Implications of Cystic Features in Vestibular Schwannomas of Patients Undergoing Microsurgical Resection

Neurosurgery ◽  
2011 ◽  
Vol 68 (4) ◽  
pp. 874-880 ◽  
Author(s):  
Brian J. Jian ◽  
Michael E. Sughrue ◽  
Rajwant Kaur ◽  
Martin J. Rutkowski ◽  
Ari J. Kane ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Postoperative Outcome ◽  
Hearing Preservation ◽  
Neck Surgery ◽  
Vestibular Schwannomas ◽  
Nerve Preservation ◽  
Cystic Tumors ◽  
Cystic Changes ◽  
Microsurgical Resection ◽  
Nerve Dysfunction

Abstract BACKGROUND: Cystic vestibular schwannomas (VSs) are described as being more aggressive than solid tumors. OBJECTIVE: We examined 468 VS patients to evaluate whether the presence of cystic components in VSs may be an important feature for predicting postoperative outcome. METHODS: We selected all VS patients from a prospectively collected database (1984–2009) who underwent microsurgical resection for VS. Hearing data were analyzed using American Association of Otolaryngology–Head and Neck Surgery. Facial nerve dysfunction was analyzed using the House-Brackmann scale. We used univariate comparisons to determine the clinical impact of cystic changes on preoperative and postsurgical hearing and facial nerve preservation. RESULTS: We identified 58 patients (11%) with cystic changes and 410 patients with solid VSs. In this analysis, cystic VS patients tended to have larger tumors (78% of patients with >2.0 cm extrameatal extension) compared with the solid VS group, which consisted of many smaller and medium-sized tumors (P < .0001). Univariate analyses found that tumors with cystic changes did not lead to worse rates of preoperative hearing loss (χ2, P = not significant) compared with solid VSs. Cystic changes conferred worse postoperative hearing in patients with medium-sized tumors (P = .035). Cystic changes also did not significantly affect facial nerve outcomes (χ2, P = not significant). CONCLUSION: Cystic tumors tend to be larger than noncystic tumors and affect outcomes by reducing the rate at which hearing preservation is attempted and by worsening hearing outcome in medium-sized tumors. Further, peripheral cysts cause lower rates of hearing preservation compared with centrally located cysts.

766 Endoscopic Surgery for Sporadic Vestibular Schwannoma Resection: A Systematic Review of Surgical Outcomes

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
S Chiuta ◽  
S Raza-Knight ◽  
A Alalade
Keyword(s):  
Facial Nerve ◽  
Hearing Preservation ◽  
Extent Of Resection ◽  
Current Data ◽  
Resection Rate ◽  
Eighth Cranial Nerve ◽  
Nerve Preservation ◽  
Microsurgical Resection ◽  
Hearing Outcomes ◽  
Series Report

Abstract Introduction Vestibular schwannomas (VS) are benign intracranial tumours originating from the vestibular division of the eighth cranial nerve. The mainstay of their surgical management is microsurgery, other options are radiotherapy or radiological monitoring. Endoscopy (ES) is becoming widely used in neurosurgery and may have a role in improving visualisation and outcomes by enhancing extent of resection, facial nerve, and hearing preservation in VS resection and describe the postoperative outcomes. Method The review was conducted according to the PRISMA guidelines and yielded 31 studies for inclusion. Systematic searches of literature databases were done for studies where endoscopic-assisted and/or endoscopic resection of VS were reported. Results ES facial nerve preservation rates (median 91.3%, range 39.0 - 100%) were comparable to microsurgical treatment. Hearing outcomes were more variable in ES series and were under-reported. A median gross total resection rate of 97.4% (61.0 - 100%) was achieved in the ES series. Conclusions Current data suggest that ES-assisted resection of sporadic VS is not inferior to microsurgical resection with respect to facial nerve outcomes and extent of resection. However, some ES series report poor hearing outcomes, which are under-reported in the literature.

scholarly journals Diamond knife dissection technique for nerve preservation during resection of large vestibular schwannomas

2021 ◽  
Vol 5 (2) ◽  
pp. V8
Author(s):  
Julia Shawarba ◽  
Cand Med ◽  
Matthias Tomschik ◽  
Karl Roessler
Keyword(s):  
Vestibular Schwannoma ◽  
Facial Nerve Palsy ◽  
Hearing Preservation ◽  
Vestibular Schwannomas ◽  
Nerve Preservation ◽  
Dissection Techniques ◽  
Dissection Technique ◽  
Large Vestibular Schwannoma ◽  
Facial Function ◽  
Diamond Knife

