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In our case the tumor recurred very rapidly and the clinical course was almost similar to malignant tumors. In contrast to the traditional belief, our patient showed concordance between high‑grade histological features and the clinical outcome. So it is difficult to prognosticate these atypical SEGAs and the clinical course may vary in different cases. Utmost caution should be exercised in managing these patients. Those with aggressive course should probably be treated as other malignant gliomas.
Devi Prasad Patra, Pravin Salunke, Debajyoti Chatterjee1, R. K. Vasishta1 Departments of Neurosurgery, and 1Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India E‑mail: [email protected]
References 1. Ouyang T, Zhang N, Benjamin T, Wang L, Jiao J, Zhao Y, et al. Subependymal giant cell astrocytoma: Current concepts, management, and future directions. Childs Nerv Syst 2014;30:561‑70. 2. Telfeian AE, Judkins A, Younkin D, Pollock AN, Crino P. Subependymal giant cell astrocytoma with cranial and spinal metastases in a patient with tuberous sclerosis. Case report. J Neurosurg 2004;100 (5 Suppl Pediatrics):498‑500. 3. Ogiwara H, Morota N. Subependymal giant cell astrocytoma with intratumoral hemorrhage. J Neurosurg Pediatr 2013;11:469‑72. 4. Svajdler M Jr, Deák L, Rychlý B, Talarčík P, Fröhlichová L. Subependymal giant cell astrocytoma with atypical clinical and pathological features: A diagnostic pitfall. Cesk Patol 2013;49:76‑9. 5. Grajkowska W, Kotulska K, Jurkiewicz E, Roszkowski M, Daszkiewicz P, Jóźwiak S, et al. Subependymal giant cell astrocytomas with atypical histological features mimicking malignant gliomas. Folia Neuropathol 2011;49:39‑46.
nerves. Schwannomas arising from the oculomotor nerve are very rare, except with neurofibromatosis. Approximately 40 cases of oculomotor nerve schwannomas have been described in the literature, of which 12 cases were large (≥2.5cm)[1,2] tumors. This report presents a case of giant oculomotor nerve schwannoma. A 24‑year‑old female complained of progressive diplopia, ptosis of left eye for 2 years. These complaints were overlooked by family members. For the last six months, she had developed gradual progressive visual loss of left eye followed by right eye. She also used to have generalized headache, vomiting and features suggesting hypo‑function of pituitary gland. On examination, her visual acuity was figure counting at 1 meter distance in both the eyes with left oculomotor nerve palsy and bilateral optic atrophy. Magnetic resonance imaging (MRI) of brain revealed a large, enhancing mass (6.1 × 3.6 × 6.2 cm) with central necrosis involving sellar and suprasellar regions, extending into left middle cranial fossa [Figures 1 and 2]. Left pterional craniotomy and wide splitting of the Sylvian fissure for tumor access was carried out. A large encapsulated, white, firm, moderately vascular, multilobulated tumor was found with a necrotic yellowish central zone. Intratumoural decompression, followed by dissection of tumor in arachnoid plane carried out. Though the tumor was abutting internal carotid artery
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144458
Received: 13-10-2014 Review completed: 14-10-2014 Accepted: 15-10-2014
Figure 1: An axial T1- and T2-weighted MRI scan showing (T1-hypointense and T2-hyperintense) sellar mass with left parasellar extension
Giant oculomotor nerve schwannoma presenting as a sellar and suprasellar mass with parasellar extension Sir, Schwannomas account for 7% of all intracranial tumors and commonly arise from the vestibulocochlear and trigeminal 548
Figure 2: Coronal and sagittal gadolinium-enhanced contrast T1weighted MRI scan showing the said enhancing mass with central area of hypointensity. The lesion was compressing the optic chiasma with ipsilateral carotid encasement
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
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but arachnoid plain was well maintained, so dissecting out the tumor from carotid was easy. After substantial debulking of the mass, the third nerve appeared from the interpeduncular cistern as a bundle and ran straight into the base of the mass. Complete removal of the tumor was done [Figure 3]. Preservation of nerve was tried but could not be preserved and was sacrificed. Postoperatively, the patient developed complete third nerve paralysis on the left side. Histopathology and immunohistochemistry confirmed the diagnosis of schwannoma [Figure 4]. During one year follow‑up, her hormonal status had improved without radiological evidence of recurrence.
