Subfrontal —
Takanobu
Divisions
Case Report—
HARADA, Masaaki Kazuhiko KYOSHIMA
of Neurosurgery
Schwannoma
KAWAUCHI, and Shigeaki
and *Pathology,
Asama
Masahide WATANABE*, KOBAYASHI**
General Hospital,
Saku, Nagano;
**Department of Neurosurgery , Shinshu University School of Medicine, Matsumoto, Nagano
Abstract A rare case of subfrontal schwannoma occurred headache. Computed tomography demonstrated Magnetic totally
resonance
imaging
indicated
removed via a subfrontal
ly origin
of the tumor
Key words:
approach.
is the meningeal
neurinoma,
schwannoma,
the
mass
in a 33-year-old a low-density extension
into
The histological branches tumor
male with the chief complaint of mass in the subfrontal region. the ethmoidal
diagnosis
or anterior localization,
sinus.
was schwannoma.
ethmoidal
The
tumor
The most
was like
nerve.
magnetic
resonance
imaging,
immunohistochemistry
Introduction
Schwannomas are neoplastic Schwann cells and may arise from any nerve with a Schwann cell sheath. Schwannomas account for about 8% of all primary intracranial tumors.") The overwhelming majority originate from the VIIIth cranial nerve, and a few from the Vth cranial nerve. Association with von Recklinghausen's disease may involve the Xth, XIth, and occasionally other motor nerves. The tu mor usually originates between the exit from the leptomeninges and the entrance to the dura mater. We describe a subfrontal schwannoma in a 33 year-old male, with an interesting computed tomography (CT) and magnetic resonance (MR) im aging appearance, and discuss the histogenesis of the tumor. Case
Report
A 33-year-old male was referred to our hospital in January, 1990 complaining of headache persisting since November, 1989. He was completely well until the onset. There was no family history of von Reck linghausen's disease. General physical examination Received Author's
February present
6, 1992;
address:
Accepted
T. Harada,
M.D.,
May Chiba
found no abnormalities or stigmata of neurofibro matosis. Neurological examination was normal ex cept for left olfactory impairment. Fundoscopy showed no papilledema. Routine laboratory tests were within normal limits. Plain skull x-ray films revealed no remarkable changes. Precontrast CT scans demonstrated a low-density mass in the midline of the anterior cranial fossa (Fig. 1 left). Postcontrast CT scans showed the rim of the mass to be heterogeneously enhanced (Fig. 1 right). The mass was hypointense at the frontal base on the T,-weighted coronal MR images (Fig. 2 left), and hyperintense extending into the left ethmoidal sinus on the T2-weighted coronal images (Fig. 2 right). There was little surrounding edema. Ti-weighted coronal and sagittal images with gadolinium diethylenetriaminepenta-acetic acid (Gd-DTPA) showed heterogeneous enhancement of the lesion (Fig. 3). Bilateral internal and external carotid angiograms revealed no feeding artery or tumor stain. The preoperative diagnosis was meningioma of the left olfactory groove. A bifrontal craniotomy was performed. The falx cerebri was incised from the crista galli and the tips of the bilateral frontal lobes were retracted laterally
18, 1992 Neurosurgical
Clinic,
Chiba,
Japan.
sion. The capsule was incised. The tumor content was yellowish with variable consistency, and was debulked by suction. The tumor was attached to the left olfactory groove. Tumor removal from the floor of the anterior cranial fossa showed tumor extension through a 1.5 cm defect of the floor into the left ethmoidal sinus. Removal of the tumor in the ethmoidal sinus exposed the mucous membrane of the paranasal sinus. The skull base was reconstructed in three layers: the bony defect with the inner table of the frontal bone flap'); the dural defect with a dural flap taken from the convexity dura, which was
Fig. 1 Preoperative pre (left) and postcontrast (right) axial CT scans, demonstrating a mass in the subfrontal region.
patched with lyophilized dura; and the frontal base covered intradurally with a galeal pericranial flap. Postoperatively, he developed bacterial meningitis which improved with antibiotics. Emotional lability and irritability lasted for 1 week.
