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Trigeminal schwannomas: experience with 57 cases and a review of the literature

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Abstract

Trigeminal schwannoma is a mostly benign tumor that can be cured by complete resection. Over the last few decades, several pioneers have developed surgical approaches enabling the total removal of such tumors. We analyzed 57 patients who underwent radical surgery, including 45 patients who underwent skull base surgery as their initial treatment, for removal of trigeminal schwannomas. Here, we report the surgical management of these cases. Since 1990, all such patients have been treated using three main types of middle fossa skull base approaches, which minimize the exposure of the brain: the anterior transpetrosal approach, subtemporal interdural approach (Dolenc), or a combination of these approaches. Before 1990, total tumor removal was achieved in only three of eight patients (38%). After 1990, the tumors were totally removed in 43 patients (90%) and were nearly completely removed in an additional three patients (6%). Among the patients who underwent skull base surgery as their initial treatment, a complete resection was achieved in 93% (42/45 patients) of the cases. However, total surgical removal after surgery and Gamma knife surgery was very difficult because of dense adhesions to the brain stem and cranial nerves. No surgery-related mortalities occurred in this series, and the individual KPS scores were more than 90% among the patients who underwent skull base surgery. No recurrences requiring additional surgery have occurred after an average follow-up period of 4.9 years. Most of the trigeminal schwannomas could be removed totally and safely during a single operation after the introduction of skull base surgery. Therefore, radiosurgery should not be applied as the treatment of first choice for younger patients. A correct anatomical knowledge is critical for minimizing brain exposure and avoiding surgical complications.

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Authors and Affiliations

  1. Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan

    Raita Fukaya, Kazunari Yoshida, Takayuki Ohira & Takeshi Kawase

Authors
  1. Raita Fukaya
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  2. Kazunari Yoshida
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  3. Takayuki Ohira
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  4. Takeshi Kawase
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Correspondence to Raita Fukaya or Takeshi Kawase.

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Comments

Sunil Manjila, Nicholas C. Bambakidis, Cleveland, USA

In this very interesting article, the authors describe a large surgical series of 57 multi-compartmental trigeminal schwannomas. The tumors were totally removed in 43 patients (90%) and were nearly completely removed in an additional three patients (6%) using skull base approaches. This is an impressive surgical series, however there are only four cases that underwent GKS (two before and two after the surgical removal of tumor), and hence do not build a strong case for the “surgery or radiosurgery” debate either one way or another. Out of 57 cases, two of them had NF II and another two were less than 15 years of age (pediatric), both categories differing widely in their natural history compared to regular non-syndromic adult lesions.

The authors have employed several skull base approaches for treatment of these multi-compartmental lesions, such as fronto-temporal approach, subtemporal approach, lateral suboccipital approach, orbitozygomatic approach, zygomatic infratemporal fossa approach, orbitozygomatic infratemporal fossa approach, anterior transpetrosal approach, zygomatic transpetrosal approach, transzygomatic approach, and supraorbital approach. The article has detailed the steps of anterior transpetrous and subtemporal interdural approaches, although the reasons of preferring them over a presigmoid or a combined orbitozygomatic–retrosigmoid approach are not highlighted. The surgical treatment of trigeminal schwannomas has proven better in those lesions with large cystic component or those becoming symptomatic from local mass effect necessitating debulking of lesion; in our opinion radiosurgery is indicated in treatment of small pre- or post-surgical residual lesions, infiltrating cavernous sinus lesions, and those patients with significant medical comorbidities. In our practice, such lesions are treated with surgical removal as a primary option, and we favor the orbitozygomatic approach often combined with an anterior petrosectomy. Ultimately, we believe the best approach is the one most familiar and comfortable for the treating surgeon.

