Teaching NeuroImages: Large vagal nerve schwannoma presenting with hemorrhage and respiratory failure

A 30-year-old man was intubated after sudden severe headache, loss of consciousness, and apnea. CT showed acute hemorrhage in the posterior fossa, brainstem compression, and intraventricular extension with early obstructive hydrocephalus (figure 1A). MRI showed a large heterogeneously enhancing extra-axial tumor extending from the cerebellopontine angle to the foramen magnum (figure 1, B and C). Intraoperatively the tumor was purely intracranial, arising from the right vagus nerve. He remained apneic postoperatively. Pathology was consistent with schwannoma (figure 2).