Efficacy of facial nerve–sparing approach in patients with vestibular schwannomas

2011 ◽  
Vol 115 (5) ◽  
pp. 917-923 ◽  
Author(s):  
Raqeeb Haque ◽  
Teresa J. Wojtasiewicz ◽  
Paul R. Gigante ◽  
Mark A. Attiah ◽  
Brendan Huang ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Residual Tumor ◽  
Subtotal Resection ◽  
Nerve Sparing ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Total Resection ◽  
Nerve Preservation ◽  
Facial Nerve Preservation ◽  
Microsurgical Resection

Object The goal of this article was to show that a combination of facial nerve–sparing microsurgical resection and Gamma Knife surgery (GKS) for expansion of any residual tumor can preserve good facial nerve function in patients with recurrent vestibular schwannoma (VS). Methods Records of individuals treated by a single surgeon with a facial nerve–sparing technique for a VS between 1998 and 2009 were retrospectively analyzed for tumor recurrence. Of the 383 patients treated for VS, 151 underwent microsurgical resection, and 20 (13.2%) of these patients required postoperative retreatment for a significant expansion of residual tumor after microsurgery. These 20 patients were re-treated with GKS. Results The rate of preservation of good facial nerve function (Grade I or II on the House-Brackmann scale) in patients treated with microsurgery for VS was 97%. Both subtotal and gross-total resection had excellent facial nerve preservation rates (97% vs 96%), although subtotal resection carried a higher risk that patients would require retreatment. In patients re-treated with GKS after microsurgery, the rate of facial nerve preservation was 95%. Conclusions In patients with tumors that cannot be managed with radiosurgery alone, a facial nerve–sparing resection followed by GKS for any significant regrowth provides excellent facial nerve preservation rates.

scholarly journals Efficacy and outcomes of facial nerve–sparing treatment approach to cerebellopontine angle meningiomas

2017 ◽  
Vol 127 (6) ◽  
pp. 1231-1241 ◽  
Author(s):  
Randy S. D'Amico ◽  
Matei A. Banu ◽  
Petros Petridis ◽  
Alexandra S. Bercow ◽  
Hani Malone ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Extent Of Resection ◽  
Nerve Sparing ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Anatomical Features ◽  
Nerve Preservation ◽  
Facial Nerve Preservation ◽  
Tumor Origin ◽  
Microsurgical Resection

OBJECTIVEAdvanced microsurgical techniques contribute to reduced morbidity and improved surgical management of meningiomas arising within the cerebellopontine angle (CPA). However, the goal of surgery has evolved to preserve the quality of the patient's life, even if it means leaving residual tumor. Concurrently, Gamma Knife radiosurgery (GKRS) has become an acceptable and effective treatment modality for newly diagnosed, recurrent, or progressive meningiomas of the CPA. The authors review their institutional experience with CPA meningiomas treated with GKRS, surgery, or a combination of surgery and GKRS. They specifically focus on rates of facial nerve preservation and characterize specific anatomical features of tumor location with respect to the internal auditory canal (IAC).METHODSMedical records of 76 patients with radiographic evidence or a postoperative diagnosis of CPA meningioma, treated by a single surgeon between 1992 and 2016, were retrospectively reviewed. Patients with CPA meningiomas smaller than 2.5 cm in greatest dimension were treated with GKRS, while patients with tumors 2.5 cm or larger underwent facial nerve–sparing microsurgical resection where appropriate. Various patient, clinical, and tumor data were gathered. Anatomical features of the tumor origin as seen on preoperative imaging confirmed by intraoperative investigation were evaluated for prognostic significance. Facial nerve preservation rates were evaluated.RESULTSAccording to our treatment paradigm, 51 (67.1%) patients underwent microsurgical resection and 25 (32.9%) patients underwent GKRS. Gross-total resection (GTR) was achieved in 34 (66.7%) patients, and subtotal resection (STR) in 17 (33.3%) patients. Tumors recurred in 12 (23.5%) patients initially treated surgically, requiring additional surgery and/or GKRS. Facial nerve function was unchanged or improved in 68 (89.5%) patients. Worsening facial nerve function occurred in 8 (10.5%) patients, all of whom had undergone microsurgical resection. Upfront treatment with GKRS for CPA meningiomas smaller than 2.5 cm was associated with preservation of facial nerve function in all patients over a median follow-up of 46 months, regardless of IAC invasion and tumor origin. Anatomical origin was associated with extent of resection but did not correlate with postoperative facial nerve function. Tumor size, extent of resection, and the presence of an arachnoid plane separating the tumor and the contents of the IAC were associated with postoperative facial nerve outcomes.CONCLUSIONSCPA meningiomas remain challenging lesions to treat, given their proximity to critical neurovascular structures. GKRS is a safe and effective option for managing CPA meningiomas smaller than 2.5 cm without associated mass effect or acute neurological symptoms. Maximal safe resection with preservation of neurological function can be performed for tumors 2.5 cm or larger without significant risk of facial nerve dysfunction, and, when combined with GKRS for recurrence and/or progression, provides excellent disease control. Anatomical features of the tumor origin offer critical insights for optimizing facial nerve preservation in this cohort.