References

1. Safavi-Abbasi S, Bambakidis NC, Zabramski JM, Workman R, Verma K, Senoglu M, Porter R, Spetzler RF (2010). Nonvestibular schwannomas: an evaluation of radiosurgical and microsurgical management. Acta Neurochi 152 (1):35–40

2. Stereotactic radiosurgery for trigeminal schwannoma: tumor control and functional preservation Clinical article. Kano H, Niranjan A, Kondziolka D, Flickinger JC, Dade Lunsford L (2009). J Neurosurg 110(3):553–8, Mar

3. Surgical management of trigeminal schwannomas. Ramina R, Mattei TA, Sória MG, da Silva EB Jr, Leal AG, Neto MC, Fernandes YB (2008). Neurosurg Focus 25(6):E6, discussion E6

Vinko V. Dolenc, Ljubljana, Slovenia

The authors present a series of 57 trigeminal neurinomas operated in the period from 1974 to 2008. The majority of tumors were operated from 1990 on. The authors are talking about so-called skull base approaches after the year 1990, and others before. They also claim that for the so-called skull base approaches the radicality was much higher after 1990 than before. Mainly they divided the approaches into three groups what is actually not the most important. What does count is that the approach to trigeminal neurinomas is epidural to the skull base, and then from the superior orbital fissure, foramen rotundum, and foramen ovale where the external layer of dura is cut, the temporal lobe still covered by the dura underneath the temporal lobe is lifted and dissected away from the tumor, which is covered then only by a thin membrane. It is self-evident that the periosteal part of the dura runs along the bone underneath the parasellar space and also into Meckel’s cave. In reality, from that point further down there are several “corridors” leading to the actual location of the tumor. It has also to be mentioned that only few trigeminal neurinomas are intradural, most of them being interdural, and this holds for all trigeminal neurinomas, since they originate from the peripheral portion of the Gasserian ganglion (GG) and from the peripheral branches over CN V, that is from V1, V2, V3.

Again, it goes without saying that from the posterior and medial portions of the GG and plexiform portion of the root of CN V, as well as from the root itself, those tumors are either only intradural in the posterior fossa, or intradural and interdural. The initial growth of the trigeminal neurinoma from any of the structures of CN V does dictate the spread of growing of the lesion anteriorly and/or posteriorly. Unfortunately, no respect is paid to this classification which has been published already in 1994 (Dolenc). From the classification in that report, one can understand from the practical point of view the necessity for the extradural approach to these extradural lesions. Even more surprising is the fact that a new classification of tumors is presented which is oriented more to the cranial fossae than to the dural envelopes. In most of the cases, in our experience, the parasellar space has been pushed antero-medially and the trigeminal neurinoma did not even invade it.

In this report—to my surprise—the author (Shiobara) who did open our mind to the fact that the posterior fossa could be easily entered through the apex of the pyramid—though at that time only for eradicating the neuromas of nerve VIII—is not mentioned at all. Profiting from his idea, we did create this approach through the apex of the pyramid, and we also did realize that by using this approach practically all of trigeminal neurinomas can be eradicated in one single surgical approach. From my point of view, the credit should be paid to those authors who really did open the new vistas at large.

What is interesting in this report is also that most authors, who were named as the pioneers of this approach, published their reports after 1994 when most important details were already published regarding the approach to the trigeminal neuronomas. The authors have to be commended to certain extent for trying to put more and more details into the description of the approaches. However, to a wise reader, 1,000 details do not tell as much as a strict general description of the anatomical basis and dural structures. For that reason, personally, I still stand for “the epidural approach” much more than for “the skull base approach”. The differentiation between these two descriptions does not mean only rhetoric, it actually means the real concept; and—what is even more important—the protection of the brain overlying the tumor, in particular when the dura on the under aspect of the temporal lobe is preserved.

Selcuk Peker, Istanbul, Turkey

Fukaya et al. report on their extensive experience about surgical treatment of trigeminal schwannomas. The authors favored skull base approaches for these tumors. Anterior transpetrosal approach was mostly in this series. The technique was explained thoroughly and the drawings are very good. They reported that complication rate is low with skull base surgery techniques and also the total excision rate is high. They conclude that surgical treatment for postradiosurgery recurrences demonstrates high complication rate. So, they recommend skull base approaches to all trigeminal schwannomas as a first line treatment.

More than 57% of the tumors were larger than 3 cm in diameter in this series. These tumors were not suitable for radiosurgery. However, for the small trigeminal schwannomas, we think that radiosurgery gives less complication with high tumor growth control rate. Even with this experienced hands the total complication rate is higher than the rate in the radiosurgery series. So, radiosurgery should be used for small tumors and skull base approaches should be kept for the large tumors.

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Fukaya, R., Yoshida, K., Ohira, T. et al. Trigeminal schwannomas: experience with 57 cases and a review of the literature. Neurosurg Rev 34, 159–171 (2011). https://doi.org/10.1007/s10143-010-0289-y

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