Tratamiento multimodal en los schwanomas vestibulares grandes / Multimodal Treatment for Large Vestibular Schwannomas

Introducción: Los schwanomas vestibulares son lesiones clasificadas como grado I por la Organización Mundial de la Salud. Las opciones conductuales incluyen la observación, la radiocirugía o la resección microquirúrgica endoscópica. Objetivo: Describir el rol del tratamiento multimodal en los schwanomas vestibulares. Métodos: Se realizó una búsqueda sistemática de literatura médica para la identificación e inclusión de artículos en las siguientes bases de datos: PubMed/Medline, SciELO y Google Scholar, además de los servidores de preprints BioRvix y MedRvix. Se usaron los siguientes descriptores: vestibular schwanoma OR acoustic neuroma AND nerve centered approach OR combined approach AND partial resection OR subtotal resection OR near total resection. Se excluyeron editoriales, cartas al editor, libros, revisiones, metaanálisis y aquellos artículos con método deficiente de más de 20 años de publicación o sin mención al tema de interés. Fueron incluidos 16 artículos. Desarrollo: Los artículos incluyeron un total de 699 pacientes, de los cuales solo 228 (32,6 porciento) recibieron radioterapia en el período posoperatorio. El período de seguimiento promedió 49,6 meses. La preservación de la función facial se logró en el 88,3 porciento de los casos y el control tumoral en el 80,7 porciento. El estado de la preservación auditiva solo fue informado en el 50 porciento de los estudios. El uso de la radioterapia adyuvante mostró gran variabilidad. Conclusiones: El tratamiento multimodal para los schwanomas vestibulares grandes -compuesto por la resección subtotal, vaciamiento intratumoral, seguido de radiocirugía- se ha convertido en una opción plausible. Se necesita la publicación de mayor cantidad de reportes para ofrecer recomendaciones y estratificar la conducta(AU)

Introduction: Vestibular schwannomas are lesions classified as grade I by the World Health Organization. Behavioral options include observation, radiosurgery or endoscopic microsurgical resection. Objective: To describe the role of multimodal treatment for vestibular schwannomas. Methods: A systematic search of medical literature, for the identification and inclusion of articles, was carried out in the databases PubMed/Medline, SciELO and Google Scholar, as well as in the preprint servers BioRvix and MedRvix. The following descriptors were used: vestibular schwannoma OR acoustic neuroma AND nerve centered approach OR combined approach AND partial resection OR subtotal resection OR near total resection. Editorials, letters to the editor, books, reviews and metaanalyses were excluded, as well as articles with deficient method of more than 20 years of publication or not mentioning the topic of interest. Sixteen articles were included. Development: The articles included a total of 699 patients, of which only 228 (32.6 ) received radiotherapy in the postoperative period. The average follow-up period was 49.6 months. Preservation of facial function was achieved in 88.3 percent of cases; and tumor control, in 80.7 percent. Hearing preservation status was reported in only 50 percent of the studies. The usage of adjuvant radiotherapy showed great variability. Conclusions: Multimodal treatment for large vestibular schwannomas -composed of subtotal resection and intratumoral draining, followed by radiosurgery- has become a plausible option. The publication of a greater amount of reports is necessary to provide recommendations and stratify the behavior(AU)

Schwannoma axilar. Reporte de un caso y revisión de la literatura / Axillary Schwannoma. Case report and literature reviewz

Introducción: El schwannoma (neurinoma o neurilemoma) es un tumor benigno originado en la vaina de mielina de los nervios periféricos a partir de la células de Schwann. En su variedad benigna es el tumor más frecuente dependiente de esta estructuras. Se manifiesta entre la tercera y quinta década de vida, sin distinción de género. La localización axilar es extremadamente infrecuente, constituyendo el 5% de todos los casos reportados. Los schwannomas son tumores bien delimitados y de lento crecimiento. La presentación más frecuente es como masa palpable o por la sintomatología clínica correspondiente al territorio de inervación del nervio afectado. Es importante tener en cuenta que estas lesiones puedes formar parte de cuadros clínicos de base genética más complejos como la neurofibromatosis, entre otros. El método diagnóstico de elección es la resonancia magnética nuclear. El tratamiento consiste en la extirpación de la lesión tratando de preservar la función de la estructura nerviosa afectada. Objetivo: El objetivo del presente trabajo es realizar el reporte de un caso de lesión compatible con schwannoma axilar y realizar un revisión de la literatura.

