Excision Of Schwannoma Research Articles

Robotic‐assisted surgical removal of pelvic schwannoma: a novel approach to a rare variant

Robotic-assisted excision of a pelvic schwannoma is presented. A 27 year-old female presented with occasional numbness of the right thigh. Imaging studies revealed a large mass adjacent to the right ovary. Robotic surgery with adjunctive electrophysiological monitoring was performed. The mass was adhered to the L4, L5 roots and was displacing the iliac vessels and the ureter. The tumour bulk was decompressed and total excision was facilitated. Pathology revealed a neoplasm consisting of spindle cells. Immunochemistry revealed S-100(+) and a growth index Ki-67 < 1%. These findings were consistent with the diagnosis of ancient schwannoma. The intraoperative time was comparable to laparoscopy and the patient had an uneventful recovery. Ancient schwannoma is often diagnosed only when it is large enough to produce symptoms. Robotic surgery with adjunctive electrophysiological monitoring is a safe technique for the removal of large pelvic neurinomas.

Schwannoma of the Cervical Vagus Nerve

A 44-year-old nonsmoking man with no significant past medical history was admitted for syncope of undetermined origin. No cardiac or neurologic finding was subsequently observed. Suspicion of epi-aortic vessel or thyroidal disease led to ultrasonography, which pointed out a hypo-echoic nodule at the right lower neck. A magnetic resonance image highlighted a 25 × 17 mm, well-defined, oval-shaped lesion, medially displacing the common carotid artery and laterally displacing the internal jugular vein, slightly compressed as far as its confluence with the anonymous vein; marked hyper-intensity and contrast-enhancement suggested hydric fat content (Fig 1A, T1-weighted, transversal section; 1B, T2-weighted contrast-enhanced coronal section; lesion indicated by arrows). Fine-needle aspiration biopsy was not diagnostic. A right cervicotomy parallel to the anterior border of the sternocleidomastoid muscle was carried out. After separate exposure of the carotid artery and jugular vein, continuity with the vagus nerve sheath was evident (Fig 2A). Careful intracapsular enucleation was performed preserving nerve integrity (Fig 2B, 2C [inset]). The patient had temporary dysphonia develop after the operation, although greatly recovered after phoniatric rehabilitation. Histopathology of the specimen confirmed the intraoperative diagnosis of schwannoma. No recurrence was noted after a 5-year period. Schwannomas are uncommon neoplasms, mainly benign [1Singer R.L. Thoracoscopic excision of a malignant schwannoma of the intrathoracic vagus nerve.Ann Thorac Surg. 1995; 59: 1586-1587Abstract Full Text PDF PubMed Scopus (18) Google Scholar]. The typical relationship with cervical vessels may be suggestive for vagal origin, although no diagnosis is generally available preoperatively. Surgical treatment is generally pursued, taking care to avoid nerve damage [2Walker W.A. Maguire F.E. Vagal schwannoma.Ann Thorac Surg. 1991; 52: 1370-1371Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 3Heitmiller R.F. Labs J.D. Lipsett P.A. Vagal schwannoma.Ann Thorac Surg. 1990; 50: 811-813Abstract Full Text PDF PubMed Scopus (19) Google Scholar].

Excision of vestibular schwannomas – is there a learning curve and how best to demonstrate it?

