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Cervical Vagal Schwannoma Causing Asymptomatic Internal Carotid Artery Compression
Case Report Cervical Vagal Schwannoma Causing Asymptomatic Internal Carotid Artery Compression Grigol Keshelava, and Zurab Robakidze, Tbilisi, Georgia
Background: Schwannoma originating from the cervical vagus nerve is a rare neoplasm. Vagal nerve schwannoma (VNS) usually occurs between the third and fifth decades of life. Methods: We operated one patient for cervical schwannoma causing internal carotid artery (ICA) compression. Results: The patient underwent en bloc excision via transcervical approach under general anesthesia. Pathological examination demonstrated the diagnosis of schwannoma. Conclusions: Our case shows that VNS can cause ICA compression and therefore brain ischemia.
Vagal nerve schwannoma (VNS) is a rare tumor usually reported to occur in patients between 30 and 50 years of age. The diagnosis can be difficult to make, and complete surgical excision is challenging due to the proximity of the vagus nerve fibers to the carotid artery.1 The most common symptom associated with VNS arising in the neck is hoarseness due to vocal cord palsy. Complete surgical excision is the gold standard for VNS.
CASE REPORT A 50-year-old male was referred to our hospital for a palpable tumor in the left side of the neck. Further investigation, including brain and neck computed tomography (CT) and ultrasound, demonstrated a tumor between left internal carotid artery (ICA)
Department of Vascular Surgery, Tbilisi Regional Hospital, Tbilisi, Georgia. Correspondence to: Grigol Keshelava, MD, PhD, Department of vascular surgery, Tbilisi Regional Hospital, Kavtaradze St. 23, Tbilisi, Georgia 0186; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e3 https://doi.org/10.1016/j.avsg.2019.09.021 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: July 31, 2019; manuscript accepted: September 1, 2019; published online: - - -
and internal jugular vein, compressed ICA (Fig. 1A). CT showed no stroke. The patient was operated under general anesthesia. The procedure was performed along the medial border of the left sternocleidomastoid muscle. The tumor was exposed between ICA and internal jugular vein, and excised en bloc. The inferior pole of the tumor appeared to be in continuity with the vagus nerve. Vagus nerve was maximally protected following intervention. After excision of the tumor, ICA returned to normal configuration. Postoperatively the patient had a weakly expressed hoarseness due to vocal cord paralysis, clinically improved following one month. Pathological examination confirmed the diagnosis of schwannoma demonstrating the spindle cells organized in small fascicles.
DISCUSSION Schwannoma is a benign nerve sheath tumor arising from Schwann cells, which normally surround the nerve. Approximately ranging between 25% and one-third of the cases, schwannomas are more frequently found in the eighth cranial nerve followed by the lower cranial nerves (IX, XI, XII) and the sympathetic chains.2,3 VNS is quite rare, 1.e1
1.e2 Case Report
Annals of Vascular Surgery
Fig. 1. (A) Preoperative CT shows that VNS displaces the internal jugular vein laterally and compressed ICA medially. (B) Excised VNS.
and until 2016, there were 133 reported cases in the English literature.4 Preoperative diagnosis of schwannoma is difficult because many VNSs do not present with neurological deficits, and several differential diagnosis may be considered, including paraganglioma, malignant lymphoma, branchial cleft cyst, metastatic cervical lymphadenopathy.5 Large schwannomas can produce dysphagic, dysphonic, or dyspnoic signs. When symptoms are present, hoarseness due to vocal cord palsy is the most common.6 In our case, VNS caused asymptomatic compression of ICA. A similar case was reported by Andreas et al.4 ICA compression in turn can cause brain ischemia.7 VNS typically presents as a low-growing asymptomatic mass, well circumscribed and encapsulated,8 having an enlargement of 2.5 to 3 mm per year.9 CT and MRI suggest the origin of the tumor relating to vascular displacement; usually VNS displaces the internal jugular vein laterally and ICA medially, while schwannoma of the sympathetic chain displaces both together without their separation.10,11
Treatment of VNS is complete surgical excision. Dissection of the tumor from the vagus with preservation of the neural pathway should be the primary aim of surgical treatment.6 Our case shows that VNS can cause ICA compression and therefore brain ischemia.
