scholarly journals Extra-Arachnoidal Dissection for Excision of Giant Vestibular Schwannomas: Improved Facial Nerve Preservation

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Sunil K Gupta
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannomas ◽  
Nerve Function ◽  
Total Excision ◽  
Facial Nerve Function ◽  
Nerve Preservation ◽  
Group A ◽  
Grade 3 ◽  
Group B

Abstract INTRODUCTION Surgical excision of giant vestibular schwannomas with preservation of facial nerve function remains a challenge. A modified surgical technique using an extra-arachnoid plane of dissection and limited meatal drilling is described here with the goal of improving the rated of functional preservation of facial nerve. METHODS The clinical material was analyzed for two groups: Group A patients of giant vestibular schwannomas operated between 2002 and 2009 with the “standard” surgical technique, Group B- patients of giant vestibular schwannomas operated between 2009 and 2015 using the new technique of pure extra-arachnoid dissection and limited meatal drilling. RESULTS Group A: Of the 115 patients in this group, total excision was possible in 103 (89.5%), near total excision in 7 (6%) and partial excision in 5 (4.3%) patients. Anatomical preservation of 7th nerve was achieved in 87.8% of patients. House and Brackman grade 1 and grade 2 facial nerve function was present in 68 (59.1%) patients, grade 3 in 10 (8.7%), grades 4 and 5 in 11 (9.6%), and 26 (22.6%) had grade 6 facial nerve involvement. Group B: Of the 127 patients operated by this technique, details and long term follow-up was available for 98 patients. Total excision was achieved in 70 (71.4%) patients, near total excision in 9 (9.2%), and subtotal excision in 19 (19.4%) cases. Four patients had repeat surgery and 14 patients underwent gamma knife radiosurgery. At follow-up, 78 (79.5%) patients had grade 1 and 2 facial nerve involvement, while 20 (20.4%) patients continued to have a poor function (grade 3-5). CONCLUSION Extra-arachnoid dissection and limited meatal drilling resulted in an improved rate of functional facial nerve preservation.

Facial Nerve Preservation Surgery for Koos Grade 3 and 4 Vestibular Schwannomas

Neurosurgery ◽  
2014 ◽  
Vol 75 (6) ◽  
pp. 671-677 ◽  
Author(s):  
Amjad N. Anaizi ◽  
Eric A. Gantwerker ◽  
Myles L. Pensak ◽  
Philip V. Theodosopoulos
Keyword(s):  
Facial Nerve ◽  
Extent Of Resection ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Nerve Preservation ◽  
Facial Nerve Preservation ◽  
Grade 3

Abstract Background: Facial nerve preservation surgery for large vestibular schwannomas is a novel strategy for maintaining normal nerve function by allowing residual tumor adherent to this nerve or root-entry zone. Objective: To report, in a retrospective study, outcomes for large Koos grade 3 and 4 vestibular schwannomas. Methods: After surgical treatment for vestibular schwannomas in 52 patients (2004–2013), outcomes included extent of resection, postoperative hearing, and facial nerve function. Extent of resection defined as gross total, near total, or subtotal were 7 (39%), 3 (17%), and 8 (44%) in 18 patients after retrosigmoid approaches, respectively, and 10 (29.5%), 9 (26.5%), and 15 (44%) for 34 patients after translabyrinthine approaches, respectively. Results: Hearing was preserved in 1 (20%) of 5 gross total, 0 of 2 near-total, and 1 (33%) of 3 subtotal resections. Good long-term facial nerve function (House-Brackmann grades of I and II) was achieved in 16 of 17 gross total (94%), 11 of 12 near-total (92%), and 21 of 23 subtotal (91%) resections. Long-term tumor control was 100% for gross total, 92% for near-total, and 83% for subtotal resections. Postoperative radiation therapy was delivered to 9 subtotal resection patients and 1 near-total resection patient. Follow-up averaged 33 months. Conclusion: Our findings support facial nerve preservation surgery in becoming the new standard for acoustic neuroma treatment. Maximizing resection and close postoperative radiographic follow-up enable early identification of tumors that will progress to radiosurgical treatment. This sequential approach can lead to combined optimal facial nerve function and effective tumor control rates.

