Trigeminal Nerve Schwannoma of the Cerebellopontine Angle

Introduction Large and even moderate sized, extra-axial cerebellopontine angle (CPA) tumors may fill this restricted space and distort the regional anatomy. It may be difficult to determine even with high resolution magnetic resonance imaging (MRI) if the tumor is dural-based, or what the nerve of origin is if a schwannoma. While clinical history and exam are helpful, they are not unequivocal, particularly since many patients present with a myriad of symptoms, or conversely an incidental finding. We present an atypical appearing, asymptomatic CPA tumor, ultimately identified at surgery to be a trigeminal schwannoma. Case History A 40-year-old man presented with new-onset seizure. MRI identified an incidental heterogeneously contrast-enhancing CPA lesion (Fig. 1A–D). The tumor was centered on the internal auditory canal (IAC) with no tumor extension into Meckel's cave, IAC or jugular foramen. Audiometry demonstrated 10db of relative left-sided hearing loss with 100% word recognition. Physical examination was negative for focal neurologic deficits. A retrosigmoid craniotomy was performed and an extra-axial, yellow-hued mass was encountered and resected, which was ultimately confirmed to originate from the trigeminal nerve (Video 1). Gross total resection was achieved, and the patient recovered from surgery with partial ipsilateral trigeminal sensory loss and no other new neurologic deficits. Conclusion Pure CPA trigeminal schwannomas are rare, but should be considered in the differential for enhancing CPA lesions. Although, Meckel's cave involvement is frequently observed, it is not universal, and pure CPA schwannomas of all cranial nerves IV–XII have been reported in the literature.The link to the video can be found at: https://youtu.be/AlodYCu70F8.

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Trigeminal Amyloidoma: A Report of Two Cases and Review of the Literature

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1693111 ◽

2019 ◽

Vol 81 (06) ◽

pp. 620-626

Author(s):

Amy Swanson ◽

Caterina Giannini ◽

Michael Link ◽

Jamie Van Gompel ◽

John Wald ◽

...

Keyword(s):

Mass Spectrometry ◽

Trigeminal Nerve ◽

Systemic Disease ◽

Protein Characterization ◽

The Other ◽

Sensory Loss ◽

Meckel’S Cave ◽

Extensive Evaluation ◽

Amyloid Deposits ◽

Meckel's Cave

AbstractCerebral amyloidomas, characterized by localized amyloid deposits in the nervous system in the absence of systemic disease, are rare. These typically consist of immunoglobulin light chain (AL)-type, predominantly lambda. Trigeminal nerve involvement is exceptionally rare with only 21 previously reported cases, three with bilateral disease. We report two additional cases of amyloid localized to Meckel’s cave with secondary involvement of the trigeminal nerves bilaterally, with protein characterization by mass spectrometry. The patients, both females, 39 and 49-years-old, respectively, presented with the insidious onset of progressive trigeminal neuropathy, including pain and numbness with sensory loss, refractory to medical therapy. One patient experienced bilateral symptoms. Magnetic resonance imaging demonstrated abnormal thickening and contrast enhancement along Meckel’s cave bilaterally in both cases. The clinical differential diagnosis included benign neoplasms and inflammatory disorders. At the time of biopsy, the trigeminal nerve was noted to be enlarged and multinodular in one case and associated with abnormal soft tan tissue in the other case. Microscopically, the nerve biopsies showed extensive Congo red-positive amyloid deposits. Liquid chromatography tandem mass spectrometry demonstrated that the amyloid was of (AL)-type in both cases (AL [kappa] in one case and AL [lambda] in the other). After extensive evaluation, there was no evidence of systemic involvement. Both patients received localized radiotherapy for their refractory symptoms. One patient has stable symptomatology and imaging. No follow-up is available for the other patient.

