Surgical Management of PICA Aneurysm and Incidental Facial Nerve Schwannoma: Case Report

ABSTRACT

We report a patient with a posterior inferior cerebellar artery (PICA) aneurysm and an incidental facial nerve schwannoma at the cerebellopontine angle (CPA). A 46-year-old woman presented with the sudden onset of a severe headache, nausea, and vomiting. She had no other abnormal neurological symptoms and signs. Computed tomography (CT) showed hemorrhage in the fourth ventricle. Cerebral angiography demonstrated an aneurysm arising from the tonsillomedullary segment of the left PICA. A facial nerve schwannoma was incidentally found as the aneurysm was being clipped. The aneurysm was clipped via a left transcondylar approach. Subsequently, the schwannoma (2 × 3 × 2 mm) was resected from the facial nerve fascicles, and the facial nerve was preserved. Postoperatively, the patient developed mild to moderate dysfunction of the facial nerve (House-Brackmann grade III [H-B III]) but her hearing was intact. Both a facial nerve schwannoma involving the CPA and an aneurysm involving the PICA can be managed through the transcondylar approach. An asymptomatic facial nerve schwannoma can be resected safely with minimal facial nerve dysfunction.

KEYWORDS

Facial nerve schwannoma - PICA - aneurysm - transcondylar approach

REFERENCES

• 1 Hudgins R J, Day A L, Quisling R G, Rhoton Jr A L, Sypert G W, Garcia-Bengochea F. Aneurysms of the posterior inferior cerebellar artery. A clinical and anatomical analysis.  J Neurosurg. 1983;  58 381-387
• 2 Yamamoto I, Tsugane R, Ohya M, Sato O, Ogura K, Hara M. Peripheral aneurysms of the posterior inferior cerebellar artery.  Neurosurgery. 1984;  15 839-845
• 3 Lipkin A F, Coker N J, Jenkins H A, Alford B R. Intracranial and intratemporal facial neuroma.  Otolaryngol Head Neck Surg. 1987;  96 71-79
• 4 Pulec J L. Facial nerve neuroma.  Ear Nose Throat J. 1994;  73 721-752
• 5 Symon L, Cheesman A D, Kawauchi M, Bordi L. Neuromas of the facial nerve.  Br J Neurosurg. 1993;  7 13-22
• 6 Sherman J D, Dagnew E, Pensak M L, von Loveren H R, Tew J M. Facial nerve neuromas: report of 10 cases and review of the literature.  Neurosurgery. 2002;  50 450-456
• 7 Nadeau D P, Sataloff R T. Facial preservation surgery for facial nerve neuromas involving the posterior cranial fossa.  Otol Neurotol. 2003;  24 317-325
• 8 Bertalanffy H, Sure U. Surgical approaches to the jugular formen. In: Robertson JT, Coakham HB, Robertson JH Cranial Base Surgery. London, UK; Churchill Livingstone 2000: 237-258
• 9 Lewis S B, Chang D J, Peace D A, Lafrentz P J, Day A L. Distal posterior inferior cerebellar artery aneurysms: clinical features and management.  J Neurosurg. 2002;  97 756-766
• 10 Kanou Y, Arita K, Kurisu K et al.. Dissecting aneurysm of the peripheral posterior inferior cerebellar artery.  Acta Neurochir (Wien). 2000;  142 1151-1156
• 11 Nabika S, Oki S, Migita K, Isobe N, Okazaki T, Watanabe Y. A ruptured distal posterior inferior cerebellar aneurysm. Our case and review of the literature.  Hiroshima J Med Sci. 2002;  51 93-96
• 12 Abrahams J M, Arle J E, Hurst R W, Flamm E S. Extracranial aneurysms of the posterior inferior cerebellar artery.  Cerebrovasc Dis. 2000;  10 466-470
• 13 Horiuchi T, Tanaka Y, Hongo K, Nitta J, Kusano Y, Kobayashi S. Characteristics of distal posteroinferior cerebellar artery aneurysms.  Neurosurgery. 2003;  53 589-595
• 14 Kallmes D F, Lanzino G, Dix J E et al.. Patterns of hemorrhage with ruptured posterior inferior cerebellar artery aneurysms: CT findings in 44 cases.  AJR Am J Roentgenol. 1997;  169 1169-1171
• 15 Tanaka A, Kimura M, Yoshinaga S, Tomonaga M. Extracranial aneurysm of the posterior inferior cerebellar artery: case report.  Neurosurgery. 1993;  33 742-745
• 16 Abe T, Kojima K, Singer R J et al.. Endovascular management of an aneurysm arising from posterior inferior cerebellar artery originated at the level of C2.  Radiat Med. 1998;  16 141-143
