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Spinal Accessory Nerve Meningioma at the Foramen Magnum with Medullar Compression: A Case Report and Literature Review
Case Report
Spinal Accessory Nerve Meningioma at the Foramen Magnum with Medullar Compression: A Case Report and Literature Review Masanao Mohri1, Jun Yamano1, Katsuhiko Saito2, Mitsutoshi Nakada3
Key words Foramen magnum - Meningioma - Spinal accessory nerve -
Abbreviations and Acronyms MRI: Magnetic resonance imaging From the Departments of 1Neurosurgery and 2Pathology, Toyama City Hospital, Toyama; and 3Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan To whom correspondence should be addressed: Masanao Mohri, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 128:158-161. https://doi.org/10.1016/j.wneu.2019.05.013 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
- BACKGROUND:
Meningiomas that arise from the cranial nerve are rare. We present a case with an intradural extramedullary tumor at the foramen magnum originating from the spinal accessory nerve.
- CASE
DESCRIPTION: The patient was a 69-year-old woman with dizziness and pain in the bilateral shoulder for 2 years. Neurologic examination revealed spinal accessory nerve palsy (difficult in raising the shoulder, deficit of 3/5) on the left side without further deficits. Magnetic resonance imaging showed medullar compression because of a left intradural extramedullary foramen magnum lesion dorsolateral to the medulla. Surgical exposure via a midline suboccipital approach with C1 laminectomy revealed that the lesion arises from the left accessory nerve without dural attachment. The tumor was resected without injury to the spinal accessory nerve, and histologic examination revealed that it was a meningothelial meningioma. The spinal accessory nerve palsy improved to 4 of 5 after 3 months after surgery.
- CONCLUSIONS:
To our knowledge, this is the first report of an accessory nerve meningioma at the foramen magnum in which the spinal accessory nerve palsy appeared before operation and improved after tumor resection.
INTRODUCTION Most benign extramedullary intradural tumors at the foramen magnum are either a meningioma or a schwannoma.1 Although meningeal tumors arise from
the dura lining, cervical spinal sheath tumors from Schwann
posterior fossa, or upper canal, peripheral nerve are known to originate cells of the cranial or
Figure 1. Preoperative images: axial (A) and coronal (B) T1-weighted magnetic resonance imaging with gadolinium showing the homogeneously well-enhanced intradural extramedullary mass (arrow)
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cervical nerves. Optic nerve sheath meningiomas are well described, but meningiomas originating from other cranial nerves are exceedingly rare.2,3 In
at the foramen magnum. The medulla (arrowhead) was compressed by the mass at the foramen magnum level.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.013
CASE REPORT MASANAO MOHRI ET AL.
SPINAL ACCESSORY NERVE MENINGIOMA
Figure 2. Intraoperative photographs. (A) Preremoval photograph showing the tumor occupying the foramen magnum with medullar compression. The spinal accessory nerve was incorporated into the tumor (arrows). (B)
this report, we present the clinical, radiologic, operative, and pathologic features of a patient who had a medullar compression tumor originating from the spinal accessory nerve at the foramen magnum. CASE REPORT History The patient, a 69-year-old right-handed woman, presented with symptoms of dizziness and pain in the bilateral shoulder for 2 years. Neurologic examination revealed incomplete spinal accessory nerve palsy (difficult in raising the shoulder, deficit of 3/5) on the left side without further deficits. Image Examination Magnetic resonance imaging (MRI) revealed an intradural extramedullary
Postremoval photograph revealing the preserved left spinal accessory nerve (arrows). The tumor was located where the left spinal accessory nerve crossed the left vertebral artery (arrowhead). M, medullar; T, tumor.
mass at the left foramen magnum that measured 2.3 2.2 2.2 cm and appeared as an isointense signal on the T1-weighted images and as a slightly high-signal intensity on the T2-weighted images. Gadolinium administration significantly enhanced the signal (Figure 1). Three-dimensional computed tomography angiography was performed to rule out vascular malformation. No dural tail sign was present. These features suggested a diagnosis of spinal accessory nerve schwannoma.
of the left spinal accessory nerve (Figure 2A). The tumor was not attached to the dura mater. These features further supported the hypothesis of a spinal accessory schwannoma. Intraoperative histologic examination confirmed that the tumor was a meningioma. Sharp dissection of tumor margin and complete resection were performed without injury to the spinal accessory nerve (Figure 2B). The wound was closed without drainage, and duraplasty was performed to close the dura.