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Case Report: Trigeminal Neuralgia Caused by a Minute Meningioma with Hyperostosed Suprameatal Tubercle

Case Reports in Neurology ◽

10.1159/000438856 ◽

2015 ◽

Vol 7 (2) ◽

pp. 167-172 ◽

Cited By ~ 7

Author(s):

Yukitomo Ishi ◽

Katsuyuki Asaoka ◽

Taku Sugiyama ◽

Yuka Yokoyama ◽

Kazuyoshi Yamazaki ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Nerve Root ◽

Cerebellopontine Angle ◽

Preoperative Imaging ◽

Decompression Surgery ◽

Vascular Compression ◽

Meckel’S Cave ◽

Trigeminal Nerve Root ◽

Meckel's Cave

Cerebellopontine angle tumors might occasionally provoke trigeminal neuralgia but are usually large enough to be diagnosed radiographically. We present a case of trigeminal neuralgia caused by a very small meningioma covering the suprameatal tubercle that displayed hyperostosis at the entrance of Meckel's cave and was not obvious on routine magnetic resonance (MR) images. A 72-year-old woman with intractable trigeminal neuralgia in the left V3 territory was referred to our institution. Preoperative imaging studies revealed that the left trigeminal nerve was medially distorted at the entrance of Meckel's cave by a laterally seated bone bulge covered by a minute enhanced lesion. Trigeminal nerve decompression surgery was performed via a retrosigmoid intradural suprameatal approach. We found a small meningioma that had compressed and flattened the trigeminal nerve root at the entrance of Meckel's cave, which was grossly and totally removed by suprameatal tubercle resection. There was no vascular compression of the trigeminal nerve root. The trigeminal neuralgia ceased completely after the operation. Accurate preoperative determination of the causative pathologies is essential to achieve adequate surgical results after microvascular decompression for neurovascular compression syndrome. Because conventional MR sequences are inadequate for the precise interpretation of complex neurovascular anatomy in the cerebellopontine angle and such small tumors can be overlooked on routine MR studies, high-resolution thin-slice MR examinations and careful radiological interpretations are required for correct diagnosis and treatment.

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Combined Transcavernous and Kawase's Approach for Gross Total Resection of a Cavernous Sinus Meningioma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1725025 ◽

2021 ◽

Author(s):

Walid Elshamy ◽

Burak Ozaydin ◽

G. Mark Pyle ◽

Mustafa K. Baskaya

Keyword(s):

Cavernous Sinus ◽

Cerebellopontine Angle ◽

Cranial Nerves ◽

World Health ◽

Gross Total Resection ◽

Surgical Removal ◽

Total Resection ◽

Meckel’S Cave ◽

Who Grade ◽

Meckel's Cave

AbstractMicrosurgery of cavernous sinus (CS) lesions is generally considered to be associated with a high rate of morbidity and cranial nerve deficits. The success for surgical removal of CS meningiomas is debatable and achieving a good functional outcome with preservation of the cranial nerves is the goal. Surgery of these lesions is challenging, recurrence rates are high, and therapeutic strategies remain controversial. In this video, we present a case of a CS meningioma that extended to Meckel's cave and the posterior fossa in a 46-year-old woman with history of a left-sided cerebellopontine angle World Health Organization (WHO) grade-I meningioma with extension to the left CS. Seven years ago, she had a microsurgical resection of a Cerebellopontine angle (CPA) meningioma. She later received radiotherapy for the slowly growing meningioma of the posterior CS. The patient presented with newly onset headache and facial pain. Magnetic resonance imaging (MRI) showed a meningioma of the left CS and Meckel's cave extending into the ambient cistern, with a mild mass effect on the pons, and a size increase compared with prior imaging. Since this area previously received radiotherapy, and the patient was symptomatic from trigeminal compression, the decision was made to proceed with surgical resection of the tumor via combined transcavernous and anterior petrosectomy. Postoperatively, the patient woke up with the same neurological status. MRI confirmed gross total resection of the tumor. The histopathology was a WHO grade-II chordoid meningioma. The patient is currently receiving radiotherapy. This video demonstrates the surgical approach and the resection steps of this pathology.The link to the video can be found at: https://youtu.be/HrU1VOzUGWU.