Histological examination of the tumor sample found mainly loosely arranged spindle cells (Fig. 4 upper). Immunoperoxidase staining for S-100 pro tein was diffusely positive (Fig. 4 lower). Staining for Leu-7 and 2-E was focally positive. The histological
Fig. 2 left: T,-weighted coronal MR image, demon strating a hypointense lesion at the frontal base. right: T2-weighted coronal MR image, showing a hyperintense lesion with extension into the ethmoidal sinus.
Fig. 3 Gd-DTPA-enhanced T,-weighted coronal (left) and sagittal (right) MR images, showing a heterogeneous enhancing lesion.
to expose the capsule of the tumor. The tumor was slightly yellowish and smooth with some surface vessels. It had displaced the faix to the right, but the right olfactory bulb appeared intact. The left olfac tory bulb was fanned and thin due to tumor compres
Fig. 4
upper: showing x 200.
Photomicrograph spindle lower:
of the tumor
cells arranged Photomicrograph,
positive immunohistochemical 100 protein. x 200.
in staining
sample, fasciculi. showing for
S
diagnosis
was schwannoma.
Discussion Subfrontal schwannoma is extremely rare, with only 12 cases previously reported (Table 1).2,4,7-9,13-18) Three were associated with von Recklinghausen's neurofibromatosis.2,8,14) Ages ranged from 17 to 63 years (average, 32 yrs), with a male preponderance of 3:1. In contrast, acoustic schwannoma is more com mon in females in the 4th and 5th decades. Nine cases of subfrontal schwannoma including ours were attached to the olfactory groove, 2,8,9,13-15,17,18) and one to the anterior cranial fossa.') Four cases had invaded the ethmoidal sinus or orbital cavity.''9,1s) Schwannomas are slowly growing tumors charac terized by expansion and thinning of the confining bone around the cavities and foramina .7,19)in our case, the tumor had thinned the frontal bone and extended into the ethmoidal sinus. Only one case of intranasal schwannoma has extended into the intra cranial compartment.19) In that case, the tumor part in the intranasal compartment was larger than the intracranial part. The most puzzling question is the origin. Schwan nomas in the central nervous system are very rare.',',") The olfactory nerves and bulbs are encased
Table
1
Published
cases
of subfrontal
schwannoma
by glial cells.') Christin and Naville2) suggested the olfactory bulb as the origin, as bilateral olfactory schwannomas had apparently arisen in the olfactory bulbs. Nelson and Rennes" demonstrated Schwann cells along nerve fibers around large arteries in the subarachnoid space, which Newly considered the source of intracerebral schwannoma. Russell and Rubinstein12) suggested that either Schwann cells sheathing the small nerve twigs innervating the meninges or ectopic cells within the neural paren chyma were the origin of intracerebral schwanno mas. General innervation of the anterior cranial fos sa and olfactory groove is by meningeal branches of the trigeminal nerve and anterior ethmoidal nerve. 4,7,9,17,18)Our case showed no adhesion of the tumor to the olfactory nerve, like in the case of Nagao et al.9) Therefore, the most likely origin of our case is the meningeal branches or anterior ethmoidal nerve. A subfrontal tumor with or without extension into the paranasal sinus includes schwannoma in the differential diagnoses.
