520 Case Reports / Journal of Clinical Neuroscience 17 (2010) 520–522

tissue plasminogen activator or anti-platelets agents may havesuppressed further thrombosis during an endovascular maneu-ver, but this procedure carries a risk of re-bleeding followingrecanalization of the aneurysm, and hemorrhagic transforma-tion in the superior trunk territory, which had already resultedin a complete infarction prior to the inferior trunk territorywas affected. Balloon angioplasty at the M1–M2 bifurcation,close to the neck of the aneurysm would carry the risk ofaneurysmal re-rupture. Coil embolization for the now angio-graphically occult thrombosed aneurysm had the potential ofincomplete obliteration or distal migration of the intra-aneurys-mal thrombus.

The protruded thrombus from the aneurysm to the M1–M2bifurcation was a cause of reduced inferior trunk blood flow withsevere vasospasm; we removed the thrombus and reconstructedthe tissue with aneurysmal clipping. Fortunately, the inferior trunkterritory did not evolve into complete infarction due to a 6 hour

doi:10.1016/j.jocn.2009.06.040

a r t i c l e i n f o

Article history:Received 4 May 2009Accepted 21 June 2009

Keywords:CranionasalSchwannomaSkull base techniquesHeterotopic

a b s t r a c t

Giant schwannomas concomityear-old male patient with anasal cavity. The patient hadnasal polyps. A CT scan and acoronal incision with a bilateanterior skull base and the dschwannoma. Schwannoma sand the surgical approach sho

* Corresponding author. Tel.: +86 028 85423622; fax: +86 028 85422411.E-mail address: jiangshu1003@sina.com (B.-y. Mao).

period between the ischemic event and surgical restoration ofblood flow.

This report highlights the importance of careful evaluation ofischemic patterns and aneurysm characteristics before choosingtreatment modalities. Various therapeutic options for the rupturedaneurysm during vasospasm should be considered.

References

1. Brisman JL, Roonprapunt C, Song JK, et al. Intentional partial coil occlusionfollowed by delayed clip application to wide-necked middle cerebral arteryaneurysms in patients presenting with severe vasospasm. Report of two cases. JNeurosurg 2004;101:154–8.

2. Murayama Y, Song JK, Uda K, et al. Combined endovascular treatment for bothintracranial aneurysm and symptomatic vasospasm. AJNR Am J Neuroradiol2003;24:133–9.

3. Sugiu K, Katsumata A, Ono Y, et al. Angioplasty and coiling of rupturedaneurysm with symptomatic vasospasm: technical case report. Surg Neurol2003;59:413–7.

Giant cranionasal schwannoma

Kai Zheng, Shu Jiang, Jian-guo Xu, Bo-yong Mao *

Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxuexiang Street, Chengdu, Sichuan, 610041, China

antly involving the intracranial and nasal cavities are rare. We report a 22-giant schwannoma involving the frontal skull base and extending into thea 2-year history of nasal obstruction that was originally misdiagnosed asn MRI revealed a large cranionasal tumor. Surgery was performed using aral frontal skull base extradural approach. The tumor originated from theura and nasal mucosa were intact. Histopathology was consistent with ahould be listed as part of the differential diagnosis of a cranionasal tumoruld be carefully selected to achieve total resection.

� 2009 Elsevier Ltd. All rights reserved.

1. Introduction

Intracranial schwannoma is a benign neoplasm arising fromSchwann cells of the peripheral nerve sheath. It is most often asso-ciated with the eighth cranial nerve1,2 and next most commonlyassociated with the fifth and ninth cranial nerves. Schwannomasconcomitantly involving the intracranial and nasal cavities are rareand present a surgical challenge.

2. Case report

A 22-year-old healthy male without a history of neurofibroma-tosis presented with a nasal obstruction, which had slowly pro-gressed over 2 years. The patient had previously been diagnosedwith nasal polyps at a local otolaryngology clinic and underwentseptoplasty for severe rhinocleisis without improvement. A CT scan

showed a 6.6 � 7.3 � 10.5 cm space-occupying lesion in the nasalcavity with inferior extension into the ethmoid sinus and anteriorextension into the frontal lobe (Fig. 1a,b). An MRI scan of the brainrevealed a well-defined, encapsulated tumor with slightly de-creased signal intensity on T1-weighted images and slightly in-creased signal intensity on T2-weighted images, which enhancedsignificantly after the administration of intravenous contrast med-ia (Fig. 1c–e).

Surgery was performed using a coronal incision and a bilateralfrontal skull base extradural approach. Complete excision of thetumor was performed in collaboration with several otolaryng-ologists.

