Clinical Neurology and Neurosurgery 109 (2007) 791–793
Cavernoma of the trochlear nerve
, Ulrich Sure
, Michel Mittelbronn
, Ralf Becker
Department of Neurosurgery, University of Marburg, Germany
Institute of Brain Research, University of Tuebingen, Germany
Department of Neurosurgery, Asklepios Hospitals Schildautal Seesen, Germany
Received 30 March 2007; received in revised form 11 June 2007; accepted 15 June 2007
Here we present the case of a 53-year old man with progressive double vision due to isolated left trochlear nerve palsy. Cranial magnetic
resonance imaging (MRI) showed a small tumor within the left quadrigeminal cistern that did not increase in size after several months.
Explorative neurosurgical intervention revealed a left trochlear nerve cavernoma. The lesion was microsurgically excised followed by end-to-
end anastomosis of the trochlear nerve. After a one-year follow up, double vision totally disappeared and cranial MRI showed no recurrence.
Cerebral cavernous malformations usually become symptomatic in seizures or focal neurological deﬁcits after intracerebral hemorrhage.
Rarely, cavernomas arise from cranial nerves. To the authors’ knowledge, this is the ﬁrst report on a symptomatic cavernous malformation
arising from the trochlear nerve and on its successful surgical management.
© 2007 Elsevier B.V. All rights reserved.
Keywords: Cavernous hemangioma; Cavernoma; Nerve regeneration; Trochlear nerve; Trochlear nerve diseases; CCM
Cavernomas account for 10–20% of cerebrovascular mal-
formations, with an incidence of ∼0.4%. Because of their
fragile and dilated vessel architecture consisting only of a fen-
estrated endothelial layer surrounded by collagenous stroma
and lacking a basal membrane, they tend to cause repeatedly
intracerebral hemorrhages [1,2]. Symptoms are mostly site-
speciﬁc, including seizures and neurological deﬁcits. Up to
now, surgical complete excision is the most effective treat-
ment modality to avoid recurrence and bleeding [3–5].
Whereas most lesions are found within the brain
parenchyma, cavernomas rarely arise from cranial nerves ,
mostly affecting optic nerve/chiasm, facial, and vestibulo-
cochlear nerves. Here, we describe an interesting case, for the
ﬁrst time to our knowledge, where a tumor of unknown origin
was intraoperatively identiﬁed as a trochlear nerve cavernoma
Abbreviations: MRI, magnetic resonance imaging; N., nerve
Corresponding author. Tel.: +49 6421 286 6447; fax: +49 6421 286 6415.
E-mail address: Sueruecu@med.uni-marburg.de (O. S
and subsequently treated microsurgically without morbidity
after one year.
2. Case report
A 53-year old man was admitted to the hospital for neuro-
surgical evaluation presenting with progressive double vision
due to an isolated left trochlear nerve palsy. Gadolinium-
-weighted magnetic resonance imaging (MRI)
demonstrated a small nodular lesion (∼0.5 cm) in the
left quadrigeminal cistern (Fig. 1). Cerebral angiography
excluded an arteriovenous malformation or a highly vascu-
larized tumor. Repeated MRI after four months showed no
change in size or signaling. Due to the unchanged double
vision of the patient, that was most likely caused by the above-
mentioned lesion, surgery was carried out via a left-sided
retrosigmoidal keyhole craniotomy.
Intraoperative view revealed a mulberry-like vascular mal-
formation arising from the trochlear nerve (Fig. 2). After
proximal and distal suture, the vascular tumor was excised
0303-8467/$ – see front matter © 2007 Elsevier B.V. All rights reserved.