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Neurology India, Vol. 59, No. 5, September-October, 2011, pp. 773-775 Letter to Editor Trigeminal schwannoma with intratumoral hemorrhage: Report of a case and review of literature Savitr B Sastri, Srinivas Dwarakanath, BA Chandramouli Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India PMID: 22019675 DOI: 10.4103/0028-3886.86567 Trigeminal schwannomas are rare tumors accounting for 0.2% of all intracranial tumors. Even rarer are instances of hemorrhage within these tumors. We present one such rare case. A 58-year-old male presented with insidious onset, gradually progressive, holocranial headache of six months duration, which had worsened since two months prior to presentation. He had also outbursts of anger during these two months and a week prior to presentation there was a sudden increase in the severity of the headache and blurring of vision in the left eye. On examination, he had mild papilledema, sensory and motor involvement of all divisions of the left trigeminal nerve, and mild left lateral rectus paresis. Cranial magnetic resonance imaging (MRI) revealed a left temporal region lesion extending into infratemporal fossa, isointense on T1-weighted, hypointense on T2-weighted images, with heterogeneous contrast enhancement. Gradient echo sequence showed tumor bleed with intraventricular extension [Figure - 1] and [Figure - 2]. He underwent a left frontotemporal craniotomy, orbitozygomatic osteotomy, and tumor excision. The tumor was seen to be extending superiorly and a decision was made to excise this portion via an intradural approach. On opening the dura and retracting the temporal lobe superiorly, the tumor was seen and had multiple large blood clots within it. The infratemporal component was also excised via the extradural corridor created earlier. Patient had uneventfully recovery and histopathological examination of the tumor revealed trigeminal schwannoma. In addition to the well recognizable architecture of a schwannoma, there were significant number of cystic spaces and dilated vascular channels. Also observed were areas of focal dark nuclear pleomorphism, which suggested a long standing lesion. Hemorrhage into schwannomas is a rare event and was first described by McCoyd in 1974. Since then, a number of reports of intra tumoral hemorrhage, both vestibular and trigeminal schwannomas have been reported. [1] The first case of trigeminal schwannoma presenting with hemorrhage was reported in 1981 by Kubota. [2],[3] A total of seven cases have been reported since then either following minor head trauma or spontaneously with an apoplectic presentation [Table - 1]. [4],[5] Interestingly, in the larger series of trigeminal schwannomas, none of the case had such complication, [4] Hemorrhage was mostly intratumoral except for one case of subarachnoid hemorrhage. [2] Only one of the six cases previously reported had associated with systemic hypertension and another patient presented following trivial head trauma. [1],[2] Interestingly, Ooi et al., suggested a genetic predisposition as all the six patients reported previously were oriental in origin. [4] Our patient is the first non-oriental patient. Histological factors seen were telangectatic vasculature in vestibular tumors, dilated channels similar to ones seen in our patient and angiomatous changes. [1] The question of a genetic predisposition is open to question. While these changes are possibly the explanation of the hemorrhagic events, the exact cause of hemorrhage in these tumors remains unknown. References
Copyright 2011 - Neurology India The following images related to this document are available:Photo images[ni11235t1.jpg] [ni11235f2.jpg] [ni11235f1.jpg] |
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