Vision Deterioration and Hydrocephalus: Rare Presentations of Vestibular Schwannoma and Evolution of Management

Abstract Introduction The incidence of vestibular schwannoma is reported as 12 to 54 new cases per million per year, increasing over time. These patients usually present with unilateral sensorineural hearing loss, tinnitus, or vertigo. Rarely, these patients present with symptoms of hydrocephalus or vision changes. Objective The study aimed to evaluate the surgical management of vestibular schwannoma at a single institution and to identify factors that may contribute to hydrocephalus, papilledema, and the need for pre-resection diversion of cerebrospinal fluid. Patients and Methods A retrospective review examining the data of 203 patients with vestibular schwannoma managed with surgical resection from May 2008 to May 2020. We stratified patients into five different groups to analyze: tumors with a diameter of ≥40 mm, clinical evidence of hydrocephalus, and of papilledema, and patients who underwent pre-resection cerebrospinal fluid (CSF) diversion. Results From May 2008 to May 2020, 203 patients were treated with surgical resection. Patients with tumors ≥40 mm were more likely to present with visual symptoms (p < 0.001). Presentation with hydrocephalus was associated with larger tumor size (p < 0.001) as well as concomitant visual symptoms and papilledema (p < 0.001). Patients with visual symptoms presented at a younger age (p = 0.002) and with larger tumors (p < 0.001). Conclusion This case series highlights the rare presentation of vision changes and hydrocephalus in patients with vestibular schwannoma. We recommend urgent CSF diversion for patients with visual symptoms and hydrocephalus, followed by definitive resection. Further, vision may still deteriorate even after CSF diversion and tumor resection.

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Vestibular schwannoma management

Journal of Neurosurgery ◽

10.3171/jns.1998.89.6.0949 ◽

1998 ◽

Vol 89 (6) ◽

pp. 949-955 ◽

Cited By ~ 95

Author(s):

Bruce E. Pollock ◽

L. Dade Lunsford ◽

Douglas Kondziolka ◽

Raymond Sekula ◽

Brian R. Subach ◽

...

Keyword(s):

Tumor Growth ◽

Surgical Resection ◽

Vestibular Schwannoma ◽

Tumor Resection ◽

Gamma Knife Radiosurgery ◽

Gross Total Resection ◽

Total Resection ◽

Content Type ◽

Tumor Enlargement ◽

Fine Print

Object. The indications, operative findings, and outcomes of vestibular schwannoma microsurgery are controversial when it is performed after stereotactic radiosurgery. To address these issues, the authors reviewed the experience at two academic medical centers. Methods. During a 10-year interval, 452 patients with unilateral vestibular schwannomas underwent gamma knife radiosurgery. Thirteen patients (2.9%) underwent delayed microsurgery at a median of 27 months (range 7–72 months) after they had undergone radiosurgery. Six of the 13 patients had undergone one or more microsurgical procedures before they underwent radiosurgery. The indications for surgery were tumor enlargement with stable symptoms in five patients, tumor enlargement with new or increased symptoms in five patients, and increased symptoms without evidence of tumor growth in three patients. Gross-total resection was achieved in seven patients and near-gross-total resection in four patients. The surgery was described as more difficult than that typically performed for schwannoma in eight patients, no different in four patients, and easier in one patient. At the last follow-up evaluation, three patients had normal or near-normal facial function, three patients had moderate facial dysfunction, and seven had facial palsies. Three patients were incapable of caring for themselves, and one patient died of progression of a malignant triton tumor. Conclusions. Failed radiosurgery in cases of vestibular schwannoma was rare. No clear relationship was demonstrated between the use of radiosurgery and the subsequent ease or difficulty of delayed microsurgery. Because some patients have temporary enlargement of their tumor after radiosurgery, the need for surgical resection after radiosurgery should be reviewed with the neurosurgeon who performed the radiosurgery and should be delayed until sustained tumor growth is confirmed. A subtotal tumor resection should be considered for patients who require surgical resection of their tumor after vestibular schwannoma radiosurgery.

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Thecoperitoneal Shunt Migration through Anus–A Rare Presentation

Indian Journal of Neurosurgery ◽

10.1055/s-0040-1712707 ◽

2020 ◽

Vol 9 (03) ◽

pp. 197-198

Author(s):

Sudheer Ambekar ◽

Mayank Vekariya

Keyword(s):

Cerebrospinal Fluid ◽

Rare Presentation ◽

Csf Diversion ◽

Shunt Migration

AbstractThe thecoperitoneal (TP) shunt is a cerebrospinal fluid (CSF) diversion technique. It is a commonly used technique in many neurosurgical conditions, and many complications are associated with it. This is a case of TP shunt migration through the anus. It is an uncommon and rare presentation of one of the complications associated with the TP shunt. Caregivers should keep this in mind about this complication, as it leads to devastating complications like meningitis and suffering for the patient.