Role of electrophysiology in guiding near-total resection for preservation of facial nerve function in the surgical treatment of large vestibular schwannomas

2018 ◽  
Vol 128 (3) ◽  
pp. 903-910 ◽  
Author(s):  
Daniele Bernardeschi ◽  
Nadya Pyatigorskaya ◽  
Antoine Vanier ◽  
Franck Bielle ◽  
Mustapha Smail ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Facial Nerve ◽  
Residual Tumor ◽  
Incomplete Resection ◽  
Nerve Function ◽  
Inclusion Criteria ◽  
Facial Nerve Function ◽  
Total Resection ◽  
Supramaximal Stimulation ◽  
Stimulation Of

OBJECTIVEIn large vestibular schwannoma (VS) surgery, the facial nerve (FN) is at high risk of injury. Near-total resection has been advocated in the case of difficult facial nerve dissection, but the amount of residual tumor that should be left and when dissection should be stopped remain controversial factors. The objective of this study was to report FN outcome and radiological results in patients undergoing near-total VS resection guided by electromyographic supramaximal stimulation of the FN at the brainstem.METHODSThis study was a retrospective analysis of a prospectively maintained database. Inclusion criteria were surgical treatment of a large VS during 2014, normal preoperative FN function, and an incomplete resection due to the strong adherence of the tumor to the FN and the loss of around 50% of the response of supramaximal stimulation of the proximal FN at 2 mA. Facial nerve function and the amount and evolution of the residual tumor were evaluated by clinical examination and by MRI at a mean of 5 days postoperatively and at 1 year postoperatively.RESULTSTwenty-five patients met the inclusion criteria and were included in the study. Good FN function (Grade I or II) was observed in 16 (64%) and 21 (84%) of the 25 patients at Day 8 and at 1 year postoperatively, respectively. At the 1-year follow-up evaluation (n = 23), 15 patients (65%) did not show growth of the residual tumor, 6 patients (26%) had regression of the residual tumor, and only 2 patients (9%) presented with tumor progression.CONCLUSIONSNear-total resection guided by electrophysiology represents a safe option in cases of difficult dissection of the facial nerve from the tumor. This seems to offer a good compromise between the goals of preserving facial nerve function and achieving maximum safe resection.

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.

scholarly journals Retrosigmoid approach for giant cystic vestibular schwannoma: subperineural dissection technique for facial nerve preservation

2021 ◽  
Vol 5 (2) ◽  
pp. V7
Author(s):  
Ali Tayebi Meybodi ◽  
Robert W. Jyung ◽  
James K. Liu
Keyword(s):  
Facial Nerve ◽  
Thin Layer ◽  
Vestibular Schwannoma ◽  
Cranial Nerve ◽  
Retrosigmoid Approach ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Total Resection ◽  
Nerve Preservation ◽  
Dissection Technique

In this illustrative video, the authors demonstrate retrosigmoid resection of a giant cystic vestibular schwannoma using the subperineural dissection technique to preserve facial nerve function. This thin layer of perineurium arising from the vestibular nerves is used as a protective buffer to shield the facial and cochlear nerves from direct microdissection trauma. A near-total resection was achieved, and the patient had an immediate postoperative House-Brackmann grade I facial nerve function. The operative nuances and pearls of technique for safe cranial nerve and brainstem dissection, as well as the intraoperative decision and technique to leave the least amount of residual adherent tumor, are demonstrated. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21128

scholarly journals An Evidence-Based Vestibular Schwannoma Surgical Outcome Grading Scale for Large-to-Giant Vestibular Schwannomas

2021 ◽  
Author(s):  
Nida Fatima ◽  
Gregory P. Lekovic
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Extent Of Resection ◽  
Subtotal Resection ◽  
Grading System ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Total Resection ◽  
Mesh Terms ◽  
Large Vestibular Schwannoma