Facial and cochlear nerve preservation in large vestibular schwannomas is a major challenge. Bimanual pincers or plate-knife dissection techniques have been described as crucial for nerve preservation. The authors demonstrate a recently applied diamond knife dissection technique to peel the nerves from the tumor capsule. This technique minimizes the nerve trauma significantly, and complete resection of a large vestibular schwannoma without any facial nerve palsy and hearing preservation is possible. The authors illustrate this technique during surgery of a 2.6-cm vestibular schwannoma in a 27-year-old male patient resulting in normal facial function and preserved hearing postoperatively. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21104

Comparison of Surgical Outcomes and Recurrence Rates of Cystic and Solid Vestibular Schwannomas

2019 ◽  
Author(s):  
Rami O. Almefty ◽  
David S. Xu ◽  
Michael A. Mooney ◽  
Andrew Montoure ◽  
Komal Naeem ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Facial Nerve ◽  
Tumor Progression ◽  
Clinical Outcomes ◽  
Univariate Analysis ◽  
Growth Patterns ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Tumor Diameter ◽  
Cystic Tumors

Abstract Objective Cystic vestibular schwannomas (CVSs) are anecdotally believed to have worse clinical and tumor-control outcomes than solid vestibular schwannomas (SVSs); however, no data have been reported to support this belief. In this study, we characterize the clinical outcomes of patients with CVSs versus those with SVSs. Design This is a retrospective review of prospectively collected data. Setting This study is set at single high-volume neurosurgical institute. Participants We queried a database for details on all patients diagnosed with vestibular schwannomas between January 2009 and January 2014. Main Outcome Measures Records were retrospectively reviewed and analyzed using univariate and multivariate analyses to study the differences in clinical outcomes and tumor progression or recurrence. Results Of a total of 112 tumors, 24% (n = 27) were CVSs and 76% (n = 85) were SVSs. Univariate analysis identified the extent of resection, Koos grade, and tumor diameter as significant predictors of recurrence (p ≤ 0.005). However, tumor diameter was the only significant predictor of recurrence in the multivariate analysis (p = 0.007). Cystic change was not a predictor of recurrence in the univariate or multivariate analysis (p ≥ 0.40). Postoperative facial nerve and hearing outcomes were similar for both CVSs and SVSs (p ≥ 0.47). Conclusion Postoperative facial nerve outcome, hearing, tumor progression, and recurrence are similar for patients with CVSs and SVSs. As CVS growth patterns and responses to radiation are unpredictable, we favor microsurgical resection over radiosurgery as the initial treatment. Our data do not support the commonly held belief that cystic tumors behave more aggressively than solid tumors or are associated with increased postoperative facial nerve deficits.

scholarly journals How I Do It: The Role of Flexible Hand-held 2μ-Thulium Laser Fiber in Microsurgical Removal of Acoustic Neuromas

2017 ◽  
Vol 78 (04) ◽  
pp. 301-307 ◽  
Author(s):  
Guglielmo Cacciotti ◽  
Raffaele Roperto ◽  
Maria Tonelli ◽  
Ettore Carpineta ◽  
Luciano Mastronardi
Keyword(s):  
Facial Nerve ◽  
Tumor Resection ◽  
Hearing Preservation ◽  
Matched Pair ◽  
Nerve Preservation ◽  
Acoustic Neuromas ◽  
Laser Fiber ◽  
Laser Focusing ◽  
Preservation Rate