Objective. To demonstrate the existence of a learning curve in a consultant neurosurgeon's performance in excising vestibular schwannomas by plotting the cumulative sum (CUSUM) chart. Also, to evaluate the influence of new technology in the form of the facial nerve monitor (FNM) and the KTP-532 Laser on surgical performance.Method. Analysis was carried out on a prospectively collected data series of 102 consecutive cases of vestibular schwannomas excisions between 1986 and 2000 by a single neurosurgeon using the retrosigmoid approach. The CUSUM score chart of the surgical outcomes across the series was plotted for all and large tumour sizes separately. The changes in CUSUM scores were assessed using statistical change-point analysis. Using the multivariate logistic regression analysis, we inspected the association between use of FNM and laser on outcome.Results. After the first 27 cases and coinciding with the introduction of the FNM there was a clear change in the direction of the slope of the CUSUM chart, showing a clear improving trend in performance (p = 0.09). The same phenomenon was also seen when plotting the CUSUM chart for large tumours only, although this was not statistically significant. The use of FNM reduces the risk of bad House Brakmann-score by approximately 90% for all tumours (risk of bad outcome with FNM = 3.2% and without FNM = 26.7%, odds ratio = 0.10 and 95% confidence interval (0.02–0.61), p = 0.013) after adjusting for age at operation, but no significant association was seen with the use of laser.Conclusion. There appears to be a learning curve in the performance of a neurosurgeon. Compared to previous reports of sequential block analysis, the CUSUM method is less arbitrary and more transparent. The CUSUM is most useful as an audit tool that can help spare patients from undesirable learning curves, and help to demonstrate good standards in appraisal and revalidation.

Long-Term Hearing Preservation After Microsurgical Excision of Vestibular Schwannoma

To examine long-term hearing outcomes after microsurgical excision of vestibular schwannoma (VS). Retrospective case review. Tertiary referral center. Forty-nine subjects at a single institution who had undergone microsurgical excision of a VS via middle cranial fossa (MCF) approach between 1994 and 2007 with immediate postoperative (PO) hearing preservation and for whom long-term audiograms were available. Diagnostic. Word Recognition Score (WRS) is defined by speech discrimination scores (SDS) greater than 70% (grade I), 50% to 70% (grade II), less than 50% (grade III), and 0% (grade IV). For subjects with more than 2 years of follow-up, WRS I hearing was present PO in 42 of 49 patients and was preserved at the latest follow-up in 38 (90%) of 42 patients. No subjects fell beyond WRS II. WRS I hearing was maintained in 23 (88%) of 26 patients with more than 5 years of follow-up. Postoperative WRS I to II hearing was maintained in 28 (96%) of 29 patients with more than 5 years of follow-up. The patient who lost significant hearing in the ear operated on had sensorineural hearing loss that paralleled deterioration in her ear that was not operated on. Most subjects maintain their initial PO SDS after microsurgical VS removal, and therefore, the initial PO WRS is predictive of long-term hearing. Postsurgical changes do not alter the natural rate or pattern of progressive bilateral sensorineural hearing loss in individual subjects.

Jugular foramen schwannoma presenting with glossopharyngeal neuralgia syncope syndrome

Jugular foramen schwannomas are rare skull base tumours which typically have a variable clinical presentation. Glossopharyngeal syncope syndrome is an unusual clinical presentation; in the following case report, it was the sole presentation of an extracranial jugular foramen tumour. The presentation of a patient with glossopharyngeal neuralgia syncope syndrome is reviewed and the pathophysiology, clinical features and treatment discussed. A 45-year-old woman presented with unilateral throat pain, bradycardia and hypotension leading to episodes of impaired consciousness when lying on her left side or turning her head to the left. Imaging detected a left-sided extracranial jugular foramen schwannoma. The tumour was excised, and the patient had no more syncopal attacks. Glossopharyngeal neuralgia syncope syndrome can be the sole presentation of a jugular foramen schwannoma. Although this syndrome may be treated with anti-dysrhythmic drugs, cardiac pacing or nerve section, in the presented patient excision of the jugular foramen schwannoma was successful in preventing further episodes of syncope.

Minimally invasive resection of an extrapelvic sciatic schwannoma

Schwannomas associated with the sciatic nerve are relatively rare. Surgical excision of symptomatic sciatic schwannomas traditionally involves a posterior sciatic nerve approach with a large, open exposure and transection of the gluteal muscles. The authors provide a technical report of a minimally invasive approach for the resection of an extrapelvic schwannoma arising from the sciatic nerve. The patient was discharged to home on the same day of surgery and his symptoms of severe sciatica immediately and dramatically improved.