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Retrosigmoid Intradural Suprameatal Approach: Advantages and Disadvantages from an Anatomical Perspective

Operative Neurosurgery ◽

10.1227/01.neu.0000220673.79877.30 ◽

2006 ◽

Vol 59 (suppl_1) ◽

pp. ONS-1-ONS-6 ◽

Cited By ~ 9

Author(s):

Amitabha Chanda ◽

Anil Nanda

Keyword(s):

Trigeminal Nerve ◽

Internal Auditory Canal ◽

Semicircular Canals ◽

Petrous Apex ◽

Microsurgical Anatomy ◽

Meckel’S Cave ◽

Advantages And Disadvantages ◽

Meckel's Cave ◽

Trigeminal Root ◽

Neurovascular Structures

Abstract OBJECTIVE: To assess the advantages and disadvantages of the retrosigmoid intradural suprameatal approach by studying the microsurgical anatomy. This study was performed primarily to assess the advantages of the retrosigmoid intradural suprameatal approach by measuring the amount of increased exposure it provides for lesions of the cerebellopontine and petroclival region as well as to identify the disadvantages of the approach. METHODS: Twenty sides of 10 cadaver heads (embalmed and injected) were dissected under ×3 to ×40 magnification. A standard retrosigmoid craniotomy was made. The cerebellopontine cistern was entered to expose the neurovascular structures, and the internal auditory canal was opened by drilling the margin of the internal auditory meatus. After this, the suprameatal tubercle was drilled, followed by additional drilling to resect the petrous apex. The trigeminal root was mobilized completely after opening Meckel's cave. During drilling, care was taken to preserve the posterior and superior semicircular canals, petrosal sinus, and the internal carotid artery. RESULTS: The approach enhanced the exposure of the cerebellopontine cistern and Meckel's cave. There was an additional exposure of 10.7 ± 1.16 mm length of trigeminal nerve on the right side and an additional 10.7 ± 1.25 mm on the left. This helped to mobilize and further retract the trigeminal root. Although it facilitated the view of the neurovascular structures medial to the internal acoustic meatus, the depth of exposure did not vary much from a traditional retrosigmoid approach nor did it increase the angle of exposure or the visualization of the clivus and more medially located structures. CONCLUSION: This approach is suitable for lesions mainly in the posterior fossa with some extension into the middle fossa in the anterolateral direction. The key benefits of this approach are the length of trigeminal nerve exposure and the subsequent mobilization that improves visualization of the structures medial to the internal auditory canal, to the petrous apex, Meckel's cave, and the posterior end of the cavernous sinus.

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Microsurgical Anatomy of the Endoscopy-Assisted Retrosigmoid Intradural Suprameatal Approach to the Meckel's Cave

Operative Neurosurgery ◽

10.1093/ons/opab096 ◽

2021 ◽

Author(s):

Yuanzhi Xu ◽

Benjamin K Hendricks ◽

Maximiliano Alberto Nunez ◽

Ahmed Mohyeldin ◽

Juan C Fernandez-Miranda ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Internal Auditory Canal ◽