Middle Fossa Approach for Resection of Vestibular Schwannomas: A Decade of Experience

2018 ◽  
Vol 16 (2) ◽  
pp. 147-158 ◽  
Author(s):  
Jennifer A Kosty ◽  
Shawn M Stevens ◽  
Yair M Gozal ◽  
Vincent A DiNapoli ◽  
Smruti K Patel ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Tumor Size ◽  
Pure Tone ◽  
Vestibular Schwannomas ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Pure Tone Average ◽  
Class A ◽  
The Mean

AbstractBACKGROUNDThe middle cranial fossa (MCF) approach is a challenging surgical technique for the resection of small and intermediate sized, primarily intracanalicular, vestibular schwannomas (VS), with the goal of hearing preservation (HP).OBJECTIVETo describe a decade-long, single institutional experience with the MCF approach for resection of VS.METHODSThis is a retrospective cohort study of 63 patients who underwent the MCF approach for resection of VS from 2006 to 2016. Audiometric data included pure-tone average (PTA), low-tone pure-tone average (LtPTA), word recognition score, and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification at presentation and follow-up. Patients with postoperative serviceable (AAO-HNS class A-B) and/or useful (AAO-HNS class A-C) hearing were compared to those without HP. Facial nerve function was assessed using the House–Brackmann scale.RESULTSThe mean age and duration of follow-up were 50 ± 13 yr and 21 ± 21 mo, respectively. The mean tumor size was 10 ± 4 mm. The serviceable and usable HP rates were 54% and 50%, respectively. Some residual hearing was preserved in 71% of patients. Large tumor size (P = .05), volume (P = .03), and extrameatal tumor extension (P = .03) were associated with poor audiometric outcomes. The presence of a fundal fluid cap (P = .01) was a favorable finding. At definitive testing, LtPTA was significantly better preserved than traditional PTA (P = .01). Facial nerve outcomes, tumor control rates, and durability of audiometric outcomes were excellent. 47% of patients pursued aural rehabilitation.CONCLUSIONIn our series, the MCF approach for VS provided excellent rates of tumor and facial nerve function, with durable serviceable HP.

Functional outcome after complete surgical removal of giant vestibular schwannomas

2010 ◽  
Vol 112 (4) ◽  
pp. 860-867 ◽  
Author(s):  
Madjid Samii ◽  
Venelin M. Gerganov ◽  
Amir Samii
Keyword(s):  
Mortality Rate ◽  
Facial Nerve ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Tumor Removal ◽  
Lower Cranial Nerve ◽  
Cranial Nerve Dysfunction ◽  
Group A ◽  
Nerve Dysfunction ◽  
Group B

Object The authors evaluated the outcome of radical surgery in a consecutive series of patients with giant vestibular schwannomas (VSs). Methods Fifty patients with VSs > 4.0 cm in maximal extrameatal diameter were included in this retrospective study (Group A). The group was compared with a matched group of 167 patients with VSs < 3.9 cm (Group B). In all cases the retrosigmoid approach was used. Outcome measures included completeness of tumor removal, facial nerve function, hearing, and the surgery-related complication rate. Results The mean tumor size in Group A was 4.4 cm and that in Group B was 2.3 cm. Total removal was achieved in all Group A patients and in 97.6% of Group B patients. The anatomical integrity of the facial nerve was preserved in 92% in Group A and in 98.8% in Group B. At last follow-up 75% of the patients with giant VSs had excellent or good facial nerve function, 19% had fair function, and 6% had poor function. In 33% of patients (3 cases) with good preoperative hearing level, it was preserved. Newly developed lower cranial nerve dysfunction occurred in 3 patients but proved to be temporary in 2 of them. A CSF leak developed in 6% of those who not previously undergone surgery. Compared with Group B, a significant difference was found only in the rates of the following parameters: excellent facial nerve function, useful and good hearing, lower cranial nerve dysfunction, and blood collection (p < 0.05). The perioperative mortality rate in both groups was 0%. Conclusions In patients with a giant VS, total tumor removal can be achieved via the retrosigmoid approach with a 0% mortality rate and low morbidity rate, especially with regards to facial nerve function. In selected cases even hearing preservation is possible. Tumor size significantly correlates with postoperative outcome.