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Extent of Surgical Resection Predicts Seizure Freedom in Low-Grade Temporal Lobe Brain Tumors

Neurosurgery ◽

10.1227/neu.0b013e31823c3a30 ◽

2011 ◽

Vol 70 (4) ◽

pp. 921-928 ◽

Cited By ~ 128

Author(s):

Dario J. Englot ◽

Seunggu J. Han ◽

Mitchel S. Berger ◽

Nicholas M. Barbaro ◽

Edward F. Chang

Keyword(s):

Surgical Resection ◽

Temporal Lobe ◽

Seizure Control ◽

Tumor Resection ◽

Case Series ◽

Subtotal Resection ◽

Seizure Outcome ◽

Seizure Freedom ◽

Low Grade ◽

Glioneuronal Tumors

Abstract BACKGROUND: Achieving seizure control in patients with low-grade temporal lobe gliomas or glioneuronal tumors remains highly underappreciated, because seizures are the most frequent presenting symptom and significantly impact patient quality-of-life. OBJECTIVE: To assess how the extent of temporal lobe resection influences seizure outcome. METHODS: We performed a quantitative, comprehensive systematic literature review of seizure control outcomes in 1181 patients with epilepsy across 41 studies after surgical resection of low-grade temporal lobe gliomas and glioneuronal tumors. We measured seizure-freedom rates after subtotal resection vs gross-total lesionectomy alone vs tailored resection, including gross-total lesionectomy with hippocampectomy and/or anterior temporal lobe corticectomy. RESULTS: Included studies were observational case series, and no randomized, controlled trials were identified. Although only 43% of patients were seizure-free after subtotal tumor resection, 79% of individuals were seizure-free after gross-total lesionectomy (OR = 5.00, 95% confidence interval [CI]: 3.33-7.14). Furthermore, tailored resection with hippocampectomy plus corticectomy conferred additional benefit over gross-total lesionectomy alone, with 87% of patients achieving seizure freedom (OR = 1.82, 95% CI: 1.23-2.70). Overall, extended resection with hippocampectomy and/or corticectomy over gross-total lesionectomy alone significantly predicted seizure freedom (OR = 1.18, 95% CI: 1.11-1.26). Age <18 years and mesial temporal location also prognosticated favorable seizure outcome. CONCLUSION: Gross-total lesionectomy of low-grade temporal lobe tumors results in significantly improved seizure control over subtotal resection. Additional tailored resection including the hippocampus and/or adjacent cortex may further improve seizure control, suggesting dual pathology may sometimes allow continued seizures after lesional excision.

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Cerebrospinal fluid drainage options for posthemorrhagic hydrocephalus in premature neonates

Arquivos de Neuro-Psiquiatria ◽

10.1590/0004-282x20170060 ◽

2017 ◽

Vol 75 (7) ◽

pp. 433-438 ◽

Cited By ~ 1

Author(s):

José Roberto Tude Melo ◽

Rosane Klein Passos ◽

Marcelo Liberato Coelho Mendes de Carvalho

Keyword(s):

Cerebrospinal Fluid ◽

Birth Weight ◽

Ventriculoperitoneal Shunt ◽

Case Series ◽

Posthemorrhagic Hydrocephalus ◽

Premature Neonates ◽

Cerebrospinal Fluid Diversion ◽

Csf Drainage ◽

Csf Diversion ◽

Preterm Newborns

ABSTRACT Objective The literature describes various cerebrospinal fluid (CSF) drainage techniques to alleviate posthemorrhagic hydrocephalus in preterm newborns; however, consensus has not been reached. The scope of this study was describing a case series of premature neonates with posthemorrhagic hydrocephalus and assessing the outcomes of different approaches used for CSF diversion. Methods A consecutive review of the medical records of neonates with posthemorrhagic hydrocephalus treated with CSF drainage was conducted. Results Forty premature neonates were included. Serial lumbar puncture, ventriculosubgaleal shunt, and ventriculoperitoneal shunt were the treatments of choice in 25%, 37.5% and 37.5% of the cases, respectively. Conclusion Cerebrospinal fluid diversion should be tailored to each case with preference given to temporary CSF drainage in neonates with lower age and lower birth-weight, while the permanent ventriculoperitoneal shunt should be considered in healthier, higher birth-weight neonates born closer to term.

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Risk Factors for Readmission with Cerebrospinal Fluid Leakage Within 30 Days of Vestibular Schwannoma Surgery

Neurosurgery ◽

10.1093/neuros/nyx197 ◽

2017 ◽

Vol 82 (5) ◽

pp. 630-637 ◽

Cited By ~ 7

Author(s):

Ali A Alattar ◽

Brian R Hirshman ◽

Brandon A McCutcheon ◽

Clark C Chen ◽

Thomas Alexander ◽

...

