Technical nuances of resection of giant (> 5 cm) vestibular schwannomas: pearls for success

2012 ◽  
Vol 33 (3) ◽  
pp. E15 ◽  
Author(s):  
Charles G. Kulwin ◽  
Aaron A. Cohen-Gadol
Keyword(s):  
Tumor Resection ◽  
Senior Author ◽  
Vestibular Schwannomas ◽  
Special Role ◽  
Acoustic Neuromas

Removal of vestibular schwannomas (VSs, or acoustic neuromas) remains one of the most challenging operations in neurosurgery. Giant or huge tumors (> 5 cm) heighten these challenges, and technical nuances play a special role in maximizing tumor resection while minimizing complications. In this article, the senior author describes his technical experience with microsurgical excision of giant VSs. The accompanying video further illustrates these details.

scholarly journals Comparison of management options for patients with acoustic neuromas

2003 ◽  
Vol 14 (5) ◽  
pp. 1-7 ◽  
Author(s):  
Douglas Kondziolka ◽  
L. Dade Lunsford ◽  
John C. Flickinger
Keyword(s):  
Stereotactic Radiosurgery ◽  
Tumor Resection ◽  
Vestibular Schwannomas ◽  
Quality Information ◽  
Management Options ◽  
Fractionated Radiotherapy ◽  
Acoustic Neuromas ◽  
Management Preferences

Management options for patients with vestibular schwannomas (acoustic neuromas) include observation, tumor resection, stereotactic radiosurgery, and fractionated radiotherapy. In this report the authors review their 15-year experience with radiosurgery and discuss indications and expectations in relation to the different approaches. They conducted a survey of neurosurgeons to determine management preferences in two different cases of intra- and extra-canalicular tumor presentations. Patient decisions must be based on quality information derived from peer-reviewed literature.

scholarly journals RADT-19. EFFECTS OF RADIATION DOSE-RATE AND TUMOR CHARACTERISTICS ON LOCAL CONTROL AND TOXICITY AFTER RADIOSURGERY FOR ACOUSTIC NEUROMAS

2020 ◽  
Vol 22 (Supplement_2) ◽  
pp. ii185-ii185
Author(s):  
Conrad Josef Villafuerte ◽  
Fred Gentili ◽  
David Shultz ◽  
Alejandro Berlin ◽  
Robert Heaton ◽  
...  
Keyword(s):  
Dose Rate ◽  
Proportional Hazards Model ◽  
Multivariable Analysis ◽  
Tumor Resection ◽  
Local Failure ◽  
Tumor Control ◽  
Tumor Diameter ◽  
Radiation Dose Rate ◽  
Acoustic Neuromas

Abstract INTRODUCTION The effect of stereotactic radiosurgery (SRS) dose-rate on tumor control for acoustic neuroma (AN, or vestibular schwannoma) is unclear. METHODS This was a retrospective study of all patients treated for AN with frame-based cobalt-60 SRS at the Toronto Western Hospital between 2005-2019. Dose rates on the day of SRS were calculated from the calibration dose-rate while accounting for the cobalt-60 half-life of 5.2713 years. Local failure was defined as continued tumor growth >36 months post-SRS, tumor resection for LF, or use of any repeat SRS for LF. Cumulative incidence of LF was reported after accounting for competing risks of death, on a per-lesion basis. Comparisons of actuarial LF were made using Gray’s test. Multivariable analysis of LF was performed using a proportional hazards model. RESULTS A total of 607 patients were treated for 617 acoustic neuromas. Median follow-up was 5.0 years. 158 tumors (26%) were cystic. 71 tumors (12%) had previous resection. Nine patients received 10-11 Gy due to large tumor size; all remaining patients received 12 Gy to approximately the 50% isodose line. Median dose rate was 2.4 Gy/min (range, 1.3-3.7). There was no association between dose rate and LF (≥ 2.4 Gy/min vs. < 2.4 Gy/min, 6.07% vs. 6.12% at 5-year follow-up, p = 0.75). The adjusted local failure-specific hazard ratio (HR) for dose rate (per Gy/min) was 1.2 (95% CI 0.69-2.1, p = 0.52). Patients with previous surgery had higher LF, with a HR of 3.6 (95% CI 1.7-7.8, p = 0.0012), after adjusting for presence of cysts (HR 0.27, p = 0.034) and maximum tumor diameter (HR 1.055 per cm, p = 0.071). CONCLUSIONS In a large cohort of patients with acoustic neuromas, radiosurgery dose-rate was not associated with tumor control. Previous resection was a strong risk factor for local failure after SRS.