Near Total Versus Gross Total Resection of Large Vestibular Schwannomas: Facial Nerve Outcome

2020 ◽  
Vol 19 (4) ◽  
pp. 414-421
Author(s):  
Julia R Schneider ◽  
Amrit K Chiluwal ◽  
Orseola Arapi ◽  
Kevin Kwan ◽  
Amir R Dehdashti
Keyword(s):  
Facial Nerve ◽  
Significant Risk ◽  
Retrospective Chart Review ◽  
Gross Total Resection ◽  
Vestibular Schwannomas ◽  
Primary Data ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Total Resection

Abstract BACKGROUND Large vestibular schwannomas (VSs) with brainstem compression are generally reserved for surgical resection. Surgical aggressiveness must be balanced with morbidity from cranial nerve injury. The purpose of the present investigation is to evaluate the clinical presentation, management modality, and patient outcomes following near total resection (NTR) vs gross total resection (GTR) of large VSs. OBJECTIVE To assess facial nerve outcome differences between GTR and NTR patient cohorts. METHODS Between January 2010 and March 2018, a retrospective chart review was completed to capture patients continuously who had VSs with Hannover grades T4a and T4b. NTR was decided upon intraoperatively. Primary data points were collected, including preoperative symptoms, tumor size, extent of resection, and postoperative neurological outcome. RESULTS A total of 37 patients underwent surgery for treatment of large and giant (grade 4a and 4b) VSs. Facial nerve integrity was preserved in 36 patients (97%) at the completion of surgery. A total of 27 patients underwent complete resection, and 10 had near total (&gt;95%) resection. Among patients with GTR, 78% (21/27) had House-Brackmann (HB) grade I-II facial nerve function at follow-up, whereas 100% (10/10) of the group with NTR had HB grade I-II facial nerve function. Risk of meningitis, cerebrospinal fluid leak, and sinus thromboses were not statistically different between the 2 groups. There was no stroke, brainstem injury, or death. The mean follow-up was 36 mo. CONCLUSION NTR seems to offer a benefit in terms of facial nerve functional outcome compared to GTR in surgical management of large VSs without significant risk of recurrence.

The behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas

2014 ◽  
Vol 120 (6) ◽  
pp. 1278-1287 ◽  
Author(s):  
Zhengnong Chen ◽  
Sampath Chandra Prasad ◽  
Filippo Di Lella ◽  
Marimar Medina ◽  
Enrico Piccirillo ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Residual Tumor ◽  
Vestibular Schwannomas ◽  
Subtotal Resection ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Incomplete Excision ◽  
Kaplan Meier ◽  
Tumor Regrowth

Object The authors evaluated the behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas (VSs). Methods The case records of all patients who underwent surgical treatment of VSs were analyzed. All patients in whom an incomplete excision had been performed were analyzed. Incomplete excision was defined as near-total resection (NTR), subtotal resection (STR), and partial resection (PR). Tumors in the NTR and STR categories were followed up with a wait-and-rescan approach, whereas the tumors in the PR category were subjected to a second-stage surgery and were excluded from this series. All patients included in the study underwent baseline MRI at the 3rd and 12th postoperative months, and repeat imaging was subsequently performed every year for 7–10 years postoperatively or as indicated clinically. Preoperative and postoperative facial function was noted. Results Of the 2368 patients who underwent surgery for VS, 111 patients who had incomplete excisions of VSs were included in the study. Of these patients, 73 (65.77%) had undergone NTR and 38 (34.23%) had undergone STR. Of the VSs, 62 (55.86%) were cystic and 44 (70.97%) of these cystic VSs underwent NTR. The residual tumor was left behind on the facial nerve alone in 62 patients (55.86%), on the facial nerve and vessels in 2 patients (1.80%), on the facial nerve and brainstem in 15 patients (13.51%), and on the brainstem alone in 25 patients (22.52%). In the 105 patients with normal preoperative facial nerve function, postoperative facial nerve function was House-Brackmann (HB) Grades I and II in 51 patients (48.57%), HB Grade III in 34 patients (32.38%), and HB Grades IV–VI in 20 patients (19.05%). Seven patients (6.3%) showed evidence of tumor regrowth on follow-up MRI. All 7 patients (100%) who showed evidence of tumor regrowth had undergone STR. No patient in the NTR group exhibited regrowth. The Kaplan-Meier plot demonstrated a 5-year tumor regrowth-free survival of 92%, with a mean disease-free interval of 140 months (95% CI 127–151 months). The follow-up period ranged from 12 to 156 months (mean 45.4 months). Conclusions The authors' report and review of the literature show that there is undoubtedly merit for NTR and STR for preservation of the facial nerve. On the basis of this they propose an algorithm for the management of incomplete VS excisions. Patients who undergo incomplete excisions must be subjected to follow-up MRI for a period of at least 7–10 years. When compared with STR, NTR via an enlarged translabyrinthine approach has shown to have a lower rate of regrowth of residual tumor, while having almost the same result in terms of facial nerve function.

Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients

2006 ◽  
Vol 105 (4) ◽  
pp. 527-535 ◽  
Author(s):  
Madjid Samii ◽  
Venelin Gerganov ◽  
Amir Samii
Keyword(s):  
Facial Nerve ◽  
Hearing Preservation ◽  
Neurological Status ◽  
Retrosigmoid Approach ◽  
Cerebrospinal Fluid Leakage ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Nerve Preservation ◽  
Permanent Morbidity

Object The aim of this study was to evaluate and present the results of current surgical treatment of vestibular schwannomas (VSs) and to report the refinements in the operative technique. Methods The authors performed a retrospective study of 200 consecutive patients who had undergone VS surgery over a 3-year period. Patient records, operative reports, follow-up data, and neuroradiological findings were analyzed. The main outcome measures were magnetic resonance imaging, neurological status, patient complaints, and surgical complications. Complete tumor removal was achieved in 98% of patients. Anatomical preservation of the facial nerve was possible in 98.5% of patients. In patients treated for tumors with extension Classes T1, T2, and T3, the rate of facial nerve preservation was 100%. By the last follow-up examination, excellent or good facial nerve function had been achieved in 81% of the cases. By at least 1 year postsurgery, no patients had total facial palsy. In the patients with preserved hearing, the rate of anatomical preservation of the cochlear nerve was 84%. The overall rate of functional hearing preservation was 51%. There was no surgery-related permanent morbidity in this series of patients. Cerebrospinal fluid leakage was diagnosed in 2% of the patients. The mortality rate was 0%. Conclusions The goal of VS treatment should be total removal in one stage and preservation of neurological function, as they determine a patient’s quality of life. This goal can be safely and successfully achieved using the retrosigmoid approach.

Microsurgical management of vestibular schwannoma after failed previous surgery

2016 ◽  
Vol 125 (5) ◽  
pp. 1198-1203 ◽  
Author(s):  
Madjid Samii ◽  
Hussam Metwali ◽  
Venelin Gerganov
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Multivariate Regression Analysis ◽  
Control Group ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Significant Difference ◽  
Group A ◽  
Group B ◽  
Control Group Group

OBJECTIVE Microsurgical treatment of recurrent vestibular schwannoma (VS) is difficult and poses specific challenges. The authors report their experience with 53 cases of surgically treated recurrent VS. Outcome of these tumors was compared to that of primarily operated on VS. Special attention was given to the facial nerve functional outcome. METHODS A retrospective analysis was performed of the patients who underwent surgery for recurrent VS at one institution from 2000 to 2013. The preoperative data, intraoperative findings, and outcome in terms of facial nerve function and improvement of the preoperative symptoms were analyzed and compared with those in a control group of 30 randomly selected patients with primarily operated on VS. A multivariate regression analysis was performed to test the factors that could affect the facial nerve outcome in each group. RESULTS Fifty-three consecutive patients underwent surgery for recurrent VS. Seventeen patients were previously operated on and received postoperative radiosurgery (Group A). Thirty-six patients were previously operated on but did not receive postoperative radiosurgery (Group B). The overall postoperative facial nerve function was significantly worse in Groups A and B in comparison with the control group (Group C). Interestingly, there was no significant difference in the facial nerve outcome among the 3 groups in patients who had good preoperative facial nerve function. The tumor size and the preoperative facial nerve function are variables that significantly affect the facial nerve outcome. Most of the patients showed improvement of the preoperative symptoms, such as trigeminal hypesthesia, gait disturbance, and headache. CONCLUSIONS Complete microsurgical tumor removal is the optimal management for patients with recurrent or regrowing VS. The procedure is safe, associated with favorable facial nerve outcome, and may also improve existing neurological symptoms.