REFERENCES 1. Ramdas AA, Yao M, Natarajan S, et al. A rare case of vagus nerve schwannoma presenting as a neck mass. Am J Case Rep 2017;18:908e11. 2. Imperatori A, Dionigi G, De Monte L, et al. Cervico- mediastinal schwannoma of the vagus nerve: resection with intraoperative nerve monitoring. Update Surg 2011;63:59e61. 3. Nakano CG, Massarollo LC, Volpi EM, et al. Ancient schwannoma of the vagus nerve, resection with continuous monitoring of the inferior laryngeal nerve. Braz J Otorhinolaryngol 2008;74:316. 4. Andrea GD, Fama I, Morello R, et al. Cervical vagal schwannoma review of all reported cases and our reports. Int J Neurol Brain Disord 2016;3:28e38. 5. Colreavy MP, Lacy PD, Hughes J, et al. Head and neck schwannomas e a 10-year review. J Laryngol Otol 2000;114:119e24.
Volume
-, -
2019
6. Chiofalo MG, Longo F, Marone U, et al. Cervical vagal schwannoma. A case report. Acta Otorhinolaryngol 2009;29:33e5. 7. Keshelava G, Nachkepia M, Arabidze G, et al. Unusual positional compression of the internal carotid artery causes carotid thrombosis and cerebral ischemia. Ann Vasc Surg 2012;26:572. 8. Lahoti BK, Kaushal M, Garge S, et al. Extra vestibular schwannoma: a two year experience. Ind J Otolaryngol Head Neck Surg 2011;63:305e9.
Case Report
1.e3
9. Gibber MJ, Zevallos JP, Urken ML. Enucleation of vagal nerve schwannoma using intraoperative nerve monitoring. Laryngoscope 2012;122:790e2. 10. Cavallaro G, Pattaro G, Lorio O, et al. A literature review on surgery for cervical vagal schwannomas. World J Surg Oncol 2015;13:130. 11. Furukawa M, Furukawa MK, Katoh K, et al. Differentiation between schwannoma of the vagus nerve and schwannoma of the cervical sympathetic chain by imaging diagnosis. Laryngoscope 1996;106(12 pt.1):1548e52.
Background: Schwannoma originating from the cervical vagus nerve is a rare neoplasm. Vagal nerve schwannoma (VNS) usually occurs between the third and fifth decades of life. Methods: We operated one patient for cervical schwannoma causing internal carotid artery (ICA) compression. Results: The patient underwent en bloc excision via transcervical approach under general anesthesia. Pathological examination demonstrated the diagnosis of schwannoma. Conclusions: Our case shows that VNS can cause ICA compression and therefore brain ischemia.
Vagal nerve schwannoma (VNS) is a rare tumor usually reported to occur in patients between 30 and 50 years of age. The diagnosis can be difficult to make, and complete surgical excision is challenging due to the proximity of the vagus nerve fibers to the carotid artery.1 The most common symptom associated with VNS arising in the neck is hoarseness due to vocal cord palsy. Complete surgical excision is the gold standard for VNS.
CASE REPORT A 50-year-old male was referred to our hospital for a palpable tumor in the left side of the neck. Further investigation, including brain and neck computed tomography (CT) and ultrasound, demonstrated a tumor between left internal carotid artery (ICA)
Department of Vascular Surgery, Tbilisi Regional Hospital, Tbilisi, Georgia. Correspondence to: Grigol Keshelava, MD, PhD, Department of vascular surgery, Tbilisi Regional Hospital, Kavtaradze St. 23, Tbilisi, Georgia 0186; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e3 https://doi.org/10.1016/j.avsg.2019.09.021 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: July 31, 2019; manuscript accepted: September 1, 2019; published online: - - -
and internal jugular vein, compressed ICA (Fig. 1A). CT showed no stroke. The patient was operated under general anesthesia. The procedure was performed along the medial border of the left sternocleidomastoid muscle. The tumor was exposed between ICA and internal jugular vein, and excised en bloc. The inferior pole of the tumor appeared to be in continuity with the vagus nerve. Vagus nerve was maximally protected following intervention. After excision of the tumor, ICA returned to normal configuration. Postoperatively the patient had a weakly expressed hoarseness due to vocal cord paralysis, clinically improved following one month. Pathological examination confirmed the diagnosis of schwannoma demonstrating the spindle cells organized in small fascicles.
