Staged resection of large vestibular schwannomas

Object Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection. Methods A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors' institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications. Results Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2–7 cm) in the 2-stage group and 3.9 cm (range 3.1–5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4%) of 28 patients in the 2-stage group and 15 (79%) of 19 patients in the single-stage group (p < 0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7%), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82%) of 28 patients in the 2-stage group and 10 (53%) of 19 patients in the single-stage group (p < 0.01). Cerebrospinal fluid leak–related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group. Conclusions The authors' results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections.

Download Full-text

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

Neurosurgical FOCUS ◽

10.3171/2017.11.focus17607 ◽

2018 ◽

Vol 44 (3) ◽

pp. E2 ◽

Cited By ~ 9

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.

Download Full-text

Facial Nerve Preservation and Surgical Outcomes of Retrosigmoid Approach to Large Vestibular Schwannoma- an Eight-year Single Institution Experience

Nepal Journal of Neuroscience ◽

10.3126/njn.v14i3.20522 ◽

2017 ◽

Vol 14 (3) ◽

pp. 19-25

Author(s):

Pratyush Shrestha ◽

Nisha Kutu ◽

Subash Lohani ◽

Upendra Prasad Devkota

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Tumor Size ◽

Statistical Significance ◽

Retrosigmoid Approach ◽

Vestibular Schwannomas ◽

P Value ◽

Exact Test ◽

Nerve Preservation ◽

Ventriculoperitoneal Shunting

Objective: To evaluate the result of microsurgical excision of vestibular schwannoma by retrosigmoid approach and to correlate the facial nerve outcome with the tumor size.Methods: Retrospective analysis of 84 patients with cerebello-pontine angle lesions (57 vestibular schwannomas) operated at National Institute of Neurological and Allied Sciences, Nepal, from Baisakh 2066 to Chaitra 2073 (eight years). Facial nerve outcomes as per the House and Brackmann grading at six months follow-up were recorded and correlated with tumor size.Result: The mean tumor size was 4.32 ± 1.23 cms and 48 (84.2%) of the patients had tumor size more than 3 cms. Patients presented late with papilloedema documented in 42.1% and preoperative ventriculoperitoneal shunting required in 31.57% patients. Of the patients whose facial nerve functions could be followed up, all patients with tumors < 3cm diameter had good House and Brackmann facial nerve outcome (grade I to III). Larger tumors had poorer facial nerve outcomes; however statistical significance could not be reached. (Fischer Exact test, p-value: 0.077). There were two mortalities (3.5%), one following cavity rebleed and one following malignant brain swelling.Conclusion: Retrosigmoid approach is a versatile surgical corridor to excise large vestibular schwannomas with minimal complications and larger tumors have poorer facial nerve outcomes. Nepal Journal of Neuroscience, Volume 14, Number 3, 2017, Page: 19-25

Download Full-text

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

Operative Neurosurgery ◽

10.1093/ons/opy126 ◽

2018 ◽

Vol 16 (2) ◽

pp. 147-158 ◽

Cited By ~ 1

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.

Download Full-text

Safety and Efficacy of Gamma Knife Radiosurgery for the Management of Koos Grade 4 Vestibular Schwannomas

Neurosurgery ◽

10.1227/neu.0000000000001154 ◽

2015 ◽

Vol 78 (4) ◽

pp. 521-530 ◽

Cited By ~ 15

Author(s):

Christian Iorio-Morin ◽

Fahd AlSubaie ◽

David Mathieu

Keyword(s):