Keyword(s):

Risk Factors ◽

Cerebrospinal Fluid ◽

Surgical Resection ◽

Vestibular Schwannoma ◽

Health Planning ◽

Csf Leak ◽

Cerebrospinal Fluid Leakage ◽

Case Volume ◽

Csf Leakage ◽

First Admission

Abstract BACKGROUND Cerebrospinal fluid (CSF) leak is a well-recognized complication after surgical resection of vestibular schwannomas and is associated with a number of secondary complications, including readmission and meningitis. OBJECTIVE To identify risk factors for and timing of 30-d readmission with CSF leak. METHODS Patients who had undergone surgical resection of a vestibular schwannoma from 1995 to 2010 were identified in the California Office of Statewide Health Planning and Development database. The most common admission diagnoses were identified by International Classification of Disease, ninth Revision, diagnosis codes, and predictors of readmission with CSF leak were determined using logistic regression. RESULTS A total of 6820 patients were identified. CSF leak, though a relatively uncommon cause of admission after discharge (3.52% of all patients), was implicated in nearly half of 490 readmissions (48.98%). Significant independent predictors of readmission with CSF leak were male sex (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.32-2.25), first admission at a teaching hospital (OR 3.32, 95% CI 1.06-10.39), CSF leak during first admission (OR 1.84, 95% CI 1.33-2.55), obesity during first admission (OR 2.10, 95% CI 1.20-3.66), and case volume of first admission hospital (OR of log case volume 0.82, 95% CI 0.70-0.95). Median time to readmission was 6 d from hospital discharge. CONCLUSION This study has quantified CSF leak as an important contributor to nearly half of all readmissions following vestibular schwannoma surgery. We propose that surgeons should focus on technical factors that may reduce CSF leakage and take advantage of potential screening strategies for the detection of CSF leakage prior to first admission discharge.

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Delayed presentation of syringomyelia after retrosigmoid craniectomy and resection of vestibular schwannoma: discussion of mechanisms

BMJ Case Reports ◽

10.1136/bcr-2021-246714 ◽

2021 ◽

Vol 14 (12) ◽

pp. e246714

Author(s):

Chinedu Brian Egu ◽

Ashwin Kumaria ◽

Alistair Paterson ◽

Iain Robertson

Keyword(s):

Cerebrospinal Fluid ◽

Vestibular Schwannoma ◽

Csf Leak ◽

Multiple Infections ◽

Delayed Presentation ◽

Csf Diversion ◽

Type Of Surgery

We present a case of syringomyelia following retrosigmoid craniectomy and resection of vestibular schwannoma complicated by Cerebrospinal fluid (CSF) leak, multiple infections and CSF diversion procedures. We believe this is the first reported case of syrinx formation after this type of surgery. Potential mechanisms by which the syrinx may have developed are discussed.

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Hydrocephalus Associated with Large Vestibular Schwannoma: Management Options and Factors Predicting Requirement of Cerebrospinal Fluid Diversion after Primary Surgery

Journal of Neurosciences in Rural Practice ◽

10.4103/jnrp.jnrp_264_17 ◽

2017 ◽

Vol 08 (S 01) ◽

pp. S027-S032 ◽

Cited By ~ 2

Author(s):

A. R. Prabhuraj ◽

Nishanth Sadashiva ◽

Santhosh Kumar ◽

Dhaval Shukla ◽

Dhananjaya Bhat ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Vestibular Schwannoma ◽

Obstructive Hydrocephalus ◽

Management Options ◽

Surgical Morbidity ◽

Duration Of Symptoms ◽

Nerve Preservation ◽

Postoperative Hematoma ◽

Increased Risk ◽

Csf Diversion

ABSTRACT Objective: Obstructive hydrocephalus (HCP) related to vestibular schwannoma occurs in large tumors compressing the fourth ventricle. Symptoms related to HCP are expected to alleviate after resection of the tumor and decompression of the cerebrospinal fluid (CSF) pathways. However, some patients may require permanent cerebrospinal diversion even after surgery due to persistent HCP. In this study, the authors try to find out the factors associated with the requirement of CSF diversion after vestibular schwannoma surgery in cases of persistent HCP. Materials and Methods: This was a retrospective study involving 193 cases of vestibular schwannoma operated between 2010 and 2013 in our institute. Cases that underwent ventriculoperitoneal (VP) shunts before surgery were compared to cases which were operated directly. In cases where vestibular schwannomas were operated without prior VP shunts, factors which were associated with persistent postoperative HCP were analyzed. Results: Comparing the group who underwent direct surgery to the group who underwent VP shunt before definitive vestibular schwannoma surgery, the facial nerve preservation rates and surgical morbidity rates were comparable. In cases who underwent direct surgery, 10 out of 75 patients required postoperative permanent CSF diversion. Older age, male gender, duration of symptoms, larger tumor size, solid lesions, severe HCP, and clinical features of HCP were associated with postoperative requirement of CSF diversion but were not statistically significant. The most significant factor that correlated with the need for additional HCP treatment was the presence of postoperative hematoma of volume >10cc. Conclusions: Primary tumor removal is the optimal treatment for vestibular schwannoma associated with HCP. Postoperative hematoma may warrant close observation as these patients are at an increased risk of persistence of HCP.

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