Outcomes of Salvage Resection and Radiosurgery Following Failed Primary Treatment of Vestibular Schwannomas

2021 ◽  
pp. 019459982110397
Author(s):  
Emily Kay-Rivest ◽  
John G. Golfinos ◽  
Sean O. McMenomey ◽  
David R. Friedmann ◽  
Daniel Jethanamest ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Retrospective Chart Review ◽  
Primary Treatment ◽  
Vestibular Schwannomas ◽  
Sensory Loss ◽  
Safe Alternative ◽  
Gradual Improvement ◽  
Tertiary Referral Center ◽  
Salvage Resection ◽  
Facial Function

Objective To evaluate outcomes following salvage microsurgery (MS) and salvage stereotactic radiosurgery (SRS) after failure of primary treatment for vestibular schwannomas (VS). Study Design Retrospective chart review. Setting Tertiary referral center. Methods Patients with more than 1 intervention for their VS were divided into 4 groups: MS followed by SRS (n = 61), MS followed by MS (n = 9), SRS followed by MS (n = 7), and SRS followed by SRS (n = 7), and outcomes were evaluated. Results A total of 77 patients were included (84 procedures). In group 1 (MS then SRS), 3% developed a decline in facial function, 3% developed trigeminal sensory loss, and 13% patients had gradual improvement of facial nerve function following SRS. Group 2 (MS then MS) had the highest rates of facial nerve deterioration, although all but 1 patient achieved a House-Brackmann score of II or III. Gross-total resection (GTR) was achieved in 56% of patients. When a different approach was used for salvage resection, GTR occurred more commonly, and facial nerve outcomes were similar. In group 3 (SRS then MS), GTR occurred in 43% of cases, and 2 of 7 patients developed worsened facial function. In group 4 (SRS then SRS), no patient developed facial weakness after reirradiation, and 1 developed a trigeminal nerve deficit. Conclusions For MS recurrences/residuals, SRS is the mainstay of treatment and does not preclude facial function recovery. If salvage microsurgery is required, an alternate approach should be considered. For SRS failures, when MS is required, less-than GTR may be preferable, and reirradiation is a potential safe alternative.

scholarly journals Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes

2018 ◽  
Vol 44 (3) ◽  
pp. E2 ◽  
Author(s):  
Reid Hoshide ◽  
Harrison Faulkner ◽  
Mario Teo ◽  
Charles Teo
Keyword(s):  
Minimally Invasive ◽  
Facial Nerve ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Retrosigmoid Approach ◽  
Vestibular Schwannomas ◽  
Tumor Diameter ◽  
Nerve Preservation ◽  
Facial Nerve Preservation

OBJECTIVEThere are numerous treatment strategies in the management for large vestibular schwannomas, including resection only, staged resections, resections followed by radiosurgery, and radiosurgery only. Recent evidence has pointed toward maximal resection as being the optimum strategy to prevent tumor recurrence; however, durable tumor control through aggressive resection has been shown to occur at the expense of facial nerve function and to risk other approach-related complications. Through a retrospective analysis of their single-institution series of keyhole neurosurgical approaches for large vestibular schwannomas, the authors aim to report and justify key techniques to maximize tumor resection and reduce surgical morbidity.METHODSA retrospective chart review was performed at the Centre for Minimally Invasive Neurosurgery. All patients who had undergone a keyhole retrosigmoid approach for the resection of large vestibular schwannomas, defined as having a tumor diameter of ≥ 3.0 cm, were included in this review. Patient demographics, preoperative cranial nerve status, perioperative data, and postoperative follow-up were obtained. A review of the literature for resections of large vestibular schwannomas was also performed. The authors’ institutional data were compared with the historical data from the literature.RESULTSBetween 2004 and 2017, 45 patients met the inclusion criteria for this retrospective chart review. When compared with findings in a historical cohort in the literature, the authors’ minimally invasive, keyhole retrosigmoid technique for the resection of large vestibular schwannomas achieved higher rates of gross-total or near-total resection (100% vs 83%). Moreover, these results compare favorably with the literature in facial nerve preservation (House-Brackmann I–II) at follow-up after gross-total resections (81% vs 47%, p < 0.001) and near-total resections (88% vs 75%, p = 0.028). There were no approach-related complications in this series.CONCLUSIONSIt is the experience of the senior author that complete or near-complete resection of large vestibular schwannomas can be successfully achieved via a keyhole approach. In this series of 45 large vestibular schwannomas, a greater extent of resection was achieved while demonstrating high rates of facial nerve preservation and low approach-related and postoperative complications compared with the literature.