Introduction: Schwannoma (neurinoma or neurilemoma) is a benign tumor originated in myelin sheath of peripheral nerves from schwann cells. In its benign variety, it is the most frequent tumor dependent of these structures. It appears between the third and fifth decade of life without distinction of geder. Axillary location is extremely rare, accounting for 5% of all reported cases. Schwqnnomas are well-defide, slow-growing tumors. The most frequent presentation is as palpabel mass or due to the clinical symptoms corresponding to the innervation territory of the affected nerve. It's important to know that these lesions can be part of more complex genetic-based clinical cases such as neurofibromatosis. The diagnostic method of choice is magnetic resonance imaging. Treatment cosists of excising the lesion, trying to preserve the function of the affected nerve structure. Objetive: The aim of this report is to describe our experience with one case of axillary schwannoma diagnosed in our institution and to perform a review of the literature.

Resección microquirúrgica de schwannoma vestibular grado IVa con preservación de la función facial / Microsurgical resection of vestibular schwannoma grade IVa with preservation of facial function

Introducción: La cirugía de los schwannoma vestibulares constituye un desafío para los neurocirujanos. Debido a que se trata de un tumor benigno la resección completa de la lesión implica la curación del paciente. Sin embargo, este objetivo no siempre es fácil de lograr preservando la función de los nervios facial y acústico, especialmente en tumores de gran tamaño. Objetivos: Presentar detalles técnicos de la cirugía de resección de un schwannoma vestibular de gran tamaño (IVa) en el que se pudo preservar la función facial. Materiales y métodos: Se presenta el caso de una paciente femenina de 36 años que consultó por hipoacusia izquierda. En la RM preoperatoria se evidenciaba una lesión ocupante de espacio del ángulo pontocerebeloso izquierdo compatible con schwannoma vestibular con compresión del tronco encefálico y sin efecto de masa sobre el IV ventrículo (grado IVa). Mediante un abordaje suboccipital retromastoideo en posición de decúbito lateral se realizó la resección de la lesión en forma completa asistida por monitoreo del nervio facial. En todo momento se pudo preservar el plano aracnoideo que separaba el tumor de los nervios adyacentes. Resultados: Se logró una resección macroscópicamente completa con preservación de la función del nervio facial. La paciente permaneció internada por 96 hs en el postoperatorio sin complicaciones derivadas del procedimiento. Conclusión: La preservación del plano aracnoideo es un detalle técnico de mucha importancia para disminuir las posibilidades de lesión de los nervios facial y auditivo en la cirugía de resección de los schwannoma vestibulares.

Introduction: The surgery of vestibular schwannomas is a challenge for neurosurgeons.Because it is a benign tumor, complete resection of the lesion involves healing the patient. However, this objective is not always easy to achieve, preserving the function of both the facial and acoustic nerves, especially when dealing with large tumors. Objective: The objective of the video is to present some technical details of a large vestibular schwannoma (IVa) surgery in which the facial function could be preserved. Materials and methods: We present the case of a 36-year-old female patient who consulted for left hearing loss. The preoperative MRI showed a space- occupying lesion of the left pontocerebellar angle, which was compatible with vestibular schwannoma, with compression of the brainstem but with no mass effect on the IV ventricle (grade IVa). By means of a retromastoid suboccipital approach in the lateral prone position, the lesion was completely resected assisted by neurophysiological monitoring of the facial nerve. At all times, the arachnoid plane separating the tumor from the adjacent nerves was preserved. Results: A macroscopically complete resection was achieved preserving the facial nerve function. The patient stayed hospitalized for 96 hours during the postoperative period without any complication from the procedure. Conclusion: Preserving the arachnoid plane is a very important technical detail to reduce the possibilities of injury of the facial and auditory nerves in the vestibular schwannoma resection surgery.

Application of posterior approach for atlantoaxial subdural extramedullary nerve sheath tumors / 中国修复重建外科杂志