Case Scenario: Acute Postoperative Negative Pressure Pulmonary Edema

A 25-yr-old man (weight, 68 kg; height, 183 cm) presentedto the surgery center for excision of back and thigh schwan-nomas on the same day. The patient’s medical history wassignificant only for his history of multiple schwannoma re-sections and a history of smoking one pack of cigarettes perweek for the past 5 yr. He denied previous problems withgeneral anesthesia, and his baseline peripheral oxygen satu-ration was 99% on ambient air.Thepatientwaspremedicatedwith2mgmidazolam,andanesthesia was induced with 250 mg fentanyl, 500 mg thio-pental, and 8 mg vecuronium given for facilitation of tra-cheal intubation. He was atraumatically intubated with a7-mm ID endotracheal tube using a no. 3 Macintosh laryn-goscope (Teleflex Medical, Research Triangle Park, NC) onthe first attempt with direct visualization of the vocal cords.The patient was turned prone, bilateral breath sounds werereconfirmed, and schwannoma excisions were performed ontheleftthighandtheleftflank.Atotalof0.5mghydromor-phone was administered for analgesia. The intraoperativecoursewasunremarkable.Thepatientwashemodynamicallystable with minimal blood loss and was easily ventilated andoxygenated. A total of 500 ml lactated Ringer’s solution wasadministeredduringthe65-minsurgicalprocedure.Thepa-

Laparoscopic excision of a retrorectal schwannoma

Retrorectal tumors are uncommon and are usually managed by open surgical excision. Recent advances in laparoscopic techniques have led to the use of laparoscopy for a variety of problems in colorectal surgery, including the excision of retrorectal tumours. This case report, which describes the laparoscopic excision of a benign schwannoma arising from the second sacral nerve root, highlights the benefits of accurate preoperative diagnosis with MR imaging and the advantages of a laparoscopic approach while pointing out principles that should be adhered to when using this approach. The tumour was successfully resected without neural compromise and with a prompt and full postoperative recovery.

Intraoperative Pulse and Blood Pressure Recordings of Neurosurgeons

Although hemodynamic changes in anesthetized patients remain well documented, no study has quantified the effect of operating stress on the neurosurgeon. We present a study of intraoperative (IOP) pulse and blood pressure (BP) recordings obtained from neurosurgeons and compare them with rest and exercise values. This prospective, single-blind comparative analysis used an ambulatory BP device to record IOP, rest and exercise BP, and pulse. The Student t test and chi test were used for statistical analysis. Five neurosurgeons performed 10 aneurysm clippings and 1 vestibular schwannoma excision. The average IOP pooled systolic, diastolic, and mean BPs and pulse rates were 140, 103, and 116 mm Hg and 94 bpm, respectively. Corresponding rest and exercise values were 116, 75, and 89 mm Hg and 76 bpm and 130, 99, and 109 mm Hg and 128 bpm, respectively. Average IOP mean and diastolic BPs were significantly elevated compared with rest readings (P = .032, P = .023). Episodes of severe IOP BP (systolic BP/diastolic BP > 180/110 mm Hg) accounted for 28% of all readings and were significantly increased over rest values (P < .001). The incidence of abnormal IOP BP (systolic BP/diastolic BP > 140/90 mm Hg) was also significantly greater than exercise and rest values (P < .001). Neurosurgery can induce a significant hemodynamic stress malresponse in the operating surgeon that appears to be greater than that induced by vigorous exercise. The correlation of this occupational hazard to long-term health and longevity remains to be studied.