scholarly journals Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

2012 ◽  
Vol 33 (3) ◽  
pp. E16 ◽  
Author(s):  
Richard K. Gurgel ◽  
Salim Dogru ◽  
Richard L. Amdur ◽  
Ashkan Monfared
Keyword(s):  
Facial Nerve ◽  
Surgical Approach ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Vestibular Schwannomas ◽  
Surgical Approaches ◽  
Subtotal Resection ◽  
Total Resection ◽  
Translabyrinthine Approach ◽  
Better Than

Object The object of this study was to evaluate facial nerve outcomes in the surgical treatment of large vestibular schwannomas (VSs; ≥ 2.5 cm maximal or extrameatal cerebellopontine angle diameter) based on both the operative approach and extent of tumor resection. Methods A PubMed search was conducted of English language studies on the treatment of large VSs published from 1985 to 2011. Studies were then evaluated and included if they contained data regarding the size of the tumor, surgical approach, extent of resection, and postoperative facial nerve function. Results Of the 536 studies initially screened, 59 full-text articles were assessed for eligibility, and 30 studies were included for analysis. A total of 1688 tumor resections were reported. Surgical approach was reported in 1390 patients and was significantly associated with facial nerve outcome (ϕ= 0.29, p < 0.0001). Good facial nerve outcomes (House-Brackmann Grade I or II) were produced in 62.5% of the 555 translabyrinthine approaches, 65.2% of the 601 retrosigmoid approaches, and 27.4% of the 234 extended translabyrinthine approaches. Facial nerve outcomes from translabyrinthine and retrosigmoid approaches were not significantly different from each other, but both showed significantly more good facial nerve outcomes, compared with the extended translabyrinthine approach (OR for translabyrinthine vs extended translabyrinthine = 4.43, 95% CI 3.17–6.19, p < 0.0001; OR for retrosigmoid vs extended translabyrinthine = 4.98, 95% CI 3.57–6.95, p < 0.0001). There were 471 patients for whom extent of resection was reported. There was a strong and significant association between degree of resection and outcome (ϕ= 0.38, p < 0.0001). Of the 80 patients receiving subtotal resections, 92.5% had good facial nerve outcomes, compared with 74.6% (n = 55) and 47.3% (n = 336) of those who received near-total resections and gross-total resections, respectively. In the 2-way comparison of good versus suboptimal/poor outcomes (House-Brackmann Grade III–VI), subtotal resection was significantly better than near-total resection (OR = 4.21, 95% CI 1.50–11.79; p = 0.004), and near-total resection was significantly better than gross-total resection (OR = 3.26, 95% CI 1.71–6.20; p = 0.0002) in producing better facial nerve outcomes. Conclusions In a pooled patient population from studies evaluating the treatment of large VSs, subtotal and near-total resections were shown to produce better facial nerve outcomes when compared with gross-total resections. The translabyrinthine and retrosigmoid surgical approaches are likely to result in similar rates of good facial nerve outcomes. Both of these approaches show better facial nerve outcomes when compared with the extended translabyrinthine approach, which is typically reserved for especially large tumors. The reported literature on treatment of large VSs is extremely heterogeneous and minimal consistency in reporting outcomes was observed.

Nonvestibular Schwannomas of the Brain: A 7-Year Experience

Neurosurgery ◽  
2002 ◽  
Vol 50 (3) ◽  
pp. 437-449 ◽  
Author(s):  
Sajjan Sarma ◽  
Laligam N. Sekhar ◽  
David A. Schessel
Keyword(s):  
Tumor Resection ◽  
Cranial Nerves ◽  
Abducens Nerve ◽  
Functional Results ◽  
Senior Author ◽  
Karnofsky Performance Scale ◽  
Lumbar Drain ◽  
Scale Scores ◽  
The Brain

