Cerebellopontine angle meningiomas: postoperative outcomes in a modern cohort

Object Tumors of the cerebellopontine angle (CPA) have always proven difficult for neurosurgeons to optimally manage. Studies investigating the natural history and treatment of vestibular schwannomas have dominated the literature in this regard. Distinguishing meningiomas from schwannomas in this location carries particular importance as each tumor type has certain prognostic and surgical considerations. In this study, the authors have characterized the outcomes of 34 patients surgically treated for CPA meningiomas and have investigated various factors that may affect postoperative neurological function. Methods The medical records of patients with CPA meningiomas who underwent surgery from 2005 to 2013 at the Duke University Health System were reviewed. Various patient, clinical, and tumor data were gathered from the medical records including patient demographics, pre- and postoperative neurological examinations, duration of symptoms, procedural details, tumor pathology and size, and treatment characteristics. Differences in continuous variables were then analyzed using the Student t-test while categorical variables were evaluated using the chi-square test. Results A total of 34 patients underwent surgical treatment for CPA meningiomas during the 8-year period. Jugular foramen invasion was seen in 17.6% of tumors, with nearly half (41.2%) extending into the internal acoustic canal. The most common presenting symptom was hearing loss (58.8%), followed by headache (52.9%) and facial numbness/pain (50.0%). The most common cranial nerve (CN) affected was CN X (11.8%), followed by CNs VI and VII (5.9%). Postoperatively, no patients experienced a decrease in hearing, with only 5.9% of patients experiencing facial nerve palsies. Patients with tumors larger than 3 cm had a significantly higher incidence of permanent CN deficits than those with smaller tumors (45.5% vs 5.9%, respectively; p = 0.011). Also, tumor extension into the jugular foramen was associated with the occurrence of lower CN deficits, none of which occurred in tumors without jugular foramen invasion. Internal acoustic canal tumor extension was not seen to be associated with postoperative complications or CN deficits. Conclusions Meningiomas of the CPA are challenging lesions to treat surgically. However, the risk of facial palsy and hearing loss is significantly lower when compared with vestibular schwannomas. Novel methods for preoperative differentiation are needed to appropriately counsel patients on surgical risks. Also, due to the significant potential for neurological deficits, further studies are needed to investigate the utility of radiotherapy for these lesions.

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Reversible Hearing Loss from Cerebellopontine Angle Tumors

Neurosurgery ◽

10.1227/00006123-199102000-00024 ◽

1991 ◽

Vol 28 (2) ◽

pp. 310-313 ◽

Cited By ~ 20

Author(s):

Eduardo A. S. Vellutini ◽

Oswaldo L. M. Cruz ◽

Otavio P. Velasco ◽

Aroldo Miniti ◽

Gilberto M. Almeida

Keyword(s):

Hearing Loss ◽

Sensorineural Hearing Loss ◽

Surgical Approach ◽

Cerebellopontine Angle ◽

Jugular Foramen ◽

Sensorineural Hearing ◽

Surgical Removal ◽

Arachnoid Membrane ◽

Tumor Removal ◽

Cerebellopontine Angle Tumors

Abstract We report two patients who presented with a dramatic recovery from severe sensorineural hearing loss after total surgical removal of cerebellopontine angle tumors (meningioma and jugular foramen neurinoma). The factors that differentiate these “non-acoustic tumors” in relation to the prognosis for hearing are discussed. A surgical approach that maintains the labyrinthine structure and preserves the arachnoid membrane of the superior cerebellopontine angle cistern during tumor removal is stressed.

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Hydroxyapatite cement cranioplasty in the setting of simultaneous translabyrinthine resection of cerebellopontine angle tumors and cochlear implantation

Neurosurgical Focus: Video ◽

10.3171/2021.7.focvid211 ◽

2021 ◽

Vol 5 (2) ◽

pp. V15

Author(s):

Robert M. Conway ◽

Nathan C. Tu ◽

Pedrom C. Sioshansi ◽

Dennis I. Bojrab ◽

Jeffrey T. Jacob ◽

...