A Giant Guteal Schwannoma with extension into the Pelvis: A case report

Schwannomas are uncommon slow growing tumours arising from the nerve sheath or Schwann cell. To report a case and the surgical removal of a giant complex schwannoma and to highlight the value of extensive investigations including a preoperative histologic diagnosis in the successful surgical management of uncommon large benign tumours. A 39-year-old man presented with a 15-year history of a large mass in the right gluteal region. He was clinically evaluated, subjected to imaging studies and surgery. Clinical examination revealed a 40 cm by 60 cm mass in the right gluteal region and continuous with a 25 cm by 15 cm pelvic mass. The ultrasound scan revealed a very complex (mixed solid and fluid containing) gluteal mass with extension to the pelvis. The CT scan showed a very large, well defined lobulated tumour with cystic spaces and enhancing nodules. The tumour extended through the ischiadic foramen into the pelvis and posteriorly into the thigh muscles. A Doppler scan of the pelvic vessels revealed that the right common and internal iliac arteries were both compressed but not occluded. An incisional biopsy was reported as a Schwannoma with xanthomatous changes and an immuno histochemistry profile of S-100+, Ki-67+ (less than 1% of the cells). A right foot drop following the surgery responded to physiotherapy. The duration of total hospital stay was 12 weeks. The staged excision of large and complex schwannomas is safe. It is essential that a preoperative histological diagnosis is made to establish that the tumor is truly benign.

Plexiform schwannoma of the esophagus in a child with neurofibromatosis type 2

Schwannoma is a benign neoplasia of the peripheral nerve sheath. Its localization in the gastrointestinal tract, and in particular in the esophagus, is very rare. According to the existing literature esophageal schwannoma has been reported so far only in adult patients. We report the case of an 11 year old patient with neurofibromatosis, type 2, who underwent surgical excision of a plexiform schwannoma of the esophagus.

Prognostic clinical and radiological parameters for immediate facial nerve function following vestibular schwannoma surgery

The paper aims to define the parameters available before surgery which could predict immediate facial nerve function after excision of a vestibular schwannoma (VS). Ninety-nine patients with VS operated consecutively by a single surgeon using an identical surgical technique have been evaluated retrospectively. Data were collected regarding patients' sex, age at onset of symptoms and at surgery, initial symptoms, neurological status at presentation, early post-operative neurological status and complications. The main radiological parameters included in the study were tumour extension pattern, diameters, shape, and volume, as well as extent of bony changes of the internal auditory canal. As the tumour stage and volume increase, facial nerve function is worse after surgery (p < 0.001 and p < 0.05, respectively). Concomitantly, larger extra-meatal tumour diameters in three dimensions (sagittal, coronal and axial) led to worse function (p < 0.01). Anterior and/or caudal tumour extension (p = 0.001 and p = 0.004, respectively) had more significant correlation than posterior and/or cranial extension (p = 0.022 and p = 0.353, respectively). Polycyclic VS had the worst prognosis, followed by the tumours with oval shape. The extent of intra-meatal tumour growth does not correlate with immediate facial nerve outcome. The different angles, lengths and diameters of the internal auditory channel showed no significant correlation with facial nerve outcome. Patients with headache as an initial symptom and those with gait instability and/or pre-operative poor facial nerve function had significantly worse immediate facial nerve outcome. Our data suggests that the analysis of the radiological and neurological patient data prior to surgery could give reliable clues regarding the immediate post-operative facial nerve function.

Transparent equine collagen biomatrix as dural repair. A prospective clinical study

Numerous materials have been used to replace defects in the dura mater as result of neurosurgical and spinal procedures. Tissudura is a biomatrix made of cross-linked equine collagen fibrils, mainly of the interstitial type I. The specially engineered dura-like layered structure provides a non porous primary water tight structure, is transparent and allows verification of the efficacy of cerebral hemostasis. A consecutive series of patients between 18 years and 75 years of age were prospectively enrolled from three separate European institutions between May 2007 and February 2008. All patients underwent elective cranial or spinal surgery and required implantation of a dural substitute. We assessed the efficacy and safety of the collagen biomatrix as a dural substitute, intraoperatively and postoperatively, with a median follow-up 4.3 months. Fifty-six patients had cranial surgery, four patients underwent a spinal operation. Surgical cranial approaches included supratentorial procedures in 45 patients and posterior cranial fossa exploration in 11. At 7-days follow-up, a CSF leak was reported in one patient after excision of a vestibular schwannoma and in another with a thoracic vertebral body fracture and spinal cord transaction. Neither needed reoperation. A subgaleal fluid collection in two patients who had been treated for a supratentorial lesion resolved after tapping. The transparency of the implant was beneficial to inspect the underlying surgical area at the end of the procedure in one patient in whom a hematoma formed after secondary to oozing glioblastoma removal. Of the 56 patients who reached the 3-month follow-up, none had a CSF leak, meningitis, wound infection or fistulae. No duroplasty failure was observed. In one patient who underwent reoperation after 40 days, histopathological findings revealed the replacement of the implant by ingrowth from the original dura. Tissudura is simple, efficacious and safe to use. The use of fibrin glue reduces suturing and facilitates the implantation of the collagen biomatrix. Its transparency makes it unique and beneficial in inspection of the underlying area of operation. The lack of adverse reaction indicates that this graft may be used as an option in the repair of dural defects.