References 1) Batsakis JG: Tumors of the Peripheral Nervous System, ed 2. Baltimore, Williams & Wilkins, 1979, pp 313-333 2) 3) 4)
5)
6)
7)
8)
Christin E, Naville F: A propos de neurofibroma toses centrales. Annales de Medcino 8: 31-50, 1920 Ghatak NR, Norwood CW, Davis CH: Intracerebral schwannoma. Surg Neurol 3: 45-47, 1975 Harano H, Hori S, Kamata K, Shinohara T, Toyama K, Nemoto H, Nakayama K: A case report of sub frontal schwannoma. No Shinkei Geka 2: 643-647, 1974 (in Japanese) Hockley AD, Hendrick EB: Unilateral proptosis and intracranial schwannoma. Surg Neurol 4: 509-512, 1975 Kyoshima K, Gibo H, Kobayashi S, Sugita K: Cranioplasty with inner table of bone flap. Technical note. J Neurosurg 62: 607-609, 1985 Mauro A, Sciolla R, Sicuro L, Ponzio R: Solitary neurinoma of the anterior cranial fossa: Case report. J Neurosurg Sci 27: 45-49, 1983 Molter K: Medullare and periphere Neurofibroma tosis (inaugural dissertation, Univeusitat zu Jena), in: Uber Gleichzeitige Cerebrale. Jena, Wendt & Klauwell, 1920
9) Nagao S, Aoki T, Kondo S, Gi H, Matsunaga M, Fujita Y: Subfrontal schwannoma: A case report. No Shinkei Geka 19: 47-51, 1991 (in Japanese) 10) 11)
Nelson E, Rennes M: Innervation arteries. Brain 93: 475-490, 1970 New PFJ: Intracerebral schwannoma: Neurosurg 36: 795-797, 1972
of intracranial Case report. J
12) Russell DS, Rubinstein LL: Pathology of Tumors of the Nervous System, ed 5. London, Edward Arnold,
1989,
13)
14)
15)
pp 537-560
Sato S, Toya S, Nakamura T, Ohtani M, Imanishi T , Kodaki K, Nakamura Y: Subfrontal schwannoma: Report of a case. No Shinkei Geka 13: 883-887, 1985 (in Japanese) Spiller WG, Handrickson WF: A report of two cases of multiple sarcomatosis of the central nervous system and of one case of intramedullary primary sar coma of the spinal cord. Amer J Med Sci 126: 10-32, 1903 Ulrich J, Levy A, Pfister Chr: Schwannoma of the olfactory groove. Acta Neurochir (Wien) 40: 315 321, 1978 -
16) Vassilouthis J, Richardson AE: Subfrontal schwan noma: Report of a case. Acta Neurochir (Wien) 53: 259-266, 1980
17)
18)
19)
Viale ES, Pau A, Turtas S: Olfactory groove neurinomas: Case report. J Neurosurg Sci 17: 193 196, 1973 von Strum KW, Bonis G, Kosmaoglou V: Uber ein Neurinoma der Lamina cribrosa. Zbl Neurochir 29: 217-222, 1968 Zovickian J, Barba D, Alksne JF: Intranasal schwan noma with extension into the intracranial compart ment: Case report. Neurosurgery 19: 813-815, 1986
Address
reprint
requests
Neurosurgical Chiba
281, Japan.
Clinic,
to:
T. 408
Harada,
M.D.,
Naganumahara-cho,
Chiba
Takanobu
Divisions
Case Report—
HARADA, Masaaki Kazuhiko KYOSHIMA
of Neurosurgery
Schwannoma
KAWAUCHI, and Shigeaki
and *Pathology,
Asama
Masahide WATANABE*, KOBAYASHI**
General Hospital,
Saku, Nagano;
**Department of Neurosurgery , Shinshu University School of Medicine, Matsumoto, Nagano
Abstract A rare case of subfrontal schwannoma occurred headache. Computed tomography demonstrated Magnetic totally
resonance
imaging
indicated
removed via a subfrontal
ly origin
of the tumor
Key words:
approach.
is the meningeal
neurinoma,
schwannoma,
the
mass
in a 33-year-old a low-density extension
into
The histological branches tumor
male with the chief complaint of mass in the subfrontal region. the ethmoidal
diagnosis
or anterior localization,
sinus.
was schwannoma.
ethmoidal
The
tumor
The most
was like
nerve.
magnetic
resonance
imaging,
immunohistochemistry
Introduction
Schwannomas are neoplastic Schwann cells and may arise from any nerve with a Schwann cell sheath. Schwannomas account for about 8% of all primary intracranial tumors.") The overwhelming majority originate from the VIIIth cranial nerve, and a few from the Vth cranial nerve. Association with von Recklinghausen's disease may involve the Xth, XIth, and occasionally other motor nerves. The tu mor usually originates between the exit from the leptomeninges and the entrance to the dura mater. We describe a subfrontal schwannoma in a 33 year-old male, with an interesting computed tomography (CT) and magnetic resonance (MR) im aging appearance, and discuss the histogenesis of the tumor. Case
Report
A 33-year-old male was referred to our hospital in January, 1990 complaining of headache persisting since November, 1989. He was completely well until the onset. There was no family history of von Reck linghausen's disease. General physical examination Received Author's
February present
6, 1992;
address:
Accepted
T. Harada,
M.D.,
May Chiba
found no abnormalities or stigmata of neurofibro matosis. Neurological examination was normal ex cept for left olfactory impairment. Fundoscopy showed no papilledema. Routine laboratory tests were within normal limits. Plain skull x-ray films revealed no remarkable changes. Precontrast CT scans demonstrated a low-density mass in the midline of the anterior cranial fossa (Fig. 1 left). Postcontrast CT scans showed the rim of the mass to be heterogeneously enhanced (Fig. 1 right). The mass was hypointense at the frontal base on the T,-weighted coronal MR images (Fig. 2 left), and hyperintense extending into the left ethmoidal sinus on the T2-weighted coronal images (Fig. 2 right). There was little surrounding edema. Ti-weighted coronal and sagittal images with gadolinium diethylenetriaminepenta-acetic acid (Gd-DTPA) showed heterogeneous enhancement of the lesion (Fig. 3). Bilateral internal and external carotid angiograms revealed no feeding artery or tumor stain. The preoperative diagnosis was meningioma of the left olfactory groove. A bifrontal craniotomy was performed. The falx cerebri was incised from the crista galli and the tips of the bilateral frontal lobes were retracted laterally
18, 1992 Neurosurgical
Clinic,
Chiba,
Japan.
