RESUMEN
BACKGROUND: Intracranial carotid sympathetic plexus (CSP) nerve sheath tumors have rarely been reported in the literature. This study describes the first reported case of a CSP neurofibroma and the first case of a CSP nerve sheath tumor treated via an endoscopic endonasal approach followed by adjuvant radiosurgery. OBSERVATIONS: A 53-year-old man presented with 3 days of headaches and diplopia and was found to have a complete left abducens nerve palsy. Computed tomography (CT) revealed a smoothly dilated left carotid canal, CT angiography revealed a superiorly displaced left internal carotid artery (ICA), and magnetic resonance imaging revealed a T2-hyperintense and avidly enhancing lesion in the left cavernous sinus encasing the ICA. The patient underwent subtotal resection via an endoscopic transsphenoidal transcavernous approach followed by Gamma Knife radiosurgery. LESSONS: Nerve sheath tumors arising from the CSP are extremely rare but need to be considered when assessing unusual cavernous sinus lesions. The clinical presentation is dependent on the anatomical location of the tumor and its relationship to the ICA. The optimal treatment paradigm is unknown.
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OBJECTIVE: Carotid sympathetic plexus (CSP) schwannomas are rare brain tumors located in a complex site around the cavernous sinus and carotid canal in the petrous bone. This study describes 3 cases of CSP schwannomas that underwent surgical removal of the tumor through an endoscopic endonasal transpterygoid approach. METHODS: Between 2016 and 2021, 3 cases of CSP schwannomas were treated using an endoscopic endonasal transpterygoid approach. Preoperative tumor size, preoperative and postoperative symptoms, internal carotid artery (ICA) displacement, extent of tumor resection, intraoperative findings showing tumor origin, and surgical complications were evaluated in all patients. RESULTS: Two tumors were in the petrous region, and the other one was in both the petrous and cavernous regions. The median tumor diameter was 41.3 mm. In the 3 cases, the ICA was displaced to the superolateral side, the anterolateral side, and the posterior side, respectively. Near-total resection was achieved in all 3 cases via an endoscopic endonasal transpterygoid approach. There were no endonasal postoperative complications, and the cranial nerve disability improved in all 3 patients at 1-year follow-up. CONCLUSIONS: The surgical technique for CPS schwannoma using an endoscopic endonasal transpterygoid approach may be a viable option because endoscopy has been proven to offer better intraoperative visualization and reduce postoperative discomfort for patients. Tumors located medial and inferior to the ICA pars cavernous sinus or anterior, inferior, and medial to the paraclival ICA are ideal candidates for surgery using this endoscopic approach.
Asunto(s)
Endoscopía , Neurilemoma , Humanos , Endoscopía/métodos , Disección , Neurilemoma/diagnóstico por imagen , Neurilemoma/cirugía , Resultado del Tratamiento , CadáverRESUMEN
BACKGROUND: Intracranial carotid sympathetic plexus schwannoma (CSPS) is extremely rare; thus differential diagnostic criteria, optimal surgical strategies, and even a precise definition are lacking. Here we describe a case of CSPS and propose a definition and classification for previously reported cases. CASE DESCRIPTION: A 54-year-old man presented with hypacusis and abducens nerve palsy. Radiologic examinations revealed a well-enhanced mass at the right medial temporal base with erosion of the petrous apex and intact perilesional cortical bone. Preoperative findings, such as spontaneous improvement of diplopia, absence of xerophthalmia or facial palsy, and laterally displaced internal carotid artery (ICA), suggested the atypical origins of the petrous apex schwannoma. The tumor was exposed using the subtemporal extradural approach and completely resected. Intact foramen ovale, rostrolateral displacement of the greater superficial petrosal nerve within the outer membrane of the tumor, eroded petrous apex and carotid canal, superolaterally displaced ICA, and lack of an obvious tumor attachment to any of the suspected nerves suggested that the tumor originated from the carotid sympathetic plexus of the petrous ICA. The patient fully recovered without neurological complications. CONCLUSIONS: Preoperative diagnosis of petrous apex schwannoma is difficult: characteristic findings such as diplopia, hypacusis, and laterally displaced ICA may help. In addition, assessment of the relationship between the tumor and cavernous sinus could be useful in the determination of the surgical approach. Complete resection with good clinical outcome could be expected using Dolenc's approach (type A) and by the middle fossa extradural approach (type B) for intracavernous and extracavernous CSPS, respectively.