Objective: To investigate the procedure and effectiveness of posterior approach for operation of atlantoaxial subdural extramedullary nerve sheath tumors. Methods: Between January 2012 and March 2017, 9 patients with atlantoaxial subdural extramedullary nerve sheath tumors were treated, including 7 males and 2 females, aged 25-62 years (mean, 45.4 years). There were 8 cases of neurinoma and 1 case of neurofibroma. The tumors were located at C1 in 1 case and C1, 2 in 8 cases. The disease duration ranged from 5 to 120 months, with an average of 45.9 months. The neural function was rated as grade D in 8 cases and grade E in 1 case according to the American Spinal Injury Association (ASIA) grading system. The Japanese Orthopaedic Association (JOA) score was 12.8±2.5. All patients underwent posterior cervical surgery. The laminae were replanted and fixed in 2 cases. The atlantoaxial or occipitocervical axis was not fixed in all patients. Results: The operation time was 90-343 minutes, with an average of 179.2 minutes. The intraoperative blood loss was 50-1 000 mL, with an average of 335.6 mL. No relevant complication occurred after operation. All patients were followed up 6-21 months (mean, 11.1 months). The postoperative X-ray films showed the good stability of the cervical spine. All patients had complete tumor resection and no recurrence. The replanted laminae achieved fusion and the internal fixation was firm. According to ASIA grading system, 3 patients of preoperative ASIA grade D had upgraded to grade E at 3 months after operation, while the remaining patients had no change in grading. The JOA score was 15.1±1.4 at 6 months after operation, which was significantly improved when compared with that before operation (t=4.221, P=0.003). Conclusion: The atlantoaxial subdural extramedullary nerve sheath tumor (including the ventral tumor) can be removed completely via posterior approach. The axis lamina can be replanted and fixed with the small titanium plate or lamina screw when necessary, and the atlantoaxial or occipitocervical fixation was not needed.

Schwannomas mediastinal y retroperitoneal metacrónicos / Metachronous mediastinal and retroperitoneal schwannomas

Los schwannomas, también llamados neurilemomas, son tumores originados en la vaina de los nervios periféricos. El 45% ocurren en cabeza y cuello, solo el 9% en mediastino y el 0,7-2,7% en retroperitoneo. La multicentricidad es extremadamente rara. Presentamos el caso de un paciente de 30 años que consultó por dolor torácico derecho asociado a derrame pleural, al que se le diagnosticó un schwannoma mediastinal posterior, el cual fue resecado en forma completa por cirugía videoasistida. A los 3 años, vuelve a consultar por dolor en flanco derecho y, al estudiarlo, se constata un nuevo schwannoma de localización retroperitoneal, que se resecó por vía abierta dada su posición retrocava. Describimos la metodología de estudio de esta neoplasia y los hallazgos histopatológicos que demostraron su benignidad. Conclusión: es una patología muy infrecuente pero con excelente pronóstico posoperatorio si la resección quirúrgica es completa.

Schwannomas, also known as neurilemmoma, are neurogenic tumors that arise from the peripheral nerve sheaths. Forty-five percent of schwannomas occur in the head and neck, 9% in the mediastinum and 0.7-2.7% in the retroperitoneum. Multiple shwannomas are extremely rare. We report the case of a 30-year old male patient with chest pain in the right hemithorax associated with pleural effusion due to schwannoma of the posterior mediastinum that was completely resected with video-assisted thoracoscopy. Three years later, he presented pain on the right lumbar region due to a retroperitoneal schwannoma behind the vena cava that was completely removed with open surgery. We describe the tests used to evaluate this tumor and the histopathological findings confirming its benign nature. Conclusion: Schwannoma is a rare condition with excellent postoperative outcome after complete surgical resection.

Neurinomas del Trigemino: resección con abordaje endonasal transeptoesfenoidal convencional / Trigeminal neuromas: resection with a conventional transeptosphenoidal endonasal approach

Introducción: Los Neurinomas del nervio trigémino (NNT) son los segundos más comunes después de los neurinomas vestibulares, constituyendo cerca del 10% de los neurinomas intracraneales y menos del 0.5% de los tumores intracraneales. Los NNT pueden ocurrir en cualquier parte del curso del ganglio trigeminal y raíces del nervio trigémino. La mayor incidencia es entre los 30 y 40 años, siendo más frecuentemente en mujeres. Por sus características benignas el objetivo del manejo quirúrgico es con fines curativos, habiéndose propuesto diferentes técnicas quirúrgicas, lo que provoca que la elección de una en particular sea motivo de controversia. El propósito es presentar nuestra experiencia quirúrgica con abordaje endonasal transeptoesfenoidal convencional con el uso de espéculos asimétricos endoscópicamente asistidos en el manejo de NNT. Materiales y métodos: Se hizo el seguimiento de 3 pacientes diagnosticados con NNT en quienes se realizó resección por abordaje endonasal transeptoesfenoidal convencional (RETC), durante el periodo entre 2014 y 2015, en el Instituto Nacional de Cancerología, Bogotá D. C., Colombia. Se describen variables demográficas, clínicas, radiológicas y quirúrgicas. Resultados: Dos de ellos fueron hombres y una mujer, la edad media fue 48.3 años (32-60 a). El principal síntoma fue hipoestesia en hemicara. La localización en los 3 casos fue en la fosa craneal media y posterior derechas. Se realizó la resección quirúrgica siguiendo el abordaje propuesto, obteniendo buena visualización del tumor con resección total del tumor en 2 casos y subtotal en 1 caso, con resolución de sintomatología, menos complicaciones, menor estancia hospitalaria posoperatoria consecuente al abordaje menos invasivo respecto a otros tipos de abordaje, sin recidiva tumoral a 1 año de seguimiento. Conclusiones: Por medio de un abordaje endonasal transeptoesfenoidal convencional se proporciona una adecuada exposición de NNT, siendo posible resecarlos adecuadamente, por lo que este enfoque ofrece una excelente alternativa para el manejo de NNT con una baja morbimortalidad.