Gamma Knife ◽

Tumor Size ◽

Gamma Knife Radiosurgery ◽

Vestibular Schwannomas ◽

Tumor Control ◽

Inclusion Criteria ◽

Shunt Insertion ◽

Safety And Efficacy ◽

Nerve Preservation

Abstract BACKGROUND: Gamma Knife radiosurgery (GKRS) is commonly used in treating small vestibular schwannomas; however, its use for larger vestibular schwannomas is still controversial. OBJECTIVE: To assess the long-term safety and efficacy of treating eligible Koos grade 4 vestibular schwannomas with GKRS. METHODS: We conducted a single-center, retrospective evaluation of patient undergoing GKRS for Koos grade 4 vestibular schwannomas. We evaluated clinical, imaging, and treatment characteristics and assessed treatment outcome. Inclusion criteria were tumor size of ≥4 cm3 and follow-up of at least 6 months. Patients with neurofibromatosis type 2 were excluded. Primary outcomes measured were tumor control rate, hearing and facial function preservation rate, and complications. All possible factors were analyzed to assess clinical significance. RESULTS: Sixty-eight patients met inclusion criteria. Median follow-up was 47 months (range, 6-125 months). Baseline hearing was serviceable in 60%. Median tumor volume at radiosurgery was 7.4 cm3 (range, 4-19 cm3). The median marginal dose used was 12 Gy at the 50% isodose line. Actuarial tumor control rates were 95% and 92% at 2 and 10 years, respectively. Actuarial serviceable hearing preservation rates were 89% and 49% at 2 and 5 years, respectively. Facial nerve preservation was 100%. Clinical complications included balance disturbance (11%), facial pain (10%), facial numbness (5%), and tinnitus (10%). Most complications were mild and transient. Hydrocephalus occurred in 3 patients, requiring ventriculoperitoneal shunt insertion. Larger tumor size was significantly associated with persisting symptoms post-treatment. CONCLUSION: Patients with Koos grade 4 vestibular schwannomas and minimal symptoms can be treated safely and effectively with GKRS.

Download Full-text

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

Neurosurgery ◽

10.1093/neuros/nyz310_429 ◽

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.

Download Full-text

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

Journal of Neurosurgery ◽

10.3171/jns.2006.105.4.527 ◽

2006 ◽

Vol 105 (4) ◽

pp. 527-535 ◽

Cited By ~ 221

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.

Download Full-text

Surgical Results and Technical Refinements in Translabyrinthine Excision of Vestibular Schwannomas

Neurosurgery ◽

10.1227/neu.0b013e31824c010f ◽

2012 ◽

Vol 70 (6) ◽

pp. 1481-1491 ◽

Cited By ~ 34

Author(s):

Mehdi Ben Ammar ◽

Enrico Piccirillo ◽

Vedat Topsakal ◽

Abdelkader Taibah ◽

Mario Sanna

Keyword(s):

Facial Nerve ◽

Tumor Size ◽

Vestibular Schwannomas ◽

Cerebrospinal Fluid Leakage ◽

Incomplete Resection ◽

Total Removal ◽

Translabyrinthine Approach ◽

Technical Modifications ◽

Main Factor

Abstract BACKGROUND: Vestibular schwannomas (VSs) are the most common cerebellopontine angle tumors, accounting for 75% of all lesions in this location. OBJECTIVE: To evaluate the results after removal of VS through the enlarged translabyrinthine approach, which is a widening of the classic translabyrinthine approach that gives larger access and provides more room to facilitate tumor removal and to minimize surgery-related morbidities. METHODS: This was a retrospective study of 1865 patients who underwent VS excision through the enlarged translabyrinthine approach between 1987 and 2009. Mean age was 50.39 years. Mean tumor size was 1.8 cm. Median follow-up was 5.7 years. RESULTS: Total removal was achieved in 92.33% of cases; 143 patients had incomplete resection with evidence of regrowth in 8. In the 1742 previously untreated patients, anatomic preservation of facial nerve was achieved in 1661 cases (95.35%), and House-Brackmann grade I or II was reached in 1047 patients (59.87%). Facial nerve outcome was significantly better in tumors ⩽ 20 mm. Surgical complications included cerebrospinal fluid leakage in 0.85%, meningitis in 0.10%, intracranial bleeding in 0.80%, non--VII/VIII cranial nerve palsy in 0.96%, cerebellar ataxia in 0.69%, and death in 0.10%. The technical modifications that evolved with increasing experience are described. CONCLUSION: The enlarged translabyrinthine approach is a safe and effective approach for the removal of VS. In our experience, the complication rate is very low and tumor size is still the main factor influencing postoperative facial nerve function with a cutoff point at around 20 mm.

Download Full-text

Preservation of Hearing and Facial Nerve Function with the Microsurgical Excision of Large Vestibular Schwannomas: Experience with the Retrosigmoid Approach

Cureus ◽

10.7759/cureus.3684 ◽

2018 ◽

Author(s):

Muhammad Shaheryar Ahmed Rajput ◽

Ahmad Nawaz Ahmad ◽

Asif Ali Arain ◽

Mohammad Adeel ◽

Saeed Akram ◽

...

Keyword(s):

Facial Nerve ◽

Retrosigmoid Approach ◽

Vestibular Schwannomas ◽

Nerve Function ◽

Facial Nerve Function

Download Full-text

Risk Factors for Progression in Vestibular Schwannomas After Incomplete Resection: A Single Center Retrospective Study

Frontiers in Neurology ◽

10.3389/fneur.2021.778590 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jiuhong Li ◽

Xueyun Deng ◽

Daibo Ke ◽

Jian Cheng ◽

Si Zhang ◽

...