space where these slow‑growing tumors expand to a large size before they produce symptoms. Preserving function of the third nerve in these large tumors can be a challenge (whether complete or partial resections done), as confirmed in previous reports.[5,6]
Kovacs, [3] who in 1927, described an isolated oculomotor nerve schwannoma observed during an autopsy, was probably the first to report such a tumor. Celli et al [4] divided oculomotor cranial nerve schwannomas into three groups: (1) Cisternal, (2) cisternocavernous and (3) cavernous lesions. This classification was based on the preferred extension of these tumors. Our case belongs to the cisternal type. The explanation for this large tumor could be that the ventral cistern of the brainstem is a potential
References
Satya Bhusan Senapati, Sudhansu Sekhar Mishra, Srikanta Das, Deepak Kumar Parida Department of Neurosurgery, Shrirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India E‑mail: [email protected]
1. Saetia K, Larbcharoensub N, Wetchagama N.Oculomotor nerve schwannoma: A case report and review of the literature. J Med Assoc Thai 2011;94:1002‑7. 2. Prabhu SS, Bruner JM. Large oculomotor schwannoma presenting as a parasellar mass: A case report and literature review. Surg Neurol Int 2010;1:15. 3. Kovacs W. Ueber ein solitares neuinom des nervus oculomotorius. Zentralbl Allg Pathol 1927;40:518‑22. 4. Celli P, Ferrante L, Acqui M, Mastronardi L, Fortuna A, Palma L. Neurinoma of the third, fourth, and sixth cranial nerves: A survey and report of a new fourth nerve case. Surg Neurol 1992;38:216‑24. 5. Kachhara R, Nair S, Radhakrishnan VV. Oculomotor nerve neurinoma: Report of two cases. Acta Neurochir (Wien) 1998;140:1147‑51. 6. Mehta VS, Singh RV, Misra NK, Choudhary C. Schwannoma of the oculomotor nerve. Br J Neurosurg 1990;4:69‑72. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144459
a
b
Figure 3: Postoperative axial and coronal contrast CT scans showing a complete resection of the lesion
Received: 29-07-2014 Review completed: 03-10-2014 Accepted: 03-10-2014
Pilomyxoid astrocytoma in an elderly patient: A case report and review of literature Sir, Pilomyxoid astrocytomas (PMAs) are considered as the infantile variant of pilocytic astrocytoma (PA) with a more aggressive course. The occurrence of these tumours in the elderly population is very rare. We report a case of PMA of the thalamic region in a 62‑year‑old male. To the best of our knowledge, this is the third reported case in literature of PMA in an individual aged > 60 years. Figure 4: Histopathology showing compact Antoni A and loose Antoni B tissue, supporting schwannoma
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
Our patient presented with sudden onset of memory disturbances and behavioural alterations of 1‑week 549
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
In our case the tumor recurred very rapidly and the clinical course was almost similar to malignant tumors. In contrast to the traditional belief, our patient showed concordance between high‑grade histological features and the clinical outcome. So it is difficult to prognosticate these atypical SEGAs and the clinical course may vary in different cases. Utmost caution should be exercised in managing these patients. Those with aggressive course should probably be treated as other malignant gliomas.
Devi Prasad Patra, Pravin Salunke, Debajyoti Chatterjee1, R. K. Vasishta1 Departments of Neurosurgery, and 1Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India E‑mail: [email protected]
References 1. Ouyang T, Zhang N, Benjamin T, Wang L, Jiao J, Zhao Y, et al. Subependymal giant cell astrocytoma: Current concepts, management, and future directions. Childs Nerv Syst 2014;30:561‑70. 2. Telfeian AE, Judkins A, Younkin D, Pollock AN, Crino P. Subependymal giant cell astrocytoma with cranial and spinal metastases in a patient with tuberous sclerosis. Case report. J Neurosurg 2004;100 (5 Suppl Pediatrics):498‑500. 3. Ogiwara H, Morota N. Subependymal giant cell astrocytoma with intratumoral hemorrhage. J Neurosurg Pediatr 2013;11:469‑72. 4. Svajdler M Jr, Deák L, Rychlý B, Talarčík P, Fröhlichová L. Subependymal giant cell astrocytoma with atypical clinical and pathological features: A diagnostic pitfall. Cesk Patol 2013;49:76‑9. 5. Grajkowska W, Kotulska K, Jurkiewicz E, Roszkowski M, Daszkiewicz P, Jóźwiak S, et al. Subependymal giant cell astrocytomas with atypical histological features mimicking malignant gliomas. Folia Neuropathol 2011;49:39‑46.