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.

Multivariate Analysis of Factors Influencing Facial Nerve Outcome following Microsurgical Resection of Vestibular Schwannoma

2016 ◽  
Vol 156 (3) ◽  
pp. 525-533 ◽  
Author(s):  
Renato Torres ◽  
Yann Nguyen ◽  
Antoine Vanier ◽  
Mustapha Smail ◽  
Evelyne Ferrary ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Predictive Factor ◽  
Conduction Block ◽  
Case Series ◽  
Advanced Tumor Stage ◽  
Tertiary Referral Center ◽  
Advanced Tumor ◽  
Facial Function

Objective To assess through multivariate analysis the clinical pre- and intraoperative factors of facial nerve outcomes at day 8 and 1-year recovery of facial palsy, as compared with day 8 status among patients who underwent total resection of unilateral vestibular schwannoma. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods This study included 229 patients with preoperative normal facial function and anatomic preservation of the facial nerve. Clinical, radiologic, and intraoperative factors were assessed according to facial nerve function at day 8 and 1 year. Results We observed that 74% and 84% of patients had good facial function (House-Brackmann [HB] I-II) at day 8 and 1 year, respectively. Of 60 patients, 26 (43%) who had impaired facial function (HB III-VI) at day 8 recovered good facial function (HB I-II) 1 year after surgery. A structured equation model showed that advanced tumor stage and strong facial nerve adhesion were independently associated with facial nerve conduction block at day 8. No predictive factor of impaired facial function recovery was seen at 1 year. In terms of the extracanalicular diameter of the tumor, the cutoff point to minimize the risk of impaired facial function was 16 mm. Conclusion At day 8 after vestibular schwannoma resection, facial function was impaired in the case of large tumors or strong facial nerve adhesion to the tumor. After 1 year, less than half of the patients recovered good facial function, and no predictive factor was found to be associated with this possible recovery.

Can an Imaging Marker of Consistency Predict Intraoperative Experience and Clinical Outcomes for Vestibular Schwannomas? A Retrospective Review

2019 ◽  
Author(s):  
Robert J. Macielak ◽  
Michael S. Harris ◽  
Jameson K. Mattingly ◽  
Varun S. Shah ◽  
Luciano M. Prevedello ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Outcome Measures ◽  
Tumor Volume ◽  
Perioperative Complications ◽  
Retrospective Chart Review ◽  
Vestibular Schwannomas ◽  
Surgical Time ◽  
Tertiary Referral Center ◽  
Microsurgical Resection ◽  
Tumor Consistency

Abstract Objective The main purpose of this article is to determine if vestibular schwannoma consistency as determined by tissue intensity on T2-weighted magnetic resonance imagings (MRIs) is predictive of intraoperative experience and postoperative clinical outcomes. Study Design Retrospective chart review. Setting Tertiary referral center. Patients Seventy-seven patients diagnosed with vestibular schwannomas who were treated with microsurgical resection. Intervention Diagnostic. Main Outcome Measures Intraoperative measures include totality of resection, surgical time and cranial nerve VII stimulation and postoperative measures include House–Brackmann grade and perioperative complications. Results Tumor consistency determined via tissue intensity on MRI was only found to correlate with surgical time, with a softer tumor being associated with a longer surgical time (p < 0.0001). However, this was primarily driven by tumor volume with larger tumors being associated with longer surgical time based on multivariate analysis. None of the other intraoperative or postoperative measures considered were found to correlate with tumor consistency. Conclusions Tumor consistency determined by MRI is not predictive of intraoperative experience or postoperative outcomes in vestibular schwannomas. Tumor volume is the strongest driver of these outcome measures as opposed to tumor consistency.