Keyword(s):

Risk Factors ◽

Multivariate Analysis ◽

Tumor Size ◽

Tumor Volume ◽

Univariate Analysis ◽

Residual Tumor ◽

Vestibular Schwannomas ◽

Incomplete Resection ◽

Cystic Component

Background and Purpose: The risk factors for progression in vestibular schwannomas (VSs) after incomplete resection (IR) remain to be elucidated. The purpose of this study was to investigate the risk factors for progression in remnant VSs after surgery.Methods: From January 2009 to January 2018, 140 consecutive patients who underwent IR of VSs via suboccipital retrosigmoid approach in our institution were retrospectively analyzed. During follow-up, if progression was detected, the patient was classified into Progressive Group (PG); if the residual tumor was stable or shrank, the patient was classified into Stable Group (SG). Univariate analysis and multivariate analysis were used to evaluate the risk factors for progression after IR of VSs.Results: After a mean follow-up of 80.4 months (range, 24–134 months), 35 (25.0%) patients (PG) had a progression, and no progression was detected in 105 (75.0%) patients (SG). The average tumor size was 36.5 ± 8.9 mm in PG and 31.0 ± 9.8 mm in SG, respectively. The residual tumor volume was 304.6 ± 443.3 mm3 in PG and 75.9 ± 60.0 mm3 in SG, respectively. Univariate analysis showed that preoperative tumor size, residual tumor volume, and irregular internal auditory canal (IAC) expansion were significantly different between the two groups, whereas gender, age, cystic component, or Ki-67 labeling index (LI) did not differ significantly between the two groups. Multivariate analysis showed residual tumor volume was the independent risk factor for progression.Conclusions: VSs that underwent IR with larger preoperative size, greater residual tumor volume, or irregular IAC expansion may have a higher progression rate. Strict follow-up with shorter interval in these patients to detect early progression is necessary.

Download Full-text

Sporadic unilateral vestibular schwannoma in the pediatric population

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.3.peds08434 ◽

2009 ◽

Vol 4 (2) ◽

pp. 125-129 ◽

Cited By ~ 8

Author(s):

Brian P. Walcott ◽

Ganesh Sivarajan ◽

Bronislava Bashinskaya ◽

Douglas E. Anderson ◽

John P. Leonetti ◽

...

Keyword(s):

Facial Nerve ◽

Tumor Size ◽

Pediatric Population ◽

Neurofibromatosis Type ◽

Neurofibromatosis Type 2 ◽

Nerve Function ◽

Facial Nerve Function ◽

Duration Of Symptoms

Object Vestibular schwannomas (VSs) are rare in the pediatric population. Most often, these lesions manifest as a bilateral disease process in the setting of neurofibromatosis Type 2. Even in the absence of additional clinical diagnostic criteria, the presentation of a unilateral VS in a young patient may be a harbinger of future penetrance for this hereditary tumor syndrome. Methods The authors retrospectively reviewed the charts of a cohort of 7 patients who presented with apparently sporadic, unilateral VSs. These patients had previously undergone surgery via translabyrinthine, retrosigmoid, or combined approaches. Clinical outcomes were reviewed with emphasis on facial nerve function and follow-up for signs and symptoms of a heritable disorder. Results All patients underwent microsurgical resection in a multidisciplinary effort by the senior authors. The average tumor size was 4.57 cm, with an average duration of symptoms prior to definitive diagnosis of 31.2 months. The tumor size at the time of presentation followed a trend different from reports in adults, while the duration of symptoms did not. At a follow-up average of 6.3 years (range 1–12 years), 100% of patients demonstrated good facial function (House-Brackmann Grade I or II). No patient in this cohort demonstrated symptoms, objective signs, or genetic analysis indicating the presence of neurofibromatosis Type 2. Conclusions Diagnosis and management of sporadic, unilateral VSs in children is complicated by clinical presentations and surgical challenges unique from their adult counterparts. Careful consideration should be given to a heritable genetic basis for sporadic unilateral VS in the pediatric population. Results of genetic testing do not preclude the necessity for long-term follow-up and systemic investigation. In patients who present with large tumors, preliminary experience leads the authors to suggest that a combined retrosigmoid-translabyrinthine approach offers the greatest opportunity for preservation of facial nerve function.

Download Full-text