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.