Aims We performed a retrospective nonrandomized study to analyze the results of microsurgery of acoustic neuromas (AN) using 2μ-thulium flexible hand-held laser fiber (Revolix jr). Methods From September 2010 to September 2015, 89 patients suffering from AN have been operated on with microsurgical technique via retrosigmoid approach. In 37 cases, tumor resection was performed with the assistance of 2μ-thulium flexible hand-held laser fiber (L-group). Eight cases operated on with the assistance of CO2 hand-held flexible laser fiber were excluded from this study. A total of 44 patients, operated on without laser assistance during the same period, were used as comparison group (C-group) (matched pair technique). Facial nerve function was assessed with the House–Brackmann (HB) scale preoperatively, and 1 week and 6 months postoperatively. Results Overall time from incision to skin suture changed in relation to size of tumor (165–575 minutes) and was not affected by the use of laser. In 7 out of 81 cases, a preoperative facial nerve palsy HB2 and in 1 case, HB4 (permanent) were observed. In the remaining 80 cases, at 6-month follow-up, facial nerve preservation rate (HB1) was 92.5%. Hearing preservation rate (AAO-HNS A/B classes) was 68.2% (26 out of 36). Adopting a 0 to 3 scale, the mean surgeon satisfaction rate of usefulness of laser fiber was 2.7. Conclusion The use of 2μ-thulium hand-held flexible laser fiber in AN microsurgery seems to be safe and subjectively facilitates tumor resection especially in “difficult” conditions (e.g., highly vascularized and hard tumors). In this limited retrospective trial, the good functional outcome following conventional microsurgery had not further improved, nor the surgical time reduced by laser. Focusing its use on “difficult” (large and vascularized) cases may lead to different results in future.

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.

scholarly journals Decompression of the labyrinthine segment of the facial nerve in acoustic neuroma surgery: a consideration for minimizing postoperative delayed facial nerve dysfunction

1998 ◽  
Vol 5 (3) ◽  
pp. E11 ◽  
Author(s):  
Michael J. Holliday ◽  
Prakash Sampath
Keyword(s):  
Facial Nerve ◽  
Nerve Palsy ◽  
Facial Nerve Palsy ◽  
Internal Auditory Canal ◽  
Acoustic Neuromas ◽  
Microsurgical Resection ◽  
Nerve Dysfunction ◽  
Group 2 ◽  
Acoustic Tumor ◽  
Group 1

Delayed facial nerve palsy, a condition characterized by spontaneous deterioration of facial nerve function in patients who had otherwise normal or near-normal facial function in the immediate postoperative period, has been reported in 15 to 29% of patients undergoing microsurgical resection of vestibular schwannomas. One putative mechanism for its occurrence suggests that edematous entrapment of the facial nerve in the meatal foramen (the narrowest segment of the internal auditory canal) may lead to nerve ischemia or necrosis and subsequent facial nerve dysfunction. To assess whether meatal decompression may help reduce the incidence of delayed facial nerve palsy during microsurgical resection of acoustic tumors, we compared 25 patients undergoing translabyrinthine removal of acoustic neuromas who received prophylactic decompression of the labyrinthine segment of the facial nerve (Group 1) with 40 patients who did not receive facial nerve decompression (Group 2). No patients in Group 1 had a delayed progressive facial paralysis with degeneration. In contrast, when Group 2 patients with larger, average-sized tumors were reviewed, eight patients (20%) developed delayed degeneration. These findings suggest that decompression of the labyrinthine segment may be of value in acoustic tumor surgery in reducing delayed facial nerve dysfunction. Further study is indicated in this important area.

Hearing preservation in medial vestibular schwannomas

2008 ◽  
Vol 109 (1) ◽  
pp. 70-76 ◽  
Author(s):  
Christian Strauss ◽  
Barbara Bischoff ◽  
Johann Romstöck ◽  
Jens Rachinger ◽  
Stefan Rampp ◽  
...  
Keyword(s):  
Growth Pattern ◽  
Auditory Evoked Potentials ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Neck Surgery ◽  
Underlying Disease ◽  
Cochlear Nerve ◽  
Vestibular Schwannomas ◽  
Consecutive Series ◽  
Tumor Removal

Object Vestibular schwannomas (VSs) with no or little extension into the internal auditory canal have been addressed as a clinical subentity carrying a poor prognosis regarding hearing preservation, which is attributed to the initially asymptomatic intracisternal growth pattern. The goal in this study was to assess hearing preservation in patients who underwent surgery for medial VSs. Methods A consecutive series of 31 cases in 30 patients with medial VSs (mean size 31 mm) who underwent surgery between 1997 and 2005 via a suboccipitolateral route was evaluated with respect to pre- and postoperative cochlear nerve function, extent of tumor removal, and radiological findings. Intraoperative monitoring of brainstem auditory evoked potentials was performed in all patients with hearing. Patients were reevaluated at a mean of 30 months following surgery. Results Preoperative hearing function revealed American Academy of Otolaryngology–Head and Neck Surgery Foundation Classes A and B in 7 patients each, Class C in 4, and D in 9. Four patients presented with deafness. Hearing preservation was achieved in 10 patients (Classes A–C in 2 patients each, and Class D in 4 patients). Tumor removal was complete in all patients with hearing preservation, except for 2 patients with neurofibromatosis. In 4 patients a planned subtotal excision was performed due to the individual's age or underlying disease. In 1 patient a recurrent tumor was completely removed 3 years after the initial procedure. Conclusions The cochlear nerve in medial VSs requires special attention due to the atypical intracisternal growth pattern. Even in large tumors, hearing could be preserved in 37% of cases, since the cochlear nerve in medial schwannomas may not exhibit the adherence to the tumor capsule seen in tumors with comparable size involving the internal auditory canal.