Schwannomas of the Left Adrenal Gland and Posterior Mediastinum

Schwannoma is a rare tumor of neural crest cell origin. Most schwannomas occur in the head, neck, stomach or limbs, with a few cases occurring in the retroperitoneal space. A 30-year-old Taiwanese woman presented with a 1-week history of left anterior chest discomfort and left flank pain. The laboratory findings and endocrine studies were all within normal limits. Chest X-ray revealed masses in the posterior mediastinum. Chest computed tomography and magnetic resonance imaging showed several masses in the left paraspinal region and in the left adrenal region. The patient underwent total excision of the left paraspinal tumors and laparoscopic left adrenalectomy. Pathologic studies showed a picture of benign schwannoma. In conclusion, preoperative differentiation of benign schwannoma from malignant peripheral nerve sheath tumor or other tumors is important for good prognosis. Total excision of benign schwannoma is associated with favourable outcome in patients.

Cutaneous Plexiform Schwannomas in a Patient with Neurofibromatosis Type 2

Plexiform schwannoma is a rare benign neoplasm of the neural sheath characterized by a multinodular plexiform growth pattern. The tumor usually occurs as an isolated finding, although rare cases have been reported in association with neurofibromatosis type 2 (NF2). A 25-year-old man was admitted for foot drop. He had an asymptomatic skin-colored nodule on his neck that had been present for 10 years. His medical history included local excision of a plexiform schwannoma on his left leg in our dermatology clinic 6 years prior. A histopathological examination of the skin-colored nodule also showed the typical microscopic features of a plexiform schwannoma, including the characteristic Antoni type A areas showing frequent nuclear palisading and Verocay bodies. Magnetic resonance imaging revealed a meningioma and a vestibular schwannoma in the cranium and multiple neurofibromas on the spinal cord. Herein we report a rare case of cutaneous plexiform schwannomas in a patient with NF2.

Vascularized Mastoid Bone Flap Cranioplasty after Translabyrinthine Vestibular Schwannoma Surgery

We describe a novel technique of cranioplasty using a vascularized mastoid bone flap in patients after translabyrinthine excision of vestibular schwannomas (VS). Postoperative outcomes in terms of pinna and postauricular deformity are evaluated. Retrospective study. Tertiary referral center. Seventeen patients underwent cranioplasty with bone flap after translabyrinthine VS excision. At minimum follow-up of 12 months, none had a cerebrospinal fluid (CSF) leak. The measured pinna projections between the operated and non-operated sides had a mean difference of 0.80 mm (+/-1.70), which is not statistically significant (p > 0.05). The mean depth of the postauricular depressions was 1.38 mm (+/-0.93). Over the same period, 10 patients underwent translabyrinthine VS surgery without cranioplasty. In this group, there was a significant difference of 4.71 mm (+/-1.53) in mean pinna underprojections on the operated sides compared with the non-operated sides. Compared with patients who have undergone cranioplasty, the retroauricular depressions were significantly deeper (p < 0.05) with a mean depth of 2.92 mm (+/-1.21). Vascularized mastoid cortical bone flap cranioplasty is a simple and effective technique to ameliorate the pinna and retroauricular deformities after translabyrinthine VS excision without increased surgical cost or the use of alloplastic materials.