Surgical Procedure The operation was performed with the patient in the prone position. A midline suboccipital craniotomy and C1 laminectomy was made, and the foramen magnum was opened. Arachnoids were dissected to mobilize the tumor, which originated from the superficial tissue layer
Histologic Examination Cells with round to oval, and pale nuclei were observed; the meningothelial cells exhibited solid lobules with ill-defined cell membranes and contained whorls and psammoma bodies (Figure 3A). The final diagnosis for this tumor was made as meningothelial meningioma that was positive for epithelial membrane antigen (Figure 3B). Postoperative Course The patient was discharged after an uneventful postoperative course. Postoperative neurologic examination 3 months after the operation revealed that the spinal accessory nerve palsy had improved to 4 of 5. MRI revealed complete tumor resection (Figure 4).
Figure 3. Photomicrograph of an excised specimen obtained during the operation. (A) Solid lobules of meningothelial cells often with ill-defined cell membranes are shown. Some cells show whorl formations (arrowheads) and psammoma bodies (arrows). Hematoxylin and eosin staining. (B) Immunohistochemical staining shows tumor cells are strongly positive for epithelial membrane antigen. Scale bar, 133 mm.
WORLD NEUROSURGERY 128: 158-161, AUGUST 2019
DISCUSSION The neurologic features that the left spinal accessory nerve palsy exhibited and the radiologic features with enhanced
www.journals.elsevier.com/world-neurosurgery
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CASE REPORT MASANAO MOHRI ET AL.
SPINAL ACCESSORY NERVE MENINGIOMA
Figure 4. Postoperative images: axial (A) and coronal (B) T1-weighted magnetic resonance imaging with gadolinium showing complete
intradural extramedullary tumor and no dural tail sign were consistent with spinal accessory schwannoma.4 Intraoperative observation confirmed that the tumor originated from the spinal accessory nerve and had no dural attachment. Histologic examination, however, confirmed that the tumor was a meningothelial meningioma. Meningiomas generally arise from dural-based arachnoid cap cells, but they can originate in any location where these cells exist. However, excluding optic nerve sheath meningioma, there is a paucity in the literature regarding meningiomas of the other cranial2,3 and spinal5,6 nerves present in the dura. The other cranial nerve meningiomas are hypothesized to occur because of a number of mechanisms.3 They originate
removal of the mass. The medulla (arrowhead) was no longer compressed.
from the ectopic arachnoid cap cells within the nerve sheath and the perineural cells of the nerve. We identified only 3 other cases of surgical resection of spinal accessory nerve meningiomas reported in the literature (Table 1).7-9 Only one of these reports was symptomatic because of spinal accessory nerve involvement, and this report revealed that the spinal accessory nerve had proximally enlarged and entered directly into the tumor mass, and consequently the nerve was sacrificed to allow radical resection.8 In the other 2 reports, the size of the tumor was small, there was no spinal nerve palsy before the operation, and the tumor was resected without injury to the nerve.7,9 In our case, spinal accessory nerve palsy appeared but the
tumor was resected without injury to the nerve, and the spinal nerve palsy improved after the operation. To our knowledge, this is the first case report on a spinal accessory nerve meningioma in which the spinal accessory nerve palsy appeared before operation and the nerve palsy improved after tumor resection. CONCLUSIONS There is a possibility of occurrence of a spinal accessory meningioma in the intradural extramedullary tumor at the foramen magnum. Additionally, even if spinal accessory nerve palsy appears, spinal accessory nerve recovery can be expected if the tumor is resected without injury to the nerve.
Table 1. Clinical Summary of 4 Cases of Spinal Accessory Nerve Meningioma Case Number
Study
Age (years)/ Sex
SAN Palsy Preoperative
SAN Palsy Postoperative
1
Thome et al., 20039
61/F
Spinal ataxia, L motor impairment
2
Tatagiba et al., 20058
35/M
R shoulder and neck pain
þ
þ
R
NR
NR
3
Liechty et al., 20077
9/M
None
R
1.5
Total
4
Present case
69/F
Dizziness, bilateral shoulder pain
þ
L
2.3
Total
Symptom
Side
Size (cm) Removal
Bilateral R: 0.3, L: 1.3
Total
SAN, spinal accessory nerve; F, female; L, left; , negative; R, right; M, male; þ, positive; NR, not reported.
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WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.013
CASE REPORT MASANAO MOHRI ET AL.