Facial Nerve Dissection Guided by Preoperative CT in Parotid Surgery

2019 ◽  
Vol 9 (8) ◽  
pp. 1782-1785
Author(s):  
Song Jin ◽  
Haili Tang ◽  
Rongyu Su
Keyword(s):  
Parotid Gland ◽  
Facial Nerve ◽  
Recovery Time ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Function Recovery ◽  
Parotid Surgery ◽  
Preoperative Ct ◽  
Group A ◽  
Group B

Objective: The parotid gland is closely related to the facial nerve. Appropriate facial nerve dissection is helpful to protect facial nerve function. The purpose of this study is to evaluate the parotid gland and its adjacent structures by preoperative CT, so as to guide the dissection of facial nerve during parotid surgery. Method: A total of 45 patients with parotid benign tumor diagnosed by pathology were collected. According the preoperative CT, two dissection methods of facial nerve was used. Twenty-one patients in group A were dissected by anterograde method from the trunk of facial nerve. Other 24 patients in Group B was dissected by retrograde method through the branch of facial nerve. The occurrence of facial nerve function injury and the recovery time of facial nerve function were observed. Result: Preoperative CT can evaluate the nature and adjacent relationship of parotid tumors. Anatomical localization markers of facial nerve can be evaluated. Group A has 1 case of facial nerve function injury (4.8%) occurred after surgery, and nerve function recovery time was (2.6 ± 0.5) m. Group B has 7 cases of facial nerve function damage (29.1%) occurred after surgery, and nerve function recovery time was (3.3 ± 0.7) m. Compared with Group A, the incidence of facial nerve function injury in Group B was higher, the nerve function recovery time was longer. Conclusion: Preoperative CT evaluation is helpful to the optimal selection of facial nerve anatomical pathway during parotid gland surgery. The anterograde and retrograde dissection of facial nerve can complete the operation successfully. The anterograde methods is the first choice as the lesser nerve function damage and faster recovery time.

scholarly journals The extracisternal approach in vestibular schwannoma surgery and facial nerve preservation

2014 ◽  
Vol 72 (12) ◽  
pp. 925-930 ◽  
Author(s):  
Eduardo A. S. Vellutini ◽  
André Beer-Furlan ◽  
Roger S. Brock ◽  
Marcos Q. T. Gomes ◽  
Aldo Stamm ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Cranial Nerves ◽  
Microsurgical Anatomy ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Tumor Removal ◽  
Total Resection ◽  
Nerve Preservation ◽  
One Year

The classical surgical technique for the resection of vestibular schwannomas (VS) has emphasized the microsurgical anatomy of cranial nerves. We believe that the focus on preservation of the arachnoid membrane may serve as a safe guide for tumor removal. Method The extracisternal approach is described in detail. We reviewed charts from 120 patients treated with this technique between 2006 and 2012. Surgical results were evaluated based on the extension of resection, tumor relapse, and facial nerve function. Results Overall gross total resection was achieved in 81% of the patients. The overall postoperative facial nerve function House-Brackmann grades I-II at one year was 93%. There was no recurrence in 4.2 years mean follow up. Conclusion The extracisternal technique differs from other surgical descriptions on the treatment of VS by not requiring the identification of the facial nerve, as long as we preserve the arachnoid envelope in the total circumference of the tumor.

scholarly journals 439 Conservative Versus Surgical Management of Complicated Diverticulitis - A Retrospective Study of Long-Term Outcomes

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
E Durity ◽  
G Elliott ◽  
T Gana
Keyword(s):  
Complicated Diverticulitis ◽  
Complication Rates ◽  
Long Term Outcomes ◽  
Female Ratio ◽  
Stoma Reversal ◽  
Group A ◽  
Grade 3 ◽  
Group B

Abstract Introduction Management of complicated diverticulitis has shifted towards a conservative approach over time. This study evaluates the feasibility and long-term outcomes of conservative management. Method We retrospectively evaluated a consecutive series of patients managed with perforated colonic diverticulitis from 2013-2017. Results Seventy-three (73) patients were included with a male to female ratio of 1:2. Thirty-one (31) underwent Hartmann’s procedure (Group A) and 42 patients were managed with antibiotics +/- radiological drainage (Group B). Mean follow-up was 64.9 months (range 3-7 years). CT Grade 3 and 4 disease was observed in 64.5% and 40.4% of Group A and Group B patients, respectively. During follow-up, 9 (21.4%) Group B patients required Hartmann’s. Group A had longer median length of stay compared to Group B (25.1 vs 9.2 days). Post-operative complications occurred in 80.6% with 40% being Clavien-Dindo grade III or higher in group A. Stoma reversal was performed in 8 patients (25.8%). Conclusions In carefully selected cases, complicated diverticulitis including CT grade 3 and 4 disease, can be managed conservatively with acceptable recurrence rates (16.7% at 30 days, 4.8% at 90 days, 19.0% at 5 years). Surgical intervention on the other hand, carries high post-operative complication rates and low stoma reversal rates.

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