sion. The capsule was incised. The tumor content was yellowish with variable consistency, and was debulked by suction. The tumor was attached to the left olfactory groove. Tumor removal from the floor of the anterior cranial fossa showed tumor extension through a 1.5 cm defect of the floor into the left ethmoidal sinus. Removal of the tumor in the ethmoidal sinus exposed the mucous membrane of the paranasal sinus. The skull base was reconstructed in three layers: the bony defect with the inner table of the frontal bone flap'); the dural defect with a dural flap taken from the convexity dura, which was
Fig. 1 Preoperative pre (left) and postcontrast (right) axial CT scans, demonstrating a mass in the subfrontal region.
patched with lyophilized dura; and the frontal base covered intradurally with a galeal pericranial flap. Postoperatively, he developed bacterial meningitis which improved with antibiotics. Emotional lability and irritability lasted for 1 week.
Histological examination of the tumor sample found mainly loosely arranged spindle cells (Fig. 4 upper). Immunoperoxidase staining for S-100 pro tein was diffusely positive (Fig. 4 lower). Staining for Leu-7 and 2-E was focally positive. The histological
Fig. 2 left: T,-weighted coronal MR image, demon strating a hypointense lesion at the frontal base. right: T2-weighted coronal MR image, showing a hyperintense lesion with extension into the ethmoidal sinus.
Fig. 3 Gd-DTPA-enhanced T,-weighted coronal (left) and sagittal (right) MR images, showing a heterogeneous enhancing lesion.
to expose the capsule of the tumor. The tumor was slightly yellowish and smooth with some surface vessels. It had displaced the faix to the right, but the right olfactory bulb appeared intact. The left olfac tory bulb was fanned and thin due to tumor compres
Fig. 4
upper: showing x 200.
Photomicrograph spindle lower:
of the tumor
cells arranged Photomicrograph,
positive immunohistochemical 100 protein. x 200.
in staining
sample, fasciculi. showing for
S
diagnosis
was schwannoma.
Discussion Subfrontal schwannoma is extremely rare, with only 12 cases previously reported (Table 1).2,4,7-9,13-18) Three were associated with von Recklinghausen's neurofibromatosis.2,8,14) Ages ranged from 17 to 63 years (average, 32 yrs), with a male preponderance of 3:1. In contrast, acoustic schwannoma is more com mon in females in the 4th and 5th decades. Nine cases of subfrontal schwannoma including ours were attached to the olfactory groove, 2,8,9,13-15,17,18) and one to the anterior cranial fossa.') Four cases had invaded the ethmoidal sinus or orbital cavity.''9,1s) Schwannomas are slowly growing tumors charac terized by expansion and thinning of the confining bone around the cavities and foramina .7,19)in our case, the tumor had thinned the frontal bone and extended into the ethmoidal sinus. Only one case of intranasal schwannoma has extended into the intra cranial compartment.19) In that case, the tumor part in the intranasal compartment was larger than the intracranial part. The most puzzling question is the origin. Schwan nomas in the central nervous system are very rare.',',") The olfactory nerves and bulbs are encased
Table
1
Published
cases
of subfrontal
schwannoma
by glial cells.') Christin and Naville2) suggested the olfactory bulb as the origin, as bilateral olfactory schwannomas had apparently arisen in the olfactory bulbs. Nelson and Rennes" demonstrated Schwann cells along nerve fibers around large arteries in the subarachnoid space, which Newly considered the source of intracerebral schwannoma. Russell and Rubinstein12) suggested that either Schwann cells sheathing the small nerve twigs innervating the meninges or ectopic cells within the neural paren chyma were the origin of intracerebral schwanno mas. General innervation of the anterior cranial fos sa and olfactory groove is by meningeal branches of the trigeminal nerve and anterior ethmoidal nerve. 4,7,9,17,18)Our case showed no adhesion of the tumor to the olfactory nerve, like in the case of Nagao et al.9) Therefore, the most likely origin of our case is the meningeal branches or anterior ethmoidal nerve. A subfrontal tumor with or without extension into the paranasal sinus includes schwannoma in the differential diagnoses.