DISCUSSION Schwannoma is a benign nerve sheath tumor arising from Schwann cells, which normally surround the nerve. Approximately ranging between 25% and one-third of the cases, schwannomas are more frequently found in the eighth cranial nerve followed by the lower cranial nerves (IX, XI, XII) and the sympathetic chains.2,3 VNS is quite rare, 1.e1
1.e2 Case Report
Annals of Vascular Surgery
Fig. 1. (A) Preoperative CT shows that VNS displaces the internal jugular vein laterally and compressed ICA medially. (B) Excised VNS.
and until 2016, there were 133 reported cases in the English literature.4 Preoperative diagnosis of schwannoma is difficult because many VNSs do not present with neurological deficits, and several differential diagnosis may be considered, including paraganglioma, malignant lymphoma, branchial cleft cyst, metastatic cervical lymphadenopathy.5 Large schwannomas can produce dysphagic, dysphonic, or dyspnoic signs. When symptoms are present, hoarseness due to vocal cord palsy is the most common.6 In our case, VNS caused asymptomatic compression of ICA. A similar case was reported by Andreas et al.4 ICA compression in turn can cause brain ischemia.7 VNS typically presents as a low-growing asymptomatic mass, well circumscribed and encapsulated,8 having an enlargement of 2.5 to 3 mm per year.9 CT and MRI suggest the origin of the tumor relating to vascular displacement; usually VNS displaces the internal jugular vein laterally and ICA medially, while schwannoma of the sympathetic chain displaces both together without their separation.10,11
Treatment of VNS is complete surgical excision. Dissection of the tumor from the vagus with preservation of the neural pathway should be the primary aim of surgical treatment.6 Our case shows that VNS can cause ICA compression and therefore brain ischemia.
REFERENCES 1. Ramdas AA, Yao M, Natarajan S, et al. A rare case of vagus nerve schwannoma presenting as a neck mass. Am J Case Rep 2017;18:908e11. 2. Imperatori A, Dionigi G, De Monte L, et al. Cervico- mediastinal schwannoma of the vagus nerve: resection with intraoperative nerve monitoring. Update Surg 2011;63:59e61. 3. Nakano CG, Massarollo LC, Volpi EM, et al. Ancient schwannoma of the vagus nerve, resection with continuous monitoring of the inferior laryngeal nerve. Braz J Otorhinolaryngol 2008;74:316. 4. Andrea GD, Fama I, Morello R, et al. Cervical vagal schwannoma review of all reported cases and our reports. Int J Neurol Brain Disord 2016;3:28e38. 5. Colreavy MP, Lacy PD, Hughes J, et al. Head and neck schwannomas e a 10-year review. J Laryngol Otol 2000;114:119e24.
Volume
-, -
2019
6. Chiofalo MG, Longo F, Marone U, et al. Cervical vagal schwannoma. A case report. Acta Otorhinolaryngol 2009;29:33e5. 7. Keshelava G, Nachkepia M, Arabidze G, et al. Unusual positional compression of the internal carotid artery causes carotid thrombosis and cerebral ischemia. Ann Vasc Surg 2012;26:572. 8. Lahoti BK, Kaushal M, Garge S, et al. Extra vestibular schwannoma: a two year experience. Ind J Otolaryngol Head Neck Surg 2011;63:305e9.
Case Report
1.e3
9. Gibber MJ, Zevallos JP, Urken ML. Enucleation of vagal nerve schwannoma using intraoperative nerve monitoring. Laryngoscope 2012;122:790e2. 10. Cavallaro G, Pattaro G, Lorio O, et al. A literature review on surgery for cervical vagal schwannomas. World J Surg Oncol 2015;13:130. 11. Furukawa M, Furukawa MK, Katoh K, et al. Differentiation between schwannoma of the vagus nerve and schwannoma of the cervical sympathetic chain by imaging diagnosis. Laryngoscope 1996;106(12 pt.1):1548e52.