Neurofibroma Right Trigemenal Nerve

Contributor:

Dr. Krishna Kumar

Consultants:

Dr. Fred Gentili
Dr. Michael Schwartz
Dr. May Tsao
Dr. Chris Ekong

Case 1

Age: 53

Sex: Male

History: - Weight loss x 2 months
- Numbness R half of face x 2 months

Examination:

Alert. Orientated. Right LMN facial weakness. Decreased R Corneal reflex. Numb R half of face. Could not open mouth fully. Weak right masseler muscles. Right Hyperreflexia. Right extensor plantae response.

Other tests:

CSF showed WCB 6 (mostly lymphocytes). Glucose 4.5 mg/L Protein 0.64 g/L.

Differential Diagnosis:

1. MS

2. Right Trigemenal Neurofibroma

Treatment:

? Surgery

? Radiosurgery

? Surgery + Radiosurgery

To Dr. F. Gentili, Dr. M. Schwartz, Dr. M. Tsao and Dr. Renn Holness - September 4, 2001

This 53-year-old man presented to Kris Kumar with weight loss and numbness of the right half of the face over a two month period. In the last few days he has evidently been developing diplopia from right sixth nerve palsy. He also has a past history of MS. The MRI scan confirms the MS as well as the mass that is suggestive of a neurofibroma of the trigeminal nerve on the right side.

Dr. F. Gentili, Neurosurgeon, Toronto

Dear Chris:

Thank you for giving me the opportunity to comment on the case below.

Although the progression of symptoms is somewhat atypical, the lesion most

likely does represent a trigeminal schwannoma. I assume that the rt facial

weakness and pyramidal findings are related to his MS as the degree of

brainstem compression is minimal. Likewise it is not common to get a 6th CNP with this lesion.

I think that treatment is definitely indicated. I would recommend a surgical

approach both for definitive diagnosis and for removal. I think that total

removal is feasible in that Trigeminal schwannomas, unlike the meningiomas

in this region compress and usually do not invade the cavernous sinus. Both

the middle and posterior fossa components can be readily accessed via a OBZ, transsylvian approach. The patient is at definite risk for a trigeminal

deficit (which he apparently he already has) especially of the division of

origin. However usually some trigeminal function can be spared.

There would be some concern with an already present rt 7th and trigeminal

deficit of corneal ulceration so a prophylactic tarrshorraphy should be

considered. I also assume that despite his MS his overall status is stable

and that he is a surgical candidate. He should be alerted to the possibility

of an exacerbation of his MS that can occur with any intervention.

I would be happy to discuss him with you further.

Regards,

Fred

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