Semicircular Canals ◽

Petrous Apex ◽

Microsurgical Anatomy ◽

Meckel’S Cave ◽

Meckel's Cave ◽

Trigeminal Root

Abstract BACKGROUND Understanding the microsurgical anatomical features of the endoscopy-assisted retrosigmoid intradural suprameatal approach (RISA) is critical for surgeons treating petroclival tumors or lesions in the cerebellopontine region that extend into Meckel's cave. OBJECTIVE To evaluate increased exposure for Meckel's cave in the RISA and assess the surgical landmarks for this approach. METHODS A standard retrosigmoid craniotomy to the cerebellopontine region was performed in 4 cadaveric specimens (8 hemispheres) with microscope-assisted endoscopy. The length and depth of the drilling region from the suprameatal tubercle to the petrous apex were analyzed. After opening Meckel's cave and mobilizing the trigeminal root completely, the landmarks for this approach were investigated. RESULTS The endoscopy-assisted RISA facilitates mobilization of the trigeminal root and enhances surgical exposure in the region of Meckel's cave and the petrous apex with increases of 10.1 ± 1.3 mm in depth, 21.4 ± 3.2 mm in length, and 6.4 ± 0.6 mm in height. The posterior and superior semicircular canals, internal auditory canal, superior petrous sinus, and internal carotid artery (petrous segment) served as important landmarks for this approach. One case illustration is presented to describe the application of this approach. CONCLUSION The RISA is suitable mainly for lesions in the posterior fossa that extend into Meckel's cave. The endoscopy-assisted reach optimizes accessibility to the petrous apex region, obviates the need for extensive drilling, and decreases the risk of internal carotid artery injury. Better realization and recognition of microsurgical landmarks and parameters of this approach are crucial for successful outcomes.

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Combined Transpetrosal Approach With Preservation of Superior Petrosal Vein Drainage for a Cerebellopontine Angle Epidermoid Cyst Extending Into Meckel's Cave: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy286 ◽

2018 ◽

Vol 16 (6) ◽

pp. E172-E173

Author(s):

Ken Matsushima ◽

Michihiro Kohno ◽

Nobuyuki Nakajima ◽

Norio Ichimasu

Keyword(s):

Epidermoid Cyst ◽

Cerebellopontine Angle ◽

Young Patients ◽

Neurological Deficits ◽

Meckel’S Cave ◽

3 Dimensional ◽

Petrosal Vein ◽

Meckel's Cave ◽

Superior Petrosal Sinus ◽

Superior Petrosal Vein

Abstract The combined transpetrosal approach enables wide exposure around the petroclival region by cutting the tentorium and superior petrosal sinus. We often choose this approach for removal of tumors ventral to the facial and vestibulocochlear nerves, such as petroclival meningioma and epidermoid cyst, because complete removal of the tumor under direct visualization is required to prevent its later recurrence, especially in young patients. Recent reports revealed anatomical variations of the drainage of the superior petrosal sinus, and dural incision considering preservation of the superior petrosal vein was proposed.1-3 This 3-dimensional video shows a patient with an epidermoid cyst, which was surgically treated using the combined transpetrosal approach, with consideration of the variation of the superior petrosal sinus and preservation of the drainage route of the superior petrosal vein. The video was reproduced after informed consent of the patient. The patient is a 31-yr-old woman who presented with a left cerebellopontine angle epidermoid cyst extending into Meckel's cave. The superior petrosal sinus was of the lateral type, draining only laterally into the transverse–sigmoid junction without medial connection with the cavernous sinus.1 The combined transpetrosal approach was performed with cutting of the superior petrosal sinus medial to the entry point of the superior petrosal vein, in order to preserve its drainage into the transverse–sigmoid junction. Meckel’ cave was opened along its lateral margin, and tumor removal was accomplished, leaving only a minute part of the capsule strongly adhering to the neurovascular structures. The patient had no new permanent neurological deficits during follow-up. The figures in the video were modified from Matsushima et al1 by permission of the Congress of Neurological Surgeons.