Introduction: Ten percent of intracranial neuromas and fewer than 0.5% of intracranial tumors are trigeminal nerve neuromas (TNN), which may occur anywhere along the course of the trigeminal nerve. They are most frequent in women between 30 and 40 years old. Since these tumors are characteristically benign tumors, the aim of surgical treatment is to be curative. Different surgical techniques have been described; however, which choice to employ remains controversial. This paper reports our surgical experience with the conventional trans-septosphenoidal endonasal approach, using endoscopically-assisted asymmetric specula, to resect TNN. Methods and materials: We reviewed three patients with a TNN who underwent tumor resection employing a conventional trans-septosphenoidal endonasal approach between 2014 and 2015 at the National Cancer Institute, Bogotá D.C., Colombia. Demographic, clinical, radiological, and surgical characteristics are described. Results: Two of our three patients were men and one a woman; the mean age was 48,3 (32- 60) years old. The main symptom was facial hypo-aesthesia. In all three patients, the tumor was located in the right mid and posterior cranial fossa. Surgical resection was performed with the proposed approach, obtaining good visualization of the tumor. Total tumor resection was achieved in two patients, and subtotal in one. We observed the complete resolution of symptoms, as well as fewer complications, and shorter postoperative hospital stays with our less-invasive approach relative to other more-invasive approaches described in the literature. No tumor recurrence was noted in the two patients who underwent total resection at one year of follow-up; the other patient remained asymptomatic. Conclusions: Utilizing a conventional trans-septosphenoidal endonasal approach, adequate exposure and resection of trigeminal nerve neuromas can be achieved. As such, this approach offers an excellent alternative to more-invasive techniques for managing TNN, being associated with low morbidity and mortality.

Diagnóstico diferencial de hernia discal / Diagnostic differences for disc herniation

Disc herniation is a frequent pathology in the radiologist's daily practice. There are different pathologies that can simulate a herniated disc from the clinical and especially the imaging point of view that we should consider whenever we report a herniated disc. These lesions may originate from the vertebral body (osteophytes and metastases), the intervertebral disc (discal cyst), the intervertebral foramina (neurinomas), the interapophyseal joints (synovial cyst) and from the epidural space (hematoma and epidural abscess).

La hernia discal es una patología frecuente en la práctica diaria del radiólogo. Hay distintas patologías que pueden simular una hernia discal desde el punto de vista clínico y especialmente imagenológico que debemos considerar cada vez que informamos una hernia discal. Estas lesiones pueden provenir del cuerpo vertebral (osteofitos y metástasis), del disco intervertebral (quiste discal), de los forámenes intervertebrales (neurinomas), de las articulaciones interapofisiarias (quiste sinovial) y desde el espacio epidural (hematoma y absceso epidural).

Schwanoma gigante do VIII nervo craniano de evolução subaguda: relato de caso / Subacute evolution of giant schwannoma of VIII cranial nerve: case report

O schwanoma vestibular é uma neoplasia que se origina das células de Schwann da porção vestibular do VIII nervo craniano e que corres- ponde a cerca de 10% dos tumores intracranianos e a 80% a 90% daqueles localizados no ângulo pontocerebelar. Apesar do crescimento lento e evolução em geral benigna, estes tumores podem evoluir de maneira desfavorável devido à localização em compartimento anatômico relativamente reduzido no crânio (fossa posterior), o que pode levar a compressão de estruturas nobres (como o tronco encefálico) e a desenvolvimento de hidrocefalia obstrutiva, especialmente nos raros casos de schawanomas gigantes (> 40 mm). Apresentamos relato de caso de paciente com quadro de tinnitus e hipoacusia à esquerda que evoluiu de forma subaguda com alterações do humor, da cognição e da marcha cujo diagnóstico final foi de schwanoma gigante do VIII nervo craniano.