ACKNOWLEDGMENTS The authors thank Editage (www.editage. jp) for English language editing. REFERENCES 1. Meyer FB, Ebersold MJ, Reese DF. Benign tumors of the foramen magnum. J Neurosurg. 1984;61: 136-142. 2. Hart AJ, Allibone J, Casey AT, Thomas DG. Malignant meningioma of the oculomotor nerve without dural attachment. Case report and review of the literature. J Neurosurg. 1998;88:1104-1106. 3. Fujimoto Y, Kato A, Taniguchi M, Maruno M, Yoshimine T. Meningioma arising from the trigeminal nerve: a case report and literature review. J Neurooncol. 2004;68:185-187. 4. Kurokawa R, Tabuse M, Yoshida K, Kawase T. Spinal accessory schwannoma mimicking a tumor
SPINAL ACCESSORY NERVE MENINGIOMA
of the fourth ventricle: case report. Neurosurgery. 2004;54:510-514 [discussion: 514]. 5. Ng TH, Chan KH, Mann KS, Fung CF. Spinal meningioma arising from a lumbar nerve root. Case report. J Neurosurg. 1989;70:646-648. 6. Missori P, Palmarini V, Elefante MG, Scapeccia M, Domenicucci M, Paolini S. Intradural angiomatous meningioma arising from a thoracic nerve root. Surg Neurol Int. 2017;8:187. 7. Liechty P, Tubbs RS, Loukas M, et al. Spinal accessory nerve meningioma in a paediatric patient: case report. Folia Neuropathol. 2007;45:23-25.
9. Thome C, Grobholz R, Boschert J, Schmiedek P. Bilateral meningiomatous lesions of the spinal accessory nerves. Acta Neurochir (Wien). 2003;145: 309-313 [discussion: 313].
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 6 April 2019; accepted 2 May 2019 Citation: World Neurosurg. (2019) 128:158-161. https://doi.org/10.1016/j.wneu.2019.05.013 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com
8. Tatagiba M, Koerbel A, Bornemann A, Freudenstein D. Meningioma of the accessory nerve extending from the jugular foramen into the parapharyngeal space. Acta Neurochir (Wien). 2005; 147:909-910.
WORLD NEUROSURGERY 128: 158-161, AUGUST 2019
1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
161
Spinal Accessory Nerve Meningioma at the Foramen Magnum with Medullar Compression: A Case Report and Literature Review Masanao Mohri1, Jun Yamano1, Katsuhiko Saito2, Mitsutoshi Nakada3
Key words Foramen magnum - Meningioma - Spinal accessory nerve -
Abbreviations and Acronyms MRI: Magnetic resonance imaging From the Departments of 1Neurosurgery and 2Pathology, Toyama City Hospital, Toyama; and 3Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan To whom correspondence should be addressed: Masanao Mohri, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 128:158-161. https://doi.org/10.1016/j.wneu.2019.05.013 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
- BACKGROUND:
Meningiomas that arise from the cranial nerve are rare. We present a case with an intradural extramedullary tumor at the foramen magnum originating from the spinal accessory nerve.
- CASE
DESCRIPTION: The patient was a 69-year-old woman with dizziness and pain in the bilateral shoulder for 2 years. Neurologic examination revealed spinal accessory nerve palsy (difficult in raising the shoulder, deficit of 3/5) on the left side without further deficits. Magnetic resonance imaging showed medullar compression because of a left intradural extramedullary foramen magnum lesion dorsolateral to the medulla. Surgical exposure via a midline suboccipital approach with C1 laminectomy revealed that the lesion arises from the left accessory nerve without dural attachment. The tumor was resected without injury to the spinal accessory nerve, and histologic examination revealed that it was a meningothelial meningioma. The spinal accessory nerve palsy improved to 4 of 5 after 3 months after surgery.
- CONCLUSIONS:
To our knowledge, this is the first report of an accessory nerve meningioma at the foramen magnum in which the spinal accessory nerve palsy appeared before operation and improved after tumor resection.
INTRODUCTION Most benign extramedullary intradural tumors at the foramen magnum are either a meningioma or a schwannoma.1 Although meningeal tumors arise from
the dura lining, cervical spinal sheath tumors from Schwann
posterior fossa, or upper canal, peripheral nerve are known to originate cells of the cranial or
Figure 1. Preoperative images: axial (A) and coronal (B) T1-weighted magnetic resonance imaging with gadolinium showing the homogeneously well-enhanced intradural extramedullary mass (arrow)
158
www.SCIENCEDIRECT.com
cervical nerves. Optic nerve sheath meningiomas are well described, but meningiomas originating from other cranial nerves are exceedingly rare.2,3 In
at the foramen magnum. The medulla (arrowhead) was compressed by the mass at the foramen magnum level.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.013
CASE REPORT MASANAO MOHRI ET AL.