Abstract Objectives: The objective of this study was to determine the relationship between facial nerve function and extent of resection (EOR) as outcomes in the surgical management of large vestibular schwannoma (VS) (≥ 2.5 cm maximal) and evaluate use of a new grading system that incorporates both outcomes.Methods: We conducted a systematic review of the electronic databases using different MeSH terms from 1990 to 2021. 5,623 patients from 56 studies were found appropriate for inclusion in the study. Surgical approach was reported in 5,144 patients, including translabyrinthine approach (TL) in 43.3% (n=2,225), retrosigmoid (RS) approach in 56.3% (n=2,899), retrolabyrinthine (RL) approach in 0.3% (n=16), and extended translabyrinthine (EX) approach in 0.1% (n=4). The proposed VS Grading System defines outcomes of gross total resection (GTR), near total resection (NTR) and subtotal resection (STR) with good facial nerve function [House-Brackmann (HB) Grade I-II] as Classes A, B and C respectively. Those with poor facial nerve outcome (HB III-VI) are graded as Classes D, E and F, respectively. Results:. As expected, patients with STR had a higher likelihood of better facial nerve outcomes (HB I-II) compared to NTR [Odds Ratio (OR): 7.30, 95%CI: 2.45-12.1, p=0.004] and GTR (OR: 9.61, 95%CI: 3.61-15.6, p=0.002), while NTR had better facial nerve outcome than GTR (OR: 1.5, 95%CI: 1.14-4.6, p<0.0001). A Class A result, representing the best possible outcome, was obtained in 55.8% of TL vs. 49.4% undergoing RS approach. Conclusion: Complete surgical resection with preservation of facial nerve function is the gold standard for large VS.

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.

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.

scholarly journals The Offprint of an Abnormal Pre-Parotidectomy Electrodiagnostic Finding in a Normally Functioning Facial Nerve: Correlation with Intraoperative Findings, Histology and Postoperative Facial Nerve Function

2022 ◽  
Vol 11 (1) ◽  
pp. 248
Author(s):  
Verena Katheder ◽  
Matti Sievert ◽  
Sarina Katrin Müller ◽  
Vivian Thimsen ◽  
Antoniu-Oreste Gostian ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Malignant Tumor ◽  
Facial Palsy ◽  
Benign Lesion ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Nerve Preservation ◽  
Clinically Normal ◽  
Parotid Tumors ◽  
Supramaximal Stimulation

The aim of this study was to search for associations between an electrodiagnostically abnormal but clinically normal facial nerve before parotidectomy and the intraoperative findings, as well as the postoperative facial nerve function. The records of all patients treated for parotid tumors between 2002 and 2021 with a preoperative House–Brackmann score of grade I but an abnormal electrophysiologic finding were studied retrospectively. A total of 285 patients were included in this study, and 222 patients had a benign lesion (77.9%), whereas 63 cases had a malignant tumor (22.1%). Electroneurographic facial nerve involvement was associated with nerve displacement in 185 cases (64.9%) and infiltration in 17 cases (6%). In 83 cases (29.1%), no tumor–nerve interface could be detected intraoperatively. An electroneurographic signal was absent despite supramaximal stimulation in 6/17 cases with nerve infiltration and in 17/268 cases without nerve infiltration (p < 0.001). The electrophysiologic involvement of a normal facial nerve is not pathognomonic for a malignancy (22%), but it presents a rather rare (~6%) sign of a “true” nerve infiltration and could also appear in tumors without any contact with the facial nerve (~29%). Of our cases, two thirds of those with an anatomic nerve preservation and facial palsy had already directly and postoperatively recovered to a major extent in the midterm.

scholarly journals Retrosigmoid Transmeatal Approach for Resection of Acoustic Neuroma: Operative Video and Technical Nuances of Subperineural Dissection for Facial Nerve Preservation

2019 ◽  
Vol 80 (S 03) ◽  
pp. S269-S270
Author(s):  
James K. Liu ◽  
Vincent N. Dodson ◽  
Robert W. Jyung
Keyword(s):  
Facial Nerve ◽  
Acoustic Neuroma ◽  
Protective Layer ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Tumor Removal ◽  
Nerve Preservation ◽  
Tumor Capsule ◽  
Acoustic Neuromas ◽  
Dissection Technique

The retrosigmoid (suboccipital) approach is the workhorse for most acoustic neuromas in the cerebellopontine angle. In this operative video atlas manuscript, the authors demonstrate the nuances of the subperineural dissection technique for microsurgical resection of an acoustic neuroma via the retrosigmoid transmeatal approach. The plane is developed by separating the perineurium of the vestibular nerve away from the tumor capsule. This perineurium provides a protective layer between the tumor capsule and the facial nerve which serves as a buffer to avoid direct dissection and potential trauma to the facial nerve. Using this technique during extracapsular tumor dissection helps to maximize the extent of tumor removal while preserving facial nerve function. A gross total resection of the tumor was achieved, and the patient exhibited normal facial nerve function (Fig. 1). In summary, the retrosigmoid transmeatal approach with the use of subperineural dissection are important strategies in the armamentarium for surgical management of acoustic neuromas with the goal of maximizing tumor removal and preserving facial nerve function (Fig. 2).The link to the video can be found at: https://youtu.be/L3lPtSvJt60.

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