Abstract OBJECTIVE: Nonvestibular schwannomas are uncommon tumors of the brain. Trigeminal nerve schwannomas are the most common of this group, followed by glossopharyngeal, vagal, facial, accessory, hypoglossal, oculomotor, trochlear, and abducens nerve schwannomas, in descending order of frequency. We present a series of nonvestibular schwannomas that were surgically treated during a 7-year period. METHODS: Forty-six patients with schwannomas of Cranial Nerves V (26 cases), VII (7 cases), IX, X, and XI (9 cases), XII (3 cases), and III (1 case) were microsurgically treated by the senior author (LNS) during a 7-year period, from 1993 to 2000. The clinical presentations, operative approaches, complications, and results were studied. RESULTS: Forty-five patients underwent gross total tumor resection in the first operation. One patient who had undergone subtotal tumor resection in the initial operation experienced a large recurrence after 4 years, and gross total tumor resection was achieved in the second operation. There were no postoperative deaths. Postoperative morbidity consisted of cerebrospinal fluid leaks for 5 patients (3 patients required a second operation to repair the leak, and 2 patients responded to lumbar drain placement), meningitis for 3 patients (2 cases were aseptic and 1 involved bacterial meningitis, which resolved with antibiotic therapy), vasospasm requiring angioplasty for 1 patient, temporary hemiparesis for 2 patients (who experienced good recoveries), and permanent hemiparesis for 1 patient. New cranial nerve deficits were observed for 24% of patients but were usually partial. The mean follow-up period was 33.3 months (range, 0.2–93 mo). No patient experienced tumor recurrence after complete tumor removal. The patient who experienced regrowth of the tumor did not exhibit recurrence after the second operation. The Karnofsky Performance Scale scores at the latest follow-up examination were 80 or more for 45 patients (98%) and 70 for 1 patient. CONCLUSION: Nonvestibular schwannomas can be treated via microsurgical excision, with excellent functional results. Recurrence is rare after total tumor excision, although much longer follow-up monitoring is required.

Radiosurgery for Acoustic Neuromas: Results of Low-dose Treatment

Neurosurgery ◽  
2003 ◽  
Vol 53 (2) ◽  
pp. 282-288 ◽  
Author(s):  
Yoshiyasu Iwai ◽  
Kazuhiro Yamanaka ◽  
Masato Shiotani ◽  
Taichi Uyama
Keyword(s):  
Tumor Growth ◽  
Low Dose ◽  
Tumor Resection ◽  
Gamma Knife Radiosurgery ◽  
Growth Control ◽  
Hearing Preservation ◽  
Trigeminal Neuropathy ◽  
Tumor Margin ◽  
Acoustic Neuromas

Abstract OBJECTIVE The results of radiosurgical treatment of acoustic neuromas have improved by reducing the tumor marginal doses. We report relatively long-term follow-up results (&gt;5 yr) for patients who underwent low-dose radiosurgery. METHODS We treated and followed 51 consecutive patients with unilateral acoustic neuromas who were treated from January 1994 to December 1996 by gamma knife radiosurgery at low doses (≤12 Gy to the tumor margin). The average age of the patients was 55 years (range, 32–76 yr). The treatment volume was 0.7 to 24.9 cm3 (median, 3.6 cm3). The marginal radiation dose was 8 to 12 Gy (median, 12 Gy), and the follow-up period ranged from 18 to 96 months (median, 60 mo). RESULTS Clinical tumor growth control (without tumor resection) was achieved in 96% of patients, and the 5-year tumor growth control rate was 92%. Hearing was preserved in 59% of those with preradiosurgical hearing preservation (Gardner-Robertson Classes 1–4), and improvements (&gt;20 dB of improvement) were noted in 9% of the patients with any hearing. Hearing was preserved at a useful level (Gardner-Robertson Classes 1 and 2) in 56% of patients. Although preexisting trigeminal neuropathy worsened in 4% of the patients, our patients did not experience new facial palsies or trigeminal neuropathies after radiosurgery. Facial spasm occurred in 6% of the patients, and intratumoral bleeding occurred in 4% of patients. CONCLUSION Low-dose radiosurgery (≤12 Gy at the tumor margin) can achieve a high tumor growth control rate and maintain low postradiosurgical morbidity (including hearing preservation) for acoustic neuromas.

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.

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