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Management of oculomotor nerve schwannomas in two different locations: surgical nuances and comprehensive review

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Abstract

Rare tumors with anecdotal reportage, oculomotor schwannomas are most often seen in the oculomotor cistern close to the anterior clinoidal region. Adding to the small series of reported cases of this unusual lesion, we report two male patients in their second decade who presented with different degrees of oculomotor palsy. The location of the lesion was caverno-cisternal in one case and orbito-cavernous in the other. Intricate neurovascular relationships of this lesion, especially in non-cavernous locations, are discussed. The risk of damage to nerve rootlets enmeshed within the lesion is high with attempts at near-total excision, rendering the anatomical preservation of the nerve an arduous exercise. The authors review literature pertaining to this unusual lesion and elucidate surgical nuances which may have a bearing on outcome.

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Authors and Affiliations

  1. Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, EPIP Area, Whitefield, Bangalore, 560066, Karnataka State, India

    Sunil V. Furtado & Alangar S. Hegde

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  1. Sunil V. Furtado
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  2. Alangar S. Hegde
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Correspondence to Sunil V. Furtado.

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Comments

Nobutaka Kawahara, Yokohama, Japan

This article reported two cases with oculomotor schwannoma and extensively summarized previous reports. Intracranial schwannoma usually arises from the vestibular or trigeminal nerves. How these tumors should be treated is well documented in the literature. Another location of tumor is the jugular foramen, where lower cranial nerves are the origins. In this regard, oculomotor schwannoma is extremely rare. Therefore, diagnosis of these tumors may be difficult even when utilizing modern MRI technology.

Treatment strategy for these tumors are not well established due to its rarity. In this report, the authors recommended surgical extirpation when the oculomotor nerve function is already compromised, which also provides a chance to reconstruct the nerve by a graft. Subtotal excision would be a reasonable alternative when its function is still maintained. We recently treated a case harboring purely cisternal oculomotor schwannoma with complete oculomotor palsy. In this case, we could not perform nerve graft reconstruction because it attached tightly to the nerve exit zone from the brain stem. Thus, treatment strategy for this rare tumor could not be uniformly made. In this regard, this article would provide clinically useful information depending on the type of location.

Chang Jin Kim, Seoul, Korea

This article adds two sporadic cases of oculomotor schwannoma which usually occurs in association with neurofibromatosis type I, and critically reviewed the previous cases in the literature. This rare neoplasm can arise all the way from the interpeduncular cistern to the orbit as the authors classified, and manifest itself with a constellation of various symptoms and signs of which oculomotor paresis is most common. Complete extirpation of the tumor is frequently infeasible especially with those cases involving the cavernous sinus and carries high risk of functional deterioration. Provided with accurate diagnosis by virtue of detailed clinical and radiological analysis, multimodal approach integrated with the radiosurgery may procure an improved functional as well as oncological outcome rather than the aggressive resection-only strategy.

Andrei Koerbel, Joinville, Brazil

This manuscript adds two more cases to other 54 cases of oculomotor nerve schwannomas published in the indexed literature so far.

These tumors often present with some degree of oculomotor nerve deficits. Although the prognosis for survival is excellent, the morbidity related to homolateral ocular function is very high.

The optimal treatment in these cases is obviously not a consensus, since these are very rare tumors and recovery of the oculomotor nerve is not satisfactory after nerve graft repair.

Thus, it seems very reasonable that total resection of these tumors are well indicated in the cases with important preoperative oculomotor nerve deficits.

However, another surgical strategy should be considered for cases without symptoms or with minimal preoperative deficits. Resection under intraoperative neurophysiological monitoring performed with electromyography of the extra-ocular muscles is mandatory in these cases. If total removal cannot be accomplished without damaging functional fibers of the oculomotor nerve, partial resection is the best option for avoiding new postoperative permanent deficits due to oculomotor nerve injury, which are devastating for the patient. Adjuvant radiosurgery in these cases, or even as a first option in asymptomatic small tumors, would be the most reasonable treatment.

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Furtado, S.V., Hegde, A.S. Management of oculomotor nerve schwannomas in two different locations: surgical nuances and comprehensive review. Neurosurg Rev 35, 27–35 (2012). https://doi.org/10.1007/s10143-011-0344-3

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