Suboccipital Retrosigmoid Approach for Removal of Vestibular Schwannomas: Facial Nerve Function and Hearing Preservation

Neurosurgery ◽  
2005 ◽  
Vol 56 (3) ◽  
pp. 560-570 ◽  
Author(s):  
Ivan Ciric ◽  
Jin-cheng Zhao ◽  
Sami Rosenblatt ◽  
Richard Wiet ◽  
Brian O'shaughnessy
Keyword(s):  
Prognostic Factors ◽  
Surgical Technique ◽  
Facial Nerve ◽  
Hearing Preservation ◽  
Vestibular Schwannomas ◽  
Neurophysiological Monitoring ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Tumor Removal ◽  
Neurovascular Anatomy

Abstract IN THIS REPORT, we discuss the pertinent bony, arachnoid, and neurovascular anatomy of vestibular schwannomas that has an impact on the surgical technique for removal of these tumors, with the goal of facial nerve and hearing preservation. The surgical technique is described in detail starting with anesthesia, positioning, and neurophysiological monitoring and continuing with the exposure, technical nuances of tumor removal, hemostasis, and closure. Positive prognostic factors for hearing preservation are also highlighted.

scholarly journals The Transcrusal Approach

Neurosurgery ◽  
2010 ◽  
Vol 66 (5) ◽  
pp. 1017-1022 ◽  
Author(s):  
Michael G. Brandt ◽  
Justin Poirier ◽  
Brian Hughes ◽  
Stephen P. Lownie ◽  
Lorne S. Parnes
Keyword(s):  
Facial Nerve ◽  
Basilar Artery ◽  
Cranial Nerve ◽  
Significant Risk ◽  
Artery Aneurysm ◽  
Hearing Preservation ◽  
Petrous Apex ◽  
Nerve Preservation ◽  
Trigeminal Schwannoma ◽  
Transcrusal Approach

Abstract OBJECTIVE This study reviewed the experience and outcomes of 1 surgical team (L.S.P., S.P.L.) using the transcrusal approach. METHODS Ten-year retrospective review of 17 consecutive patients requiring transcrusal exposure of the petrous apex and upper brainstem was performed. The main outcome measures included hearing and facial nerve preservation as measured by standard audiography and postoperative assessment using the House-Brackmann scale. RESULTS Operative indications included meningioma (5 patients), epidermoid/dermoid cyst (3 patients), trigeminal schwannoma (3 patients), giant or large upper basilar artery aneurysm (3 patients), pontine cavernoma (1 patient), chondrosarcoma (1 patient), and clival melanocytoma (1 patient). Average tumor size was 3.6 cm. Complete resection was achieved in 50% of patients with petroclival tumors. Follow-up data were obtained for 14 patients at 20 ± 4 months. Serviceable hearing was preserved in 58%. Sixty-four percent of patients demonstrated House-Brackmann stage I facial nerve function. Two patients died perioperatively (brainstem infarction). Two patients became hemiparetic, with 1 improving substantially. CSF leaks developed in 3 patients. Forty-seven percent of patients demonstrated cranial nerve V deficits. Forty-one percent of patients demonstrated deficits of cranial nerve III, IV, or VI. Vertigo, vestibular disturbance, hydrocephalus, temporal lobe contusion, or hematoma did not develop in any patients. CONCLUSION The transcrusal approach provides adequate exposure for most petroclival lesions and giant aneurysms of the upper basilar artery while offering the possibility of hearing preservation. Like all approaches to large tumors and aneurysms in this region, there is a significant risk of morbidity and mortality. However, this approach is an excellent alternative to other techniques that necessitate deliberate sacrifice of ipsilateral hearing.

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