nerves. Schwannomas arising from the oculomotor nerve are very rare, except with neurofibromatosis. Approximately 40 cases of oculomotor nerve schwannomas have been described in the literature, of which 12 cases were large (≥2.5cm)[1,2] tumors. This report presents a case of giant oculomotor nerve schwannoma. A 24‑year‑old female complained of progressive diplopia, ptosis of left eye for 2 years. These complaints were overlooked by family members. For the last six months, she had developed gradual progressive visual loss of left eye followed by right eye. She also used to have generalized headache, vomiting and features suggesting hypo‑function of pituitary gland. On examination, her visual acuity was figure counting at 1 meter distance in both the eyes with left oculomotor nerve palsy and bilateral optic atrophy. Magnetic resonance imaging (MRI) of brain revealed a large, enhancing mass (6.1 × 3.6 × 6.2 cm) with central necrosis involving sellar and suprasellar regions, extending into left middle cranial fossa [Figures 1 and 2]. Left pterional craniotomy and wide splitting of the Sylvian fissure for tumor access was carried out. A large encapsulated, white, firm, moderately vascular, multilobulated tumor was found with a necrotic yellowish central zone. Intratumoural decompression, followed by dissection of tumor in arachnoid plane carried out. Though the tumor was abutting internal carotid artery
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144458
Received: 13-10-2014 Review completed: 14-10-2014 Accepted: 15-10-2014
Figure 1: An axial T1- and T2-weighted MRI scan showing (T1-hypointense and T2-hyperintense) sellar mass with left parasellar extension
Giant oculomotor nerve schwannoma presenting as a sellar and suprasellar mass with parasellar extension Sir, Schwannomas account for 7% of all intracranial tumors and commonly arise from the vestibulocochlear and trigeminal 548
Figure 2: Coronal and sagittal gadolinium-enhanced contrast T1weighted MRI scan showing the said enhancing mass with central area of hypointensity. The lesion was compressing the optic chiasma with ipsilateral carotid encasement
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application fo journal Letters to Editor
but arachnoid plain was well maintained, so dissecting out the tumor from carotid was easy. After substantial debulking of the mass, the third nerve appeared from the interpeduncular cistern as a bundle and ran straight into the base of the mass. Complete removal of the tumor was done [Figure 3]. Preservation of nerve was tried but could not be preserved and was sacrificed. Postoperatively, the patient developed complete third nerve paralysis on the left side. Histopathology and immunohistochemistry confirmed the diagnosis of schwannoma [Figure 4]. During one year follow‑up, her hormonal status had improved without radiological evidence of recurrence.
space where these slow‑growing tumors expand to a large size before they produce symptoms. Preserving function of the third nerve in these large tumors can be a challenge (whether complete or partial resections done), as confirmed in previous reports.[5,6]
Kovacs, [3] who in 1927, described an isolated oculomotor nerve schwannoma observed during an autopsy, was probably the first to report such a tumor. Celli et al [4] divided oculomotor cranial nerve schwannomas into three groups: (1) Cisternal, (2) cisternocavernous and (3) cavernous lesions. This classification was based on the preferred extension of these tumors. Our case belongs to the cisternal type. The explanation for this large tumor could be that the ventral cistern of the brainstem is a potential
References
Satya Bhusan Senapati, Sudhansu Sekhar Mishra, Srikanta Das, Deepak Kumar Parida Department of Neurosurgery, Shrirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India E‑mail: [email protected]
1. Saetia K, Larbcharoensub N, Wetchagama N.Oculomotor nerve schwannoma: A case report and review of the literature. J Med Assoc Thai 2011;94:1002‑7. 2. Prabhu SS, Bruner JM. Large oculomotor schwannoma presenting as a parasellar mass: A case report and literature review. Surg Neurol Int 2010;1:15. 3. Kovacs W. Ueber ein solitares neuinom des nervus oculomotorius. Zentralbl Allg Pathol 1927;40:518‑22. 4. Celli P, Ferrante L, Acqui M, Mastronardi L, Fortuna A, Palma L. Neurinoma of the third, fourth, and sixth cranial nerves: A survey and report of a new fourth nerve case. Surg Neurol 1992;38:216‑24. 5. Kachhara R, Nair S, Radhakrishnan VV. Oculomotor nerve neurinoma: Report of two cases. Acta Neurochir (Wien) 1998;140:1147‑51. 6. Mehta VS, Singh RV, Misra NK, Choudhary C. Schwannoma of the oculomotor nerve. Br J Neurosurg 1990;4:69‑72. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144459
a
b
Figure 3: Postoperative axial and coronal contrast CT scans showing a complete resection of the lesion
Received: 29-07-2014 Review completed: 03-10-2014 Accepted: 03-10-2014
Pilomyxoid astrocytoma in an elderly patient: A case report and review of literature Sir, Pilomyxoid astrocytomas (PMAs) are considered as the infantile variant of pilocytic astrocytoma (PA) with a more aggressive course. The occurrence of these tumours in the elderly population is very rare. We report a case of PMA of the thalamic region in a 62‑year‑old male. To the best of our knowledge, this is the third reported case in literature of PMA in an individual aged > 60 years. Figure 4: Histopathology showing compact Antoni A and loose Antoni B tissue, supporting schwannoma
Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
Our patient presented with sudden onset of memory disturbances and behavioural alterations of 1‑week 549
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