Vestibular schwannoma is a Schwann cells neoplasia of the vestibular branch of the VIII cranial nerve and it accounts for 10% of intracranial tumours and to 80%-90% of those located at the cerebellopontine angle. Despite slow growth and usual benign evolution, unfavourable outcomes may occur, especially in the rare cases of giant schwanno- mas (> 40mm). Owing the fact that this tumours are located in a relatively narrow space (posterior fossa), giant schwannomas may compress noble areas (as the brainstem), which can also cause obstructive hydrocephalus. We discuss a case report of a 48 years old woman complaining of left-sided hearing loss and tinnitus that developed a subacute cognitive impairment, mood disorder and gait disturbance, diagnosed with giant schwannoma of the VIII nerve.

Surgical exposure of the internal auditory canal through the retrosigmoid approach with semicircular canals anatomical preservation / Avaliação da exposição do fundo do conduto auditivo interno através do acesso retrosigmóide-transmeatal

Objective Evaluate the feasibility of an adequate exposure with anatomical preservation of labyrinth structures through retrosigmoid transmeatal approach (RSA) in surgeries for resection of acoustic neuromas/vestibular schwannomas (VS). Method Thirty patients underwent surgical resection and were preoperatively evaluated with fine slice high definition CT scans and 3D-MRI volumetric reconstructions. Extension of internal auditory canal (IAC) opening during surgery was measured using 3 mm right-angle calibrated hook and neuronavigation parameters. Postoperatively, the extension of IAC opening and integrity of the labyrinth were confirmed through preoperatively images procedures. Results The preoperative length of IACs varied between 7.8 and 12.0 mm (mean 9.3 mm, SD 0.98, 95%CI 8.9 to 9.6, and median 9.0 mm). Postoperative images demonstrated adequate opening of the IAC and semicircular channels integrity. Conclusion A complete drilling of the posterior wall of IAC through the RSA is feasible and allows direct visualization of the IAC-fundus without damaging the semicircular canals. .

Objetivo Avaliar a possibilidade de exposição adequada preservando anatomia das estruturas labirínticas pelo acesso retrosigmóide-transmeatal (RSA) nas ressecções de schwannomas do vestibular (VS). Método Trinta pacientes foram submetidos à ressecção cirúrgica e avaliados no pré-operatório com tomografias de alta definição e reconstruções de ressonância magnética 3D. A extensão da abertura do conduto auditivo interno (CAI) foi medida e confirmada com parâmetros de neuronavegação. No pós-operatório, a extensão da abertura e a integridade do labirinto foram confirmadas por imagens de tomografia computadorizada. Resultados A extensão do CAI no pré-operatório apresentou variação de 7,8-12 mm (média 9,3 mm, DP 0,98, IC95% de 8,9-9,6 e mediana 9 mm). Imagens pós-operatórias demonstraram abertura adequada do IAC e integridade dos canais semicirculares. Conclusão A abertura completa da parede posterior do CAI pelo RSA é possível e permite a visualização direta do fundo do conduto sem prejudicar os canais semicirculares. .

The extracisternal approach in vestibular schwannoma surgery and facial nerve preservation / A abordagem extracisternal na cirurgia de schwannoma vestibular e preservação do nervo facial

The classical surgical technique for the resection of vestibular schwannomas (VS) has emphasized the microsurgical anatomy of cranial nerves. We believe that the focus on preservation of the arachnoid membrane may serve as a safe guide for tumor removal. Method The extracisternal approach is described in detail. We reviewed charts from 120 patients treated with this technique between 2006 and 2012. Surgical results were evaluated based on the extension of resection, tumor relapse, and facial nerve function. Results Overall gross total resection was achieved in 81% of the patients. The overall postoperative facial nerve function House-Brackmann grades I-II at one year was 93%. There was no recurrence in 4.2 years mean follow up. Conclusion The extracisternal technique differs from other surgical descriptions on the treatment of VS by not requiring the identification of the facial nerve, as long as we preserve the arachnoid envelope in the total circumference of the tumor. .