Vascularized Mastoid Bone Flap Cranioplasty after Translabyrinthine Vestibular Schwannoma Surgery

Objective: Cerebellospinal fluid (CSF) leak and postauricular deformity can be significant problems in patients after translabyrinthine excision of vestibular schwannomas (VS). We describe a novel technique of cranioplasty using a vascularized mastoid bone flap in combination with abdominal fat graft.

Reconstructive options for skull defects following translabyrinthine surgery for vestibular schwannomas

Advances in microsurgical techniques have dramatically decreased the major complications of translabyrinthine vestibular schwannoma surgery. Recent trends in the reconstruction of the skull defect following this type of surgery have focused on addressing two postoperative morbidities: cerebrospinal fluid leak and postauricular deformity. Various reconstructive paradigms have shown an improvement in both areas over traditional techniques. Options for addressing these problems continue to evolve as surgeons strive to improve patient satisfaction. This review highlights such reconstructive options and their respective challenges. Current techniques include the use of various materials such as hydroxyapatite, titanium and vascularized cortical bone flap. Hydroxyapatite and titanium mesh alloplastic reconstruction are associated with improved outcome but increased surgical cost. Vascularized cranioplasty bone flap appears to achieve the same endpoint with no added cost. Cranioplasty following translabyrinthine vestibular schwannoma excision has evolved in an effort to reduce postoperative cerebrospinal fluid leaks and cosmetic deformities. Long-term results and cost-benefit analysis are needed to determine the efficacy and general application of these techniques.

Retroperitoneal giant schwannoma eroding lumbal vertebra: A case report with a literature review

AbstractA huge schwannoma, located in the retroperitoneal space, is found very rarely. The main purpose of this paper is to present the case of a giant retroperitoneal schwannoma which partly invaded L4 vertebral body. The secondary purpose is to summarize the case-report articles on retroperitoneal schwannomas. A circumscribed heterogenic tumour was revealed on transabdominal sonography. It extended into the right retroperitoneal space. CT and MRI revealed a paravertebral tumour in the size of 11 cm × 9 cm, which is causing a partial lysis of L4 vertebral body (15% of vertebral capacity), expanding intravertebral foramen and filling the right retroperitoneal space. A preoperative core needle biopsy was performed and a benign schwannoma was diagnosed. A complete surgical excision of the tumour was achieved by a two-step operation. During the first step, the neurosurgeons made L4 hemilaminectomy, facetectomy and a transverse process resection by posterior extended approach. The general surgeons excised the residual retroperitoneal part of the tumour by midline transabdominal approach 10 days later. The diagnosis of benign schwannoma was verified histochemically. There were no sign of tumour recurrence or spine destabilization at the six-month follow-up. In conclusion, although majority of giant retroperitoneal schwannomas can be completely removed performing one-step operation, a preoperative consideration about rationality of two-step operation should be mandatory when tumour destructs a part of vertebral body. Our case shows that the combined two stage complete surgical excision of a giant retroperitoneal schwannoma, eroding 15% of L4 vertebra’s osseous capacity, is effective and does not have any negative influence on spinal stability.

Ventriculostomy for Treatment of Persistent Cervical Cerebral Spinal Fluid Leak After Excision of Cervical Schwannoma

Intradural spinal cord tumors present many challenges to patients and the healthcare professionals providing treatment. Given the tumor's attachment to dural tissue, cerebrospinal fluid (CSF) leaks are an anticipated challenge. If present, CSF leaks can lead to infection and increased length of stay. A 59-year-old female admitted for surgical excision of a cervical schwannoma developed a persistent postoperative CSF leak. Following multiple surgical attempts to repair the dura with concomitant lumbar drainage for decompression, a ventriculostomy with conversion to a shunt was performed. Following the procedure, the patient's wound healed completely 6 weeks after her initial surgery. Ventriculostomy is a viable option for treatment of persistent CSF wound drainage after excision of cervical schwannoma surgery.