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LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 5  |  Page : 773-775

Trigeminal schwannoma with intratumoral hemorrhage: Report of a case and review of literature


Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India

Date of Submission20-Mar-2011
Date of Decision20-Mar-2011
Date of Acceptance21-Mar-2011
Date of Web Publication22-Oct-2011

Correspondence Address:
Srinivas Dwarakanath
Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.86567

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How to cite this article:
Sastri SB, Dwarakanath S, Chandramouli B A. Trigeminal schwannoma with intratumoral hemorrhage: Report of a case and review of literature. Neurol India 2011;59:773-5

How to cite this URL:
Sastri SB, Dwarakanath S, Chandramouli B A. Trigeminal schwannoma with intratumoral hemorrhage: Report of a case and review of literature. Neurol India [serial online] 2011 [cited 2019 Jun 27];59:773-5. Available from: http://www.neurologyindia.com/text.asp?2011/59/5/773/86567


Sir

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.
Figure 1: T1-weighted (post contras - sagittal): The lesion shows a heterogenous pattern of contrast enhancement with the hyperintense component not enhancing

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Figure 2: Gradient echo sequence shows central blooming of the superior part of the tumor, suggestive of intratumoral bleed with intraventricular extension

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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.
Table 1: List of cases of trigeminal schwannoma with bleed

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  References Top

1.Asari S, Katayama S, Itoh T, Tsuchida S, Furuta T, Ohmoto T. Neurinomas presenting as spontaneous intratumoral hemorrhage. Neurosurgery 1992;31:406-11.  Back to cited text no. 1
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2.Kubota T, Hayashi M, Yamamoto S. Subarachnoid hemorrhage due to trigeminal neurinoma. Surg Neurol 1981;16:157-60.  Back to cited text no. 2
    
3.Shimabukuro H, Masuzawa T, Miyagi K, Sato F. Trigeminal neurinoma revealed by intratumoral hemorrhage following a minor head injury. Surg Neurol 1983;19:346-50.  Back to cited text no. 3
[PUBMED]    
4.Ooi GC, Peh WC, Fung CF. Case report: Acute haemorrhagic presentation of trigeminal neuroma. Br J Radiol 1996;69:363-5.  Back to cited text no. 4
[PUBMED]    
5.Lieu AS, Howng SL. Trigeminal neurinoma presenting as intratumoral hemorrhage--case report. Kaohsiung J Med Sci 1998;14:181-5.  Back to cited text no. 5
[PUBMED]    


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