A técnica cirúrgica clássica para ressecção de schwannomas vestibulares enfatiza a anatomia microcirúrgica dos nervos cranianos. Acreditamos que o foco na preservação da membrana aracnóide pode servir como parâmetro seguro para a remoção do tumor. Método A abordagem extracisternal é descrita em detalhe. Analisamos o prontuário de 120 pacientes tratados com esta técnica entre 2006 e 2012. Os resultados cirúrgicos foram baseados em extensão de ressecção, recorrência tumoral e função do nervo facial. Resultados Ressecção total foi obtida em 81% dos pacientes. O resultado global da função do nervo facial (House-Brackmann graus I-II) após um ano da cirurgia foi de 93%. Não houve recidiva em um seguimento médio de 4,2 anos. Conclusão A técnica extracisternal difere de outras descrições cirúrgicas no tratamento de schwannoma vestibular pois não requer a identificação do nervo facial, contanto que o plano de aracnóide seja preservado em toda circunferência do tumor. .

A Purely Paraspinally Located Schwannoma from a Dorsal Root of a Spinal Nerve.

Background: Spinal Schwannomas are benign nerve sheet tumors and the most common intradural extramedullary tumors of the spine, mainly occurring in the cervical and lumbar region. Case Description: Here we illustrate the case of a 34-year-old woman with a paraspinal lesion presenting with severe lumbar pain. There were no focal sensory or motor deficits. Magnetic resonance imaging (MRI) disclosed a nodular lesion embedded in the paraspinal lumbar musculature, suspicious of tumorous growth. Complete surgical excision of the lesion was performed with clear margins and neuropathological analysis revealed a Schwannoma. Postoperative imaging confirmed a gross total resection with no recurrence after 6 months. Conclusion: Although Schwannomas are frequently encountered in the lumbar spine, a location distinct from the spinal canal is very rare. To be adequately treated, it needs to be considered in the differential diagnosis of any spinal or paraspinal mass. As with other accessible and symptomatic lesions, the treatment of choice is complete excision with clean margins to avoid local recurrence.

Neurinoma del plexo braquial simulando metastasis de adenocarcinoma de mama / Schwannoma of the brachial plexus resembling a breast adenocarcinoma metastasis

Los neurinomas del plexo braquial son tumores infrecuentes que pueden confundirse con otras lesiones de índole tumoral. Se presenta el caso de una mujer de 40 años, tratada previamente de un adenocarcinoma de mama derecha en el pasado, que en el estudio de extensión realizado 5 años después se detectó una lesión localizada en el plexo braquial derecho. La paciente se encontraba asintomática. El diagnóstico radiológico de presunción fue metástasis de adenocarcinoma mamario. Se realizó un abordaje axilar derecho descubriendo una lesión bien delimitada en el plexo braquial. Con ayuda de la monitorización neurofisiológica intraoperatoria, se observó que la lesión dependía de la rama cubital y se pudo realizar una resección completa preservando la función de dicho nervio. El estudio anatomopatológico confirmó que se trataba de un neurinoma, descartando así la existencia de metástasis. La evolución postoperatoria fue satisfactoria. Seis años después de la intervención no existe recidiva tumoral. En nuestro conocimiento este es el primer caso publicado en la literatura de un neurinoma del plexo braquial dependiente de la rama cubital. La monitorización neurofisiológica intraoperatoria resulta fundamental para abordar este tipo de lesiones con baja morbilidad.

Schwa nomas originating from the brachial plexus, although rare, may be mistaken for another type of tumour. A 40 year-old woman, who had been treated years earlier for a breast adenocarcinoma, showed in the 5-year follow-up magnetic resonance examination a localized lesion in the right brachial plexus. The presumptive radiological diagnosis was a metastasis from the primary adenocarcinoma. Following surgical access via the right axilla, a well-circumscribed mass in the brachial plexus was detected. Under intraoperative electrophysiological guidance, the lesion was observed to depend on the ulnar nerve and its complete resection was possible without compromising nerve function. Histological findings indicated a schwannoma thus ruling out the presence of metastasis. The postoperative development was uneventful and six years after surgery, the patient is to date tumour-free. To the best of our knowledge, this is the first report of a brachial plexus schwannoma arising from the ulnar branch. Intraoperative electrophysiological monitoring is essential for a good surgical outcome.

Schwannoma of the tongue: An unusual presentation in a child.

Schwannomas are benign tumors of nerve sheath and quite uncommon in the oral cavity. In contrast to the earlier reports in the literature, a confounding case of a lingual schwannoma presenting as a symptomatic and exophytic growth on the ventral surface of the tongue in a 12-year-old boy is discussed here.