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Microsurgical Resection of a Petroclival Epidermoid Cyst Using an Anterior Petrosectomy Approach: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab364 ◽

2021 ◽

Author(s):

Kunal V Vakharia ◽

Ryan M Naylor ◽

Ashley M Nassiri ◽

Colin L W Driscoll ◽

Michael J Link

Keyword(s):

Epidermoid Cyst ◽

Cranial Nerves ◽

Residual Tumor ◽

Middle Meningeal Artery ◽

Neural Tube Closure ◽

Petrous Apex ◽

Meckel’S Cave ◽

Postoperative Mri ◽

Meckel's Cave ◽

Anterior Petrosectomy

Abstract Epidermoid cysts are rare, benign lesions that result from inclusion of ectodermal elements during neural tube closure.1 Cysts are composed of desquamated epithelial cells and restrict diffusion on magnetic resonance imaging (MRI).2,3 Symptoms are attributable to anatomic location.4,5 In this video, we illustrate the surgical treatment of an epidermoid cyst located in the right cerebellopontine angle, petrous apex, and Meckel's cave. The patient, a 33-yr-old female with right-sided V1 trigeminal hypoesthesia, underwent surveillance imaging for 2 yr. However, she developed progressive V1 and V2 trigeminal hypoesthesia and imaging revealed enlargement of the lesion. Therefore, surgical resection was pursued. The patient consented to the procedure. The patient underwent a right middle fossa craniotomy and anterior petrosectomy. After identifying the greater superficial petrosal nerve and cutting the middle meningeal artery as it exited foramen spinosum, Kawase's triangle was drilled, and the dura over Meckel's cave and the subtemporal dura were opened. The lesion was resected, taking care to preserve the trigeminal nerve and the basilar artery. A retrosigmoid craniotomy was then fashioned. The cyst and its capsule were dissected off the brainstem and cranial nerves utilizing natural corridors between the trigeminal and vestibulocochlear nerves as well as between the facial and lower cranial nerves. Gross total resection was confirmed on postoperative MRI, and she was discharged home on postoperative day 5. Three months after surgery, she underwent formal pinprick testing, which revealed 95% loss of sensation in V1, 20% loss in V2, and normal sensation in V3. Three-month postoperative MRI showed no residual tumor.

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A Side Door to Meckel's Cave: Anatomic Feasibility Study for the Lateral Transorbital Approach

Operative Neurosurgery ◽

10.1093/ons/opx042 ◽

2017 ◽

Vol 13 (5) ◽

pp. 614-621 ◽

Cited By ~ 17

Author(s):

Blake Harrison Priddy ◽

Cristian Ferrareze Nunes ◽

Andre Beer-Furlan ◽

Ricardo Carrau ◽

Iacopo Dallan ◽

...

Keyword(s):

Skull Base ◽

Surgical Navigation ◽

Cranial Nerves ◽

Anatomical Study ◽

Middle Cranial Fossa ◽

Middle Fossa ◽

Meckel’S Cave ◽

Side Door ◽

Meckel's Cave ◽

Brain Retraction

Abstract BACKGROUND: In the last decade, endoscopic skull base surgery has significantly developed and generated a plethora of techniques and approaches for access to the cranial ventral floor. However, the exploration for the least-aggressive, maximally efficient approach continues. OBJECTIVE: To describe in detail an anatomical study, along with the technical nuances of a novel endoscopic approach to Meckel's Cave (MC) using a lateral transorbital (LTO) route. METHODS: Eighteen orbits of injected cadaveric specimens were operated on, using an endoscopic LTO approach to MC, middle cranial fossa, and paramedian skull base preserving the orbital rim. Surgical navigation and an after-the-fact infratemporal craniectomy were utilized to identify the limits of the approach. RESULTS: Following a transorbital approach opening a trapezoid window at the superolateral aspect (average 166.7 mm2), a middle fossa “peeling” and full visualization of MC was accomplished with no difficulties in all specimens. The entire approach was performed extradurally without the need to expose the temporal lobe. CONCLUSION: In a cadaveric model, the endoscopic LTO approach affords a direct route to access MC. Its main advantage is that it is minimally disruptive in nature, less brain retraction is required, and it reaches the middle fossa in an anterolateral perspective. It also requires no manipulation of the temporalis muscle, limited cosmetic incision, and rapid recovery. It seems a viable alternative to traditional approaches for lesions lateral to the cranial nerves at the cavernous sinus and MC, that is, schwannomas. Clinical utilization of this approach will challenge its efficacy and identify limitations.