Resection of large vestibular schwannomas: facial nerve preservation in the context of surgical approach and patient-assessed outcome

2005 ◽  
Vol 102 (4) ◽  
pp. 643-649 ◽  
Author(s):  
Douglas E. Anderson ◽  
John Leonetti ◽  
Joshua J. Wind ◽  
Denise Cribari ◽  
Karen Fahey
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannomas ◽  
Facial Nerve Paralysis ◽  
Nerve Paralysis ◽  
Nerve Monitoring ◽  
Content Type ◽  
Nerve Preservation ◽  
Facial Nerve Monitoring ◽  
Facial Function ◽  
Fine Print

Object. Vestibular schwannoma surgery has evolved as new therapeutic options have emerged, patients' expectations have risen, and the psychological effect of facial nerve paralysis has been studied. For large vestibular schwannomas for which extirpation is the primary therapy, the goals remain complete tumor resection and maintenance of normal neurological function. Improved microsurgical techniques and intraoperative facial nerve monitoring have decreased the complication rate and increased the likelihood of normal to near-normal postoperative facial function. Nevertheless, the impairment most frequently reported by patients as an adverse effect of surgery continues to be facial nerve paralysis. In addition, patient assessment has provided a different, less optimistic view of outcome. The authors evaluated the extent of facial function, timing of facial nerve recovery, patients' perceptions of this recovery and function, and the prognostic value of intraoperative facial nerve monitoring following resection of large vestibular schwannomas; they then analyzed these results with respect to different surgical approaches. Methods. The authors retrospectively reviewed a database of 67 patients with 71 vestibular schwannomas measuring 3 cm or larger in diameter. The patients had undergone surgery via translabyrinthine, retrosigmoid, or combined approaches. Clinical outcomes were analyzed with respect to intraoperative facial nerve activity, responses to intraoperative stimulation, and time course of recovery. Eighty percent of patients obtained normal to near-normal facial function (House—Brackmann Grades I and II). Patients' perceptions of facial nerve function and recovery correlated well with the clinical observations. Conclusions. Trends in the data lead the authors to suggest that a retrosigmoid exposure, alone or in combination with a translabyrinthine approach, offers the best chance of facial nerve preservation in patients with large vestibular schwannomas.

Facial Nerve Function After Vestibular Schwannoma Surgery Following Failed Conservative Management

Neurosurgery ◽  
2011 ◽  
Vol 70 (2) ◽  
pp. 278-282 ◽  
Author(s):  
Mikkel Kaltoft ◽  
Sven-Eric Stangerup ◽  
Per Caye-Thomasen
Keyword(s):  
Tumor Growth ◽  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Conservative Management ◽  
Vestibular Schwannomas ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Number Of Patients ◽  
A Minor ◽  
Facial Function

Abstract BACKGROUND: Because only a limited proportion of vestibular schwannomas display growth after diagnosis, an increasing number of patients are managed conservatively. Tumor growth during “wait and scan” may, however, necessitate surgery. In these cases, increased tumor size is likely to increase the risk of impaired facial nerve function after surgery. OBJECTIVE: To compare facial nerve function in patients operated on soon after diagnosis with patients allocated to conservative management and the subgroup of these who later had surgery because of tumor growth. METHODS: A total of 1378 consecutive patients diagnosed with a vestibular schwannoma 20 mm extrameatal or smaller were included; 419 patients were operated on soon after diagnosis, and 959 patients were initially managed conservatively. In the latter group, 161 patients were subsequently operated on owing to tumor growth. RESULTS: All conservatively managed patients had normal facial nerve function at the end of observation. Good facial nerve outcome was found in 87% of patients operated on at diagnosis and in 84% of patients operated on after established tumor growth. For the subgroup of small extrameatal tumors, this difference was significant. When all patients allocated primarily to conservative management were pooled, good facial function was found in 97%, which was significantly better than the result for primary operation (87%). CONCLUSION: Overall, conservative management of small to medium-sized vestibular schwannomas is the best option in terms of preservation of facial nerve function. Tumor growth during observation is found in only a minor proportion of the patients, and in these cases, surgery or irradiation should be performed immediately.