Clinical research on 46 cases of microoperation for acoustic neurinomas under the F wave assisted electrophysiological monitoring intraoperatively / 肿瘤研究与临床

ObjectiveTo study the methods of how to protect facial nerve function following complete resection of acoustic neurinomas and the value of the techniques of F wave assisted electrophysiological monitoring intraoperatively.Methods Retrospectivelysummarizing theresultsof combining three electrophysiological monitoring techniques such as nasal muscle F wave recording,online EMG and triggered EMG to monitor 46 cases of microoperations for acoustic neurinomas intraoperatively during the period of Feb.2004 to Dec. 2008. Correlating every intraoperative monitoring index with their follow-up results of facial nerve function 1 day and 6 months after their operations.The tendency of the two continuous monitoring techniques between nasal F wave recording and online EMG of facial muscles has also been studied in this paper. Results Among 46 cases of acoustic neurinomas, 45(97.83 %) tumors have been totally resected, and 1 (2.17 %) tumor subtotally resected,lcase (2.17 %)died after operation,and 2ases occurred the leakage of cerebrospinal fluid(CSF) which have been cured through conservative treatment. The whole anatomic protection rate of facial nerve is 97.83 %,and their functional protection rates 6 months after operation are:HB Ⅰ - Ⅱ,75.56 %;Ⅲ-Ⅳ,22.22 % and Ⅴ-Ⅵ,2.22 %.The completely accordant rate between the intraoperative findings of nasal F wave recording and online EMG is 52.17 %, partially accordant rate is 45.65 %, and totally opposite rate is 2.17 % (x2 趋势= 6.113, P ＜0.05). The intraoperative monitoring indexes in nasal muscle F wave recording are correlated well with the facial nerve function in the 6th month' s follow-up (κ=0.429, P ＜0.001).In triggered EMG monitoring after tumors being resected,the stimulus threshold ratio and maximum amplitude ratio of facial nerve between leaving brain stem part and inner acoustic porus part are also correlated well with the facial nerve function 6 months after operation(κ=0.576, P ＜0.001; κ=0.595, P ＜0.001). ConclusionNasal muscle F wa recording cooperated well with online EMG and triggered EMG intraoperatively and correlates well with the postoperative facial nerve function, so they should be routinely applied together intraoperatively.

Neurinoma del acústico diagnosticado durante el embarazo: reporte de un caso / Acoustic neurinoma during pregnancy: a case report

Los tumores cerebrales son infrecuentes durante el embarazo. Los neurinomas del acústico pueden ser sintomáticos por primera vez durante la gestación y representan el 6-8 por ciento de las neoplasias intracraneales. El objetivo de esta comunicación es presentar el caso de una primigesta adolescente que presentó sintomatología neurológica de afectación del VIII par y de fosa posterior, característica de la neurofibromatosis tipo 2.

Brain tumors are infrequent during pregnancy. Neurinomas of auditive nerve can get to be symptomatic during gestation, representing 6-8 percent of the intracranial neoplasias. The objective is to report a case of a pregnant adolescent who present a neurological symptoms of VIII pair affectation and posterior cranial fossa, characteristic of the neurofibromatosis type 2.

Schwannoma vestibular: involução tumoral espontânea / Vestibular Schwannoma: spontaneous tumor involution

A história natural dos schwannomas vestibulares ainda não está totalmente elucidada, mas sua maioria tende a apresentar crescimento lento, muitos permanecendo sem sintomas durante toda a vida do paciente. Cerca de 69 por cento deste tipo de tumor diagnosticados não apresentam crescimento e, destes, 16 por cento chegam a apresentar regressão tumoral. Considerando os tumores que apresentam crescimento, cerca de 70 por cento crescem menos de 2 mm ao ano. O avanço nos métodos de diagnóstico por imagem, particularmente à ressonância magnética com contraste de gadolínio, permite o diagnóstico cada vez mais de lesões com sintomas mínimos e tamanhos menores. O tratamento de escolha para estes tumores ainda é a ressecção completa do tumor. As técnicas cirúrgicas apresentaram grande avanço nas últimas décadas, o que possibilitou diminuição da mortalidade. Assim, a cirurgia, que antes tinha como objetivo apenas a ressecção completa do tumor, agora visa também à preservação da audição e da função do nervo facial. Considerações finais: Considerando-se sua história natural, abre-se a possibilidade de uma conduta conservadora já que o ritmo de crescimento no primeiro ano após o diagnóstico prediz o comportamento do tumor nos próximos anos. A conduta conservadora não implica em repúdio à cirurgia, devendo ser utilizada em casos de aumento tumoral, piora dos sintomas ou desejo do paciente. Além disso, em relatos de literatura não há diferença estatisticamente significante entre os pacientes submetidos à cirurgia logo após o diagnóstico ou após conduta conservadora inicial, no que diz respeito às seqüelas pós-operatórias.

