with good results.

Descrevemos dois casos de neurinoma do trigêmeo operados no Serviço de Neurocirurgia do Hospital Felício Rocho, Belo Horizonte, Estado de Minas Gerais, Brasil. Utilizamos com sucesso a microcirurgia assistida por endoscopia para abordagem de tumores da porção gasseriana.

Cerebellopontine angle cysticercus and concurrent vascular compression in a case of trigeminal neuralgia.

The authors present the case of a 59-year-old woman with an 8 months history of lancinating pain and hyphestesia on the right side of the face along with hearing impairment. She had poor tolerance to carbamazepine. A non-enhancing cystic image was observed at the right cerebellopontine angle on magnetic resonance imaging. The patient underwent surgery. Through a right retromastoid minicraniectomy and under microscopic magnification the VII and VIII cranial nerve complex was found involved by multiple adhesions around a cysticercus. After the cyst was removed a loop of the anteroinferior cerebellar artery was identified compressing the V right nerve at its root entry zone. Decompression was performed by the insertion of a Teflon implant. The postoperative course was uneventful and trigeminal neuralgia (TN) disappeared after surgery. Five previous cases of cranial nerve hyperactive dysfunction syndromes, four of trigeminal neuralgia and one of hemifacial spasm associated to cerebellopontine angle cysticercosis are briefly commented. We suggest that in some of these cases microvascular compression was probably present, and during surgery of cerebellopontine angle cysticercus by either trigeminal neuralgia or hemifacial spasm, vascular compression must be carefully searched and treated when found.

Pathological laughter in a patient with trigeminal neurinoma.

We present a 47-year-old woman with a long history of anxiety and a more recent history of shock-like facial pain and episodes of laughter without any motivation. She could not explain the laughing bursts and did not have a sense of mirth preceding it. On neurological examination she presented a VI nerve palsy and trigeminal hypoesthesia (V2 and V3) on the right side. Magnetic resonance imaging exhibited a large cystic lesion on the right middle fossa causing significant compression on the brain stem. A frontoorbitozygomatic and pretemporal combined approach was performed. During intra and extradural exploration a large tumor was found on the trigeminal nerve. The whole lesion was resected, revealing to be a neurinoma on pathological exhamination. She maintained a VI nerve palsy but had complete remission of the unmotivated laughing episodes during the one year follow up.

Trigeminal schwannoma. Classification and surgical approaches

This paper reviews and expands the Jefferson's Classification regarding the localization of trigeminal schwannomas. The authors present a series of specific surgical approaches best suited to remove these tumors. Using skull base neurosurgical techniques, the authors present the most direct, efficient and safety surgical approaches to remove each of five different types of trigeminal schwannomas. Three illustrative cases of their own are also presented.