Cerebellopontine Angle Surgery Assisted by Continuous Mapping of the Facial Nerve Via the Ultrasonic Aspirator

2020 ◽  
Author(s):  
Marco Cenzato ◽  
Roberto Stefini ◽  
Francesco Zenga ◽  
Maurizio Piparo ◽  
Alberto Debernardi ◽  
...  
Keyword(s):  
Electrical Stimulation ◽  
Facial Nerve ◽  
Cerebellopontine Angle ◽  
Continuous Mapping ◽  
Cost Effective ◽  
Current Intensity ◽  
Vestibular Schwannomas ◽  
Constant Current ◽  
Surgical Workflow ◽  
Ultrasonic Aspirator

Abstract Background Cerebellopontine angle (CPA) surgery carries the risk of lesioning the facial nerve. The goal of preserving the integrity of the facial nerve is usually pursued with intermittent electrical stimulation using a handheld probe that is alternated with the resection. We report our experience with continuous electrical stimulation delivered via the ultrasonic aspirator (UA) used for the resection of a series of vestibular schwannomas. Methods A total of 17 patients with vestibular schwannomas, operated on between 2010 and 2018, were included in this study. A constant-current stimulator was coupled to the UA used for the resection, delivering square-wave pulses throughout the resection. The muscle responses from upper and lower face muscles triggered by the electrical stimulation were displayed continuously on multichannel neurophysiologic equipment. The careful titration of the electrical stimulation delivered through the UA while tapering the current intensity with the progression of the resection was used as the main strategy. Results All operations were performed successfully, and facial nerve conduction was maintained in all patients except one, in whom a permanent lesion of the facial nerve followed a miscommunication to the neurosurgeon. Conclusion The coupling of the electrical stimulation to the UA provided the neurosurgeon with an efficient and cost-effective tool and allowed a safe resection. Positive responses were obtained from the facial muscles with low current intensity (lowest intensity: 0.1 mA). The availability of a resection tool paired with a stimulator allowed the surgeon to improve the surgical workflow because fewer interruptions were necessary to stimulate the facial nerve via a handheld probe.

scholarly journals Sensitivity and Negative Predictive Value of Motor Evoked Potentials of the Facial Nerve

2021 ◽  
Author(s):  
Nicolas Bovo ◽  
Shahan Momjian ◽  
Renato Gondar ◽  
Philippe Bijlenga ◽  
Karl Schaller ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Evoked Potentials ◽  
Negative Predictive Value ◽  
Patient Group ◽  
Vestibular Schwannoma ◽  
Predictive Value ◽  
Cerebellopontine Angle ◽  
Motor Evoked Potentials ◽  
Vestibular Schwannomas ◽  
Predictive Values

Abstract Objective The objective of this study was to determine the performance of the standard alarm criterion of motor evoked potentials (MEPs) of the facial nerve in surgeries performed for resections of vestibular schwannomas or of other lesions of the cerebellopontine angle. Methods This retrospective study included 33 patients (16 with vestibular schwannomas and 17 with other lesions) who underwent the resection surgery with transcranial MEPs of the facial nerve. A reproducible 50% decrease in MEP amplitude, resistant to a 10% increase in stimulation intensity, was applied as the alarm criterion during surgery. Facial muscular function was clinically evaluated with the House–Brackmann score (HBS), pre- and postsurgery at 3 months. Results In the patient group with vestibular schwannoma, postoperatively, the highest sensitivity and negative predictive values were found for a 30% decrease in MEP amplitude, that is, a criterion stricter than the 50% decrease in MEP amplitude criterion, prone to trigger more warnings, used intraoperatively. With this new criterion, the sensitivity would be 88.9% and the negative predictive value would be 85.7%. In the patient group with other lesions of the cerebellopontine angle, the highest sensitivity and negative predictive values were found equally for 50, 60, or 70% decrease in MEP amplitude. With these criteria, the sensitivities and the negative predictive values would be 100.0%. Conclusion Different alarm criteria were found for surgeries for vestibular schwannomas and for other lesions of the cerebellopontine angle. The study consolidates the stricter alarm criterion, that is, a criterion prone to trigger early warnings, as found previously by others for vestibular schwannoma surgeries (30% decrease in MEP amplitude).

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