The natural history of Vestibular Schwannomas (VS) is yet not totally known, but most of them have the tendency to slow growth, sometimes without any kind of symptoms during the individual’s entire time. About 69 percent of diagnosed VS do not grow at all and 16 percent of these can even regress. Considering tumors that grow, about 70 percent have grown less than 2mm an year. Advanced radiological diagnosis, especially magnetic resonance imaging with gadolinium helps us diagnose small and less symptomatic tumors. Treatment of choice still is complete tumor resection. Surgical approaches have improved considerably and have helped preserve facial nerve function and hearing. Considering VS’s natural history, there is a possibility for conservative treatment for these tumors, because their growth in the first year after diagnosis predicts tumor growth behavior in the next years. Surgery should be done in cases of tumor growth, patient’s desire or symptoms worsening. Moreover, in terms of postoperative sequelae, there is no difference between patients who underwent surgery immediately after diagnosis and those who underwent initial conservative treatment for these tumors.

Acoustic neuroma (vestibular schwannoma): surgical results on 240 patients operated on dorsal decubitus position

OBJECTIVE: To evaluate the result of the surgical treatment of vestibular schwannoma (VS) operated in dorsal decubitus (mastoid position). METHOD: 240 patients with a VS underwent a retrosigmoid craniotomy for tumor resection in dorsal decubitus (mastoid position). The function of 7th and 8th cranial nerves was monitored during surgery and the opened internal auditory canal (IAC) was reconstructed using a vascularized dura flap, muscle and fibrin glue. RESULTS: Complete tumor removal was achieved in 99 percent of the cases, with a mortality of 1.6 percent. The facial nerve function was preserved in 85 percent of cases and hearing in 40 percent of the patients (with preoperative hearing) with tumors of up 1.5 cm in diameter. The incidence of cerebrospinal fluid leak was 5.8 percent and meningitis 2.9 percent. Venous air embolism was registered in 3 percent of cases; it was not associated to mortality. CONCLUSION: Surgical removal of VS in dorsal position has several advantages; the morbidity and mortality are very low.

OBJETIVO: Avaliar o resultado do tratamento cirúrgico de pacientes portadores de schwannoma do vestibular (SV) operados em decúbito dorsal (posição de mastóide). MÉTODO: 240 pacientes foram submetidos a craniotomia retrosigmóide na posição de mastóide. A função do VII e VIII nervos cranianos foi monitorizada durante a cirurgia e a reconstrução da abertura do conduto auditivo interno foi realizada com retalho vascularizado de dura-mater, músculo e cola de fibrina. RESULTADOS: A exérese foi completa em 99 por cento dos casos, com mortalidade de 1,6 por cento. Houve preservação da função do nervo facial em 85 por cento dos casos e da audição em 40 por cento dos pacientes com audição prévia e tumores menores de 1,5 cm. A incidência de fístula liquórica foi 5,8 por cento e meningite 2,9 por cento. Embolia gasosa foi registrada em 3 por cento dos casos, não associada à mortalidade. CONCLUSÃO: O tratamento cirúrgico dos SV utilizando-se a posição de mastóide tem várias vantagens, com baixa morbidade e mortalidade.

Expression of EGFR and LRIG-1 in Human Trigeminal Neurinoma / 华中科技大学学报（医学）（英德文版）

The expression of epidermal growth factor receptor (EGFR) and leucine-rich repeats and immunoglobulinqike domain 1 (LRIG-1) in humantrigeminal neurinoma was investigated and their effect on the origination and development of trigeminal neurinoma, and the relationship between them was studied. By using immunohistochemistry with tissue chip, the expression of EGFR and LRIG-1 was detected in 23 cases of trigeminal neurinoma. It was found that in the 23 cases, the expression rate of EGFR was 21.74 %, while that of the LRIG-1 was 78.26 %. There was a negative correlation between them. It wassuggested that LRIG-1 might inhibit the malignant differentiation and proliferation of the trigeminal neurinoma possibly by the negative feedback loop of EGFR.