During surgery, we found the tumor originated from the ante-rior skull base rather than the olfactory nerve. The tumor appearedvascular and was adherent to the dura; however, the nasal mucosawas intact. After careful removal of the tumor, the remaining6 � 7 cm cranial defect was repaired using artificial dura. A postop-erative contrast CT scan demonstrated complete resection of thetumor and satisfactory surgical reconstruction of the anterior skull

Fig. 1. (a) Pre-operative non-enhanced axial CT scan showing a large space-occupying lesion in the nasal cavity, ethmoid sinus and frontal lobe. (b) Pre-operative enhancedaxial CT scan showing the tumor extending intracranially and compressing the frontal lobe. (c) Pre-operative T2-weighted axial MRI showing the tumor compressing theintracranial structures. (d) Pre-operative T1-weighted coronal MRI showing the tumor with a well-defined capsule with slightly lower signal intensity (insert: sagittal view).(e) Pre-operative sagittal MRI enhanced by gadolinium injection. (f) Non-enhanced axial CT scan performed postoperatively demonstrating total removal of the tumor.

Case Reports / Journal of Clinical Neuroscience 17 (2010) 520–522 521

base defect (Fig. 1f). At the 6-month follow-up no complicationshave occurred.

Histologically, the tumor consisted of compact spindle cellswith palisading neoplastic proliferation. Cellular areas with theappearance of Antoni A tissue, and loosely textured areas ofrounded cells resembling Antoni B tissue, were noted focally onhematoxylin and eosin (H&E) staining (Supplementary Fig. 1a).Immunophenotypically, the neoplastic cells showed positive stain-ing for S-100 antiserum (Supplementary Fig. 1b,c), negative stain-ing for epithelial membrane antigen (Supplementary Fig. 1d) andglial fibrillary acidic protein (Supplementary Fig. 1e), and therewere approximately 3–5% Ki-67 positive tumor cells (Supplemen-tary Fig. 1f).

3. Discussion

A typical intracranial schwannoma is a benign tumor arisingfrom Schwann cells of the peripheral nerve sheath.2 As Schwanncells are present in the meningeal branch of the trigeminal nerve,3

and the glossopharyngeal nerve at the skull base and olfactorygroove,4 this is the most likely origin of the tumor in our patient.

Unusual sources for intracranial schwannoma include dysplasiaof Schwann cells in a perivascular plexus,1 origin from a spinal dor-sal root,5 transformation of mesoderm cells from the pia mater intoSchwann cells,2 and ectopic Schwann cells due to abnormal embry-onic development.6

Immunohistochemical studies showed positive staining forS-100, which is one of the characteristic markers of nerve sheathtumors. The schwannoma was also easily distinguished frommeningioma and glioma by the negative staining for both EMAand GFAP.

Although schwannomas are primarily benign, one malignantintracerebral schwannoma has been reported.7 The growth fractionin malignant schwannomas, as determined by Ki-67/MIB-1 immu-noreactivity, ranges from 5–65%. The 3–5% growth fraction in ourpatient’s tumor is consistent with borderline malignant potential.However, the additional features such as a complete capsule andslow growth of the tumor are more consistent with benign etiol-ogy. Close long-term clinical follow-up will be necessary to moni-tor for recurrence.

CT scans and MRI are critical when choosing the appropriatesurgical approach for resection of the tumor. Our surgical approachis commonly used for other tumors in a similar anatomical loca-tion, including olfactory neuroblastoma, adenocarcinoma, andsquamous cell carcinoma. However, for tumors that invade the na-sal cavity and paranasal sinuses, a combined craniofacial approachmay be preferred. The addition of a lateral rhinotomy or mid-facialdegloving approach could also extend the exposure of such atumor.8 During surgery, collaboration with otolaryngologists isrecommended to ensure successful total tumor resection.

Appendix A. Supplementary material

Supplementary material associated with this article can befound, in the online version, at doi:10.1016/j.jocn.2009.06.039.

References

1. Adelman LS, Aronson SM. I nerve fiber and Schwann cell proliferation within thespinal cord (schwannosis). Neurology 1972;22:726–31.

2. Russel DS, Rubenstein LJ. Pathology of tumors of the nervous system. 5thed. London, England: Edward Arnold; 1989.

522 Case Reports / Journal of Clinical Neuroscience 17 (2010) 522–523

3. Guthikonda B, Theodosopoulos PV, van Loveren H, et al. Evolution in theassessment and management of trigeminal schwannoma. Laryngoscope2008;118:195–203.

4. Erongun U, Ozkal E, Acar O, et al. Intracerebral schwannoma: case report andreview. Neurosurg Rev 1996;19:269–74.

5. McCormick WF. Intramedullary spinal cord schwannoma. A unique case. ArchPathol 1964;77:378–82.

doi:10.1016/j.jocn.2009.06.039

a r t i c l e i n f o

Article history:Received 7 August 2008Accepted 24 April 2009

Keywords:Intramedullary cysticercosisMagnetic resonance imagingSpinal cord compressionTaenia solium

a b s t r a c t

Intramedullary cysticercosis iswoman was admitted with lowshowed a well-defined intramecontrast. She underwent a T7–lesion to be a cysticercus grashowed significant neurologica

* Corresponding author. Tel.: +91 11 239 77 930; fax: +91 11 239 32 412.E-mail address: dramithanda@yahoo.com (A. Handa).