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Trigeminal Neuralgia Caused by Venous Compression

Neurosurgery ◽

10.1227/01.neu.0000129552.87291.87 ◽

2004 ◽

Vol 55 (2) ◽

pp. 334-339 ◽

Cited By ~ 72

Author(s):

Toshio Matsushima ◽

Phuong Huynh-Le ◽

Masayuki Miyazono

Keyword(s):

Trigeminal Neuralgia ◽

Trigeminal Nerve ◽

Microvascular Decompression ◽

Complete Relief ◽

Surgical Results ◽

Meckel’S Cave ◽

Trigeminal Pain ◽

Venous Compression ◽

Facial Numbness ◽

Meckel's Cave

Abstract OBJECTIVE: The purpose of this study is to clarify whether venous compression on the trigeminal nerve really causes trigeminal neuralgia or not, and to identify which veins are the offending veins. METHODS: We used microvascular decompression in operations on 121 patients with typical trigeminal neuralgia. We analyzed the intraoperative findings and surgical results in these 121 cases. RESULTS: In 7 of the 121 cases, only the vein was identified as a compressive factor on the trigeminal nerve. In 6 of these 7 cases, single venous compression was found, whereas the remaining case had two offending veins. The transverse pontine vein was most frequently found as the offending vein near Meckel's cave. All patients showed complete relief of trigeminal pain after decompression of the veins, but four of them developed facial numbness after surgery, which tended to be slight and did not require any treatment. CONCLUSION: Our surgical experiences showed that venous compression could cause trigeminal neuralgia by itself and that the transverse pontine vein should be carefully observed because it is most frequently the offending vein.

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Posterior Approach to Meckel's Cave: Retrosigmoid Craniectomy with Endoscopic Assistance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1677851 ◽

2019 ◽

Vol 80 (S 03) ◽

pp. S331-S332

Author(s):

Paramita Das ◽

Hamid Borghei-Razavi ◽

Nina Z. Moore ◽

Pablo F. Recinos

Keyword(s):

Tumor Resection ◽

Cranial Nerves ◽

Auditory Brainstem ◽

Technical Note ◽

Auditory Brainstem Responses ◽

Case Review ◽

Meckel’S Cave ◽

Meckel's Cave ◽

Endoscopic Assistance ◽

Loss Of Hearing

Background Meckel's cave involvement in tumors pose a challenge due to their surrounding neurovascular structure and deep location. Case Review A 24-year-old male presented with progressive headaches and right sided trigeminal neuralgia with a large epidermoid. The tumor extended from the ambient cistern to the cerebellomedullary cistern and involved Meckel's cave (Fig. 1). Technical Note/Video Description A retrosigmoid craniectomy was performed. Cranial nerves 3, 4, 6, 7, and 10, and auditory brainstem responses were monitored. Once the craniectomy was completed the dura was opened and cerebrospinal fluid (CSF) was released from the cisterna magna to allow for the tumor resection to be done without the use of any retractors (Fig. 2). Care was taken to ensure that cranial nerves in the posterior fossa were detethered to prevent any traction injury. Using ring curettes the pearly white epidermoid tumor was able to be debulked. After all the possible tumor was resected with the microscope, the 30-degree endoscope was used to identify the porus trigeminus. Malleable ring curettes and a malleable suction were used to remove the soft tumor from this location. The patient transiently had loss of hearing but this returned within 2 weeks after surgery. Conclusions The retrosigmoid approach is familiar to all neurosurgeons and with the adjunct of an angled endoscope, the posterior Meckel's cave can be easily reached. This is particularly useful for tumors with soft consistency. The assistance of the endoscope allows Meckel's cave visualization without additional drilling while still allowing safe resection of tumor from around the trigeminal nerve.The link to the video can be found at: https://youtu.be/01aqOyUmSW0.

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