References 1) Batsakis JG: Tumors of the Peripheral Nervous System, ed 2. Baltimore, Williams & Wilkins, 1979, pp 313-333 2) 3) 4)
5)
6)
7)
8)
Christin E, Naville F: A propos de neurofibroma toses centrales. Annales de Medcino 8: 31-50, 1920 Ghatak NR, Norwood CW, Davis CH: Intracerebral schwannoma. Surg Neurol 3: 45-47, 1975 Harano H, Hori S, Kamata K, Shinohara T, Toyama K, Nemoto H, Nakayama K: A case report of sub frontal schwannoma. No Shinkei Geka 2: 643-647, 1974 (in Japanese) Hockley AD, Hendrick EB: Unilateral proptosis and intracranial schwannoma. Surg Neurol 4: 509-512, 1975 Kyoshima K, Gibo H, Kobayashi S, Sugita K: Cranioplasty with inner table of bone flap. Technical note. J Neurosurg 62: 607-609, 1985 Mauro A, Sciolla R, Sicuro L, Ponzio R: Solitary neurinoma of the anterior cranial fossa: Case report. J Neurosurg Sci 27: 45-49, 1983 Molter K: Medullare and periphere Neurofibroma tosis (inaugural dissertation, Univeusitat zu Jena), in: Uber Gleichzeitige Cerebrale. Jena, Wendt & Klauwell, 1920
9) Nagao S, Aoki T, Kondo S, Gi H, Matsunaga M, Fujita Y: Subfrontal schwannoma: A case report. No Shinkei Geka 19: 47-51, 1991 (in Japanese) 10) 11)
Nelson E, Rennes M: Innervation arteries. Brain 93: 475-490, 1970 New PFJ: Intracerebral schwannoma: Neurosurg 36: 795-797, 1972
of intracranial Case report. J
12) Russell DS, Rubinstein LL: Pathology of Tumors of the Nervous System, ed 5. London, Edward Arnold,
1989,
13)
14)
15)
pp 537-560
Sato S, Toya S, Nakamura T, Ohtani M, Imanishi T , Kodaki K, Nakamura Y: Subfrontal schwannoma: Report of a case. No Shinkei Geka 13: 883-887, 1985 (in Japanese) Spiller WG, Handrickson WF: A report of two cases of multiple sarcomatosis of the central nervous system and of one case of intramedullary primary sar coma of the spinal cord. Amer J Med Sci 126: 10-32, 1903 Ulrich J, Levy A, Pfister Chr: Schwannoma of the olfactory groove. Acta Neurochir (Wien) 40: 315 321, 1978 -
16) Vassilouthis J, Richardson AE: Subfrontal schwan noma: Report of a case. Acta Neurochir (Wien) 53: 259-266, 1980
17)
18)
19)
Viale ES, Pau A, Turtas S: Olfactory groove neurinomas: Case report. J Neurosurg Sci 17: 193 196, 1973 von Strum KW, Bonis G, Kosmaoglou V: Uber ein Neurinoma der Lamina cribrosa. Zbl Neurochir 29: 217-222, 1968 Zovickian J, Barba D, Alksne JF: Intranasal schwan noma with extension into the intracranial compart ment: Case report. Neurosurgery 19: 813-815, 1986
Address
reprint
requests
Neurosurgical Chiba
281, Japan.
Clinic,
to:
T. 408
Harada,
M.D.,
Naganumahara-cho,
Chiba