• 17 Barr J D, Lemley T J. Endovascular arterial occlusion accomplished using microcoils deployed with and without proximal flow arrest: results in 19 patients.  AJNR Am J Neuroradiol. 1999;  20 1452-1456
• 18 Cloft H J, Kallmes D F, Jensen M E, Lanzino G, Dion J E. Endovascular treatment of ruptured, peripheral cerebral aneurysms: parent artery occlusion with short Guglielmi detachable coils.  AJNR Am J Neuroradiol. 1999;  20 308-310
• 19 Fagan P A, Misra S N, Doust B. Facial neuroma of the cerebellopontine angle and the internal auditory canal.  Laryngoscope. 1993;  103 442-446
• 20 Matsushima T, Matsukado K, Natori Y, Inamura T, Hitotsumatsu T, Fukui M. Surgery on a saccular vertebral artery-posterior inferior cerebellar artery aneurysm via the transcondylar fossa (supracondylar transjugular tubercle) approach or the transcondylar approach: surgical results and indications for using two different lateral skull base approaches.  J Neurosurg. 2001;  95 268-274
• 21 Mukonoweshuro W, Laitt R D, Hughes D G. Endovascular treatment of PICA aneurysms.  Neuroradiology. 2003;  45 188-192
• 22 Tikkakoski T, Leinonen S, Siniluoto T, Koivukangas J. Isolated dissecting aneurysm of the left posterior inferior cerebellar artery: endovascular treatment with a Guglielmi detachable coil.  AJNR Am J Neuroradiol. 1997;  18 936-938
• 23 Todaka T, Hamada J, Yano S, Kai Y, Morioka M, Ushio Y. Successful clipping of a distal posterior inferior cerebellar artery aneurysms located on the anterior surface of the medulla oblongata-case report.  Neurol Med Chir (Tokyo). 2002;  42 158-161
• 24 Schmidt C. Neuron des nervus facialis.  Schweiz Med Wochenschr. 1931;  61 190-191
• 25 Sataloff R T, Frattali M A, Myers D L. Intracranial facial neuromas: total tumor removal with facial nerve preservation: a new surgical technique.  Ear Nose Throat J. 1995;  74 244-256
• 26 Kubota Y, Kawamata T, Kubo O, Kasuya H, Muragaki Y, Hori T. Large facial nerve schwannomas without facial palsy: case reports and review of the literature.  Neurosurg Rev. 2005;  28 234-238
• 27 Furuta S, Hatakeyama T, Zenke K, Nagato S. Huge facial schwannoma extending into the middle cranial fossa and cerebellopontine angle without facial nerve palsy-case report.  Neurol Med Chir (Tokyo). 2000;  40 528-531
• 28 Latack J T, Gabrielsen T O, Knake J E et al.. Facial nerve neuromas: radiologic evaluation.  Radiology. 1983;  149 731-739
• 29 Eckard D A, O'Boynick P L, McPherson C M et al.. Coil occlusion of the parent artery for treatment of symptomatic peripheral intracranial aneurysms.  AJNR Am J Neuroradiol. 2000;  21 137-142
• 30 Fenton J E, Chin R Y, Tonkin J P, Fagan P A. Transtemporal facial nerve schwannoma without facial nerve paralysis.  J Laryngol Otol. 2001;  115 559-560
• 31 Kudo A, Suzuki M, Kubo N, Kuroda K, Ogawa A, Iwasaki Y. Schwannoma arising from the intermediate nerve and manifesting as hemifacial spasm. Case report.  J Neurosurg. 1996;  84 277-279
• 32 Kwiek S J, Bierzynska-Macyszyn G, Luszawski J et al.. Correlation of facial nerve paresis and histopathological type of vestibular schwannoma.  Folia Neuropathol. 2003;  41 237-239
• 33 Yamaki T, Morimoto S, Ohtaki M et al.. Intracranial facial nerve neuroma: surgical strategy of tumor removal and functional reconstruction.  Surg Neurol. 1998;  45 538-546
• 34 Kim J, Bhattacharjee M, Amedee R G. Facial nerve schwannoma.  Ann Otol Rhinol Laryngol. 2003;  112 185-187
• 35 Liu R, Fagan P. Facial nerve schwannoma. Surgical excision versus conservative management.  Ann Otol Rhinol Laryngol. 2001;  110 1025-1029
• 36 Angeli S I, Brackmann D E. Is surgical excision of facial nerve always indicated?.  Otolaryngol Head Neck Surg. 1997;  117 144-147
• 37 Ulku C H, Uyar Y, Acar O, Yaman H, Avunduk M C. Facial nerve schwannomas: a report of four cases and a review of the literature.  Am J Otolaryngol. 2004;  25 426-431