SPINAL ACCESSORY NERVE MENINGIOMA
Figure 2. Intraoperative photographs. (A) Preremoval photograph showing the tumor occupying the foramen magnum with medullar compression. The spinal accessory nerve was incorporated into the tumor (arrows). (B)
this report, we present the clinical, radiologic, operative, and pathologic features of a patient who had a medullar compression tumor originating from the spinal accessory nerve at the foramen magnum. CASE REPORT History The patient, a 69-year-old right-handed woman, presented with symptoms of dizziness and pain in the bilateral shoulder for 2 years. Neurologic examination revealed incomplete spinal accessory nerve palsy (difficult in raising the shoulder, deficit of 3/5) on the left side without further deficits. Image Examination Magnetic resonance imaging (MRI) revealed an intradural extramedullary
Postremoval photograph revealing the preserved left spinal accessory nerve (arrows). The tumor was located where the left spinal accessory nerve crossed the left vertebral artery (arrowhead). M, medullar; T, tumor.
mass at the left foramen magnum that measured 2.3 2.2 2.2 cm and appeared as an isointense signal on the T1-weighted images and as a slightly high-signal intensity on the T2-weighted images. Gadolinium administration significantly enhanced the signal (Figure 1). Three-dimensional computed tomography angiography was performed to rule out vascular malformation. No dural tail sign was present. These features suggested a diagnosis of spinal accessory nerve schwannoma.
of the left spinal accessory nerve (Figure 2A). The tumor was not attached to the dura mater. These features further supported the hypothesis of a spinal accessory schwannoma. Intraoperative histologic examination confirmed that the tumor was a meningioma. Sharp dissection of tumor margin and complete resection were performed without injury to the spinal accessory nerve (Figure 2B). The wound was closed without drainage, and duraplasty was performed to close the dura.
Surgical Procedure The operation was performed with the patient in the prone position. A midline suboccipital craniotomy and C1 laminectomy was made, and the foramen magnum was opened. Arachnoids were dissected to mobilize the tumor, which originated from the superficial tissue layer
Histologic Examination Cells with round to oval, and pale nuclei were observed; the meningothelial cells exhibited solid lobules with ill-defined cell membranes and contained whorls and psammoma bodies (Figure 3A). The final diagnosis for this tumor was made as meningothelial meningioma that was positive for epithelial membrane antigen (Figure 3B). Postoperative Course The patient was discharged after an uneventful postoperative course. Postoperative neurologic examination 3 months after the operation revealed that the spinal accessory nerve palsy had improved to 4 of 5. MRI revealed complete tumor resection (Figure 4).
Figure 3. Photomicrograph of an excised specimen obtained during the operation. (A) Solid lobules of meningothelial cells often with ill-defined cell membranes are shown. Some cells show whorl formations (arrowheads) and psammoma bodies (arrows). Hematoxylin and eosin staining. (B) Immunohistochemical staining shows tumor cells are strongly positive for epithelial membrane antigen. Scale bar, 133 mm.
WORLD NEUROSURGERY 128: 158-161, AUGUST 2019
DISCUSSION The neurologic features that the left spinal accessory nerve palsy exhibited and the radiologic features with enhanced
www.journals.elsevier.com/world-neurosurgery
159
CASE REPORT MASANAO MOHRI ET AL.
SPINAL ACCESSORY NERVE MENINGIOMA
Figure 4. Postoperative images: axial (A) and coronal (B) T1-weighted magnetic resonance imaging with gadolinium showing complete
intradural extramedullary tumor and no dural tail sign were consistent with spinal accessory schwannoma.4 Intraoperative observation confirmed that the tumor originated from the spinal accessory nerve and had no dural attachment. Histologic examination, however, confirmed that the tumor was a meningothelial meningioma. Meningiomas generally arise from dural-based arachnoid cap cells, but they can originate in any location where these cells exist. However, excluding optic nerve sheath meningioma, there is a paucity in the literature regarding meningiomas of the other cranial2,3 and spinal5,6 nerves present in the dura. The other cranial nerve meningiomas are hypothesized to occur because of a number of mechanisms.3 They originate
removal of the mass. The medulla (arrowhead) was no longer compressed.