6. Pardatselier K, Iraci G, Cappellotto P, et al. Multiple intramedullary neurinomasof the spinal cord. Case report. J Neurosurg 1979;50:817–22.

7. Gonzalez LF, Lekovic GP, Eschbacher J, et al. A true malignant schwannoma of theeighth cranial nerve: case report. Neurosurgery 2007;61:E421–2.

8. Zhao JC, Liu G, Zhang YT, et al. Microsurgery of skull base [In Chinese]. 1sted. Tianjin, China: Science and Technology Translation Publishing Company;2005.

Intramedullary cysticercosis

S. Kumar a, A. Handa a,*, S. Chavda a, R. Tiwari a, P. Abbey b

a Department of Neurosurgery, St Stephen’s Hospital, Marg Tis Hazari, Delhi 110 054, Indiab Department of Radiology, All India Institute of Medical Sciences, New Delhi, India

a rare form of cysticercosis in the central nervous system. A 55-year-oldback pain, urinary incontinence, paraparesis and sensory deficit. Her MRI

dullary cystic lesion at T7 vertebral level with peripheral enhancement onT8 laminectomy and excision of the lesion. Histopathology revealed thenuloma. A postoperative course of albendazole was given. The patientl improvement at follow-up.

� 2009 Elsevier Ltd. All rights reserved.

1. Introduction

Cysticercosis, caused by Taenia solium, is one of the commonestparasitic diseases that involve the central nervous system. How-ever, an intramedullary cysticercus granuloma is rare. Mohantyet al. reported a series of eight patients;1 otherwise there havebeen sporadic reports.2–5 In our patient the cyst came out easilyfrom the surrounding well-defined granuloma, which is unusual.

2. Case report

A 55-year-old female was admitted with low back pain of 1-month duration, followed 2 days later by numbness and weaknessin both lower limbs. She developed urinary incontinence 1 weekprior to admission, for which she underwent catheterisation ofthe bladder. On examination she was bedridden with grade 1/5spastic paraparesis in the right lower limb and grade 2/5 on the leftside. All sensations were impaired by 50% to 60% below L1. Routineblood and urine investigations were normal. A plain radiograph ofthe thoracolumbar spine was within normal limits. MRI of the tho-racolumbar spine, however, revealed a well-defined intramedul-lary cystic lesion at the T7 level with signal intensitiesresembling cerebrospinal fluid (CSF) and peripheral enhancementon gadolinium administration (Fig. 1).

Intraoperatively the cord was found to be bulging and pale.Purulent fluid was drained via a midline myelotomy, followingwhich a well-defined greyish white cyst was removed intact. Awell-defined granuloma surrounding the cyst was dissected com-pletely with a good plane from the cord tissue. There was nogrowth of any organism on microbiological culture of the fluid.Her postoperative course was uneventful. Histopathology con-firmed the diagnosis of cysticercosis (Supplementary Fig. 1). She

was given a course of albendazole 400 mg twice daily for 3 weeks.At the 6-month follow-up, power in her lower limbs had improvedto grade 4/5 with reduced spasticity and she could walk with sup-port. Her bladder function had also returned to normal.

3. Discussion

Cysticercosis is endemic to Brazil, Mexico, Korea and SouthAsian countries.1–3,6 Cysticercal involvement of the spinal cord israre even in endemic areas and accounts for 0.7% to 5.85% of all pa-tients.1,3–5,7 Among patients with spinal cysticercosis, intramedul-lary involvement is relatively uncommon, the commonest being inthe intradural–extramedullary region. Extradural and vertebrallocations have also been reported.1,4,5,8 About half the reportedcases have concomitant extra spinal involvement.9 Singh and Sahairemarked that only 45 patients with intramedullary cysticercosishad been documented worldwide until 2004.4

The thoracic cord, which receives the maximum blood supply,is most commonly affected, followed by cervical, lumbar and sa-cral regions.10,11 Neurological symptoms in intramedullary cysti-cercosis can be attributed to direct mechanical compression,inflammatory changes, cord edema, gliosis, pachymeningitis orsyrinx formation. The patient usually presents with progressiveneurological worsening with spastic quadriparesis or paraparesisdepending on the site of the lesion; sphincter involvement,impotence and sensory deficit may also be present. Neurologicalinvolvement may be acute. MRI normally shows a cystic lesionwith signal intensities similar to CSF on both T1-weighted andT2-weighted MRI. The scolex when present, appears to be isoin-tense or hyperintense on T1-weighted MRI. The cyst wall usuallyenhances on contrast administration. An associated syrinx isgenerally secondary to arachnoiditis, circulatory insufficiency orcord atrophy.

In the absence of any extraspinal evidence of cysticercosisand in a setting of neurological deficits attributable to the lesion,