from the ectopic arachnoid cap cells within the nerve sheath and the perineural cells of the nerve. We identified only 3 other cases of surgical resection of spinal accessory nerve meningiomas reported in the literature (Table 1).7-9 Only one of these reports was symptomatic because of spinal accessory nerve involvement, and this report revealed that the spinal accessory nerve had proximally enlarged and entered directly into the tumor mass, and consequently the nerve was sacrificed to allow radical resection.8 In the other 2 reports, the size of the tumor was small, there was no spinal nerve palsy before the operation, and the tumor was resected without injury to the nerve.7,9 In our case, spinal accessory nerve palsy appeared but the
tumor was resected without injury to the nerve, and the spinal nerve palsy improved after the operation. To our knowledge, this is the first case report on a spinal accessory nerve meningioma in which the spinal accessory nerve palsy appeared before operation and the nerve palsy improved after tumor resection. CONCLUSIONS There is a possibility of occurrence of a spinal accessory meningioma in the intradural extramedullary tumor at the foramen magnum. Additionally, even if spinal accessory nerve palsy appears, spinal accessory nerve recovery can be expected if the tumor is resected without injury to the nerve.
Table 1. Clinical Summary of 4 Cases of Spinal Accessory Nerve Meningioma Case Number
Study
Age (years)/ Sex
SAN Palsy Preoperative
SAN Palsy Postoperative
1
Thome et al., 20039
61/F
Spinal ataxia, L motor impairment
2
Tatagiba et al., 20058
35/M
R shoulder and neck pain
þ
þ
R
NR
NR
3
Liechty et al., 20077
9/M
None
R
1.5
Total
4
Present case
69/F
Dizziness, bilateral shoulder pain
þ
L
2.3
Total
Symptom
Side
Size (cm) Removal
Bilateral R: 0.3, L: 1.3
Total
SAN, spinal accessory nerve; F, female; L, left; , negative; R, right; M, male; þ, positive; NR, not reported.
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WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.013
CASE REPORT MASANAO MOHRI ET AL.
ACKNOWLEDGMENTS The authors thank Editage (www.editage. jp) for English language editing. REFERENCES 1. Meyer FB, Ebersold MJ, Reese DF. Benign tumors of the foramen magnum. J Neurosurg. 1984;61: 136-142. 2. Hart AJ, Allibone J, Casey AT, Thomas DG. Malignant meningioma of the oculomotor nerve without dural attachment. Case report and review of the literature. J Neurosurg. 1998;88:1104-1106. 3. Fujimoto Y, Kato A, Taniguchi M, Maruno M, Yoshimine T. Meningioma arising from the trigeminal nerve: a case report and literature review. J Neurooncol. 2004;68:185-187. 4. Kurokawa R, Tabuse M, Yoshida K, Kawase T. Spinal accessory schwannoma mimicking a tumor
SPINAL ACCESSORY NERVE MENINGIOMA
of the fourth ventricle: case report. Neurosurgery. 2004;54:510-514 [discussion: 514]. 5. Ng TH, Chan KH, Mann KS, Fung CF. Spinal meningioma arising from a lumbar nerve root. Case report. J Neurosurg. 1989;70:646-648. 6. Missori P, Palmarini V, Elefante MG, Scapeccia M, Domenicucci M, Paolini S. Intradural angiomatous meningioma arising from a thoracic nerve root. Surg Neurol Int. 2017;8:187. 7. Liechty P, Tubbs RS, Loukas M, et al. Spinal accessory nerve meningioma in a paediatric patient: case report. Folia Neuropathol. 2007;45:23-25.
9. Thome C, Grobholz R, Boschert J, Schmiedek P. Bilateral meningiomatous lesions of the spinal accessory nerves. Acta Neurochir (Wien). 2003;145: 309-313 [discussion: 313].
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 6 April 2019; accepted 2 May 2019 Citation: World Neurosurg. (2019) 128:158-161. https://doi.org/10.1016/j.wneu.2019.05.013 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com
8. Tatagiba M, Koerbel A, Bornemann A, Freudenstein D. Meningioma of the accessory nerve extending from the jugular foramen into the parapharyngeal space. Acta Neurochir (Wien). 2005; 147:909-910.
WORLD NEUROSURGERY 128: 158-161, AUGUST 2019
1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
161