Keyword(s):

Hearing Loss ◽

Vestibular Schwannoma ◽

Cochlear Implantation ◽

Cerebellopontine Angle ◽

Similar Efficacy ◽

Abdominal Fat ◽

Vestibular Schwannomas ◽

Fat Graft ◽

Surgical Video ◽

Hydroxyapatite Cement

Cochlear implantation (CI) has become an option for the treatment of hearing loss after translabyrinthine resection of vestibular schwannomas. The surgical video presents the case of a 67-year-old male who had translabyrinthine resection of vestibular schwannoma with simultaneous CI and closure with a hydroxyapatite (HA) cement cranioplasty. HA cement cranioplasty can be utilized in place of abdominal fat graft for the closure of translabyrinthine approaches with similar efficacy and complication profile. To the authors’ knowledge, this is the first reported case of a simultaneous CI and translabyrinthine resection of vestibular schwannoma with HA cement cranioplasty. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID211

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Management of Hydrocephalus Associated with Vestibular Schwannoma and Other Cerebellopontine Angle Tumors

Neurosurgery ◽

10.1097/00006123-200106000-00010 ◽

2001 ◽

Vol 48 (6) ◽

pp. 1246-1254 ◽

Cited By ~ 10

Author(s):

Farhad Pirouzmand ◽

Charles H. Tator ◽

John Rutka

Keyword(s):

Cerebrospinal Fluid ◽

Retrospective Study ◽

Tumor Size ◽

Cerebellopontine Angle ◽

Tumor Resection ◽

Internal Auditory Canal ◽

Vestibular Schwannomas ◽

Tumor Type ◽

Management Options ◽

Tumor Excision

Abstract OBJECTIVE Hydrocephalus (HCP) resulting from cerebellopontine angle (CPA) tumors is not rare. This retrospective study was designed to investigate the incidence of HCP and the clinical presentations, management options, and outcomes of HCP in 284 patients with CPA tumors. METHODS A retrospective study of 284 consecutive patients with CPA tumors (mostly vestibular schwannomas) treated from 1985 to 1996 at Toronto Western Hospital managed by one surgical team consisting of a neurosurgeon and a neuro-otologist. RESULTS Thirty-nine patients (13.7%) had radiographic and/or clinical evidence of HCP, 37 preoperatively and 2 postoperatively. Tumor type distribution was 33 vestibular schwannomas, 5 meningiomas, and 1 cavernous hemangioma. Only five patients (12%) had obvious obstruction at the fourth ventricular level. In 36 patients (92%), symptoms were mostly chronic and mild, consistent with normal pressure hydrocephalus. Multivariate analysis confirmed the strong association of tumor size and incidence of HCP (P < .0001). Four patients underwent permanent shunting before microsurgical tumor excision, mainly because of florid symptoms of HCP. Microsurgical tumor excision without preoperative shunting was performed in 23 patients, 5 of whom required postoperative shunting in the first 2 months after tumor excision. Eighteen patients (78%) did not need shunts after tumor resection. With regard to tumor size, the postoperatively shunted group did not differ from the patients who had surgery but did not require shunt treatment (P < 0.50). The remaining 10 patients with preoperative HCP received shunts as the only treatment (3 patients), stereotactic radiosurgery (3 patients), or expectant management (4 patients). Two other patients without preoperative HCP developed postoperative HCP and required shunts. Postoperatively, we observed a significant (P < 0.001) increase in the incidence of pseudomeningocele and a nonsignificant (P < 0.1) increase in cerebrospinal fluid leaks (rhinorrhea and/or otorrhea) in patients without shunts as compared with postoperative patients without HCP. The patients were followed after any treatment for a mean of 3.2 years (range, 6 mo–10 yr). Follow-up in the patients who had surgery but did not require a shunt revealed a 61% decrease in clinical symptoms related to HCP and a 75% decrease in radiographic signs of HCP. CONCLUSION In the presence of HCP, operative resection of CPA tumors can be performed without permanent cerebrospinal fluid shunting. Precautionary measures to decrease the incidence of postoperative complications related to cerebrospinal fluid leak in patients with preoperative HCP include meticulous obliteration of any exposed air cells, including those around the internal auditory canal, accurate restoration of the dural barrier, and temporary lowering of intracranial pressure with a ventricular or lumbar drain. Patients with persistent symptomatic HCP after tumor excision should be treated with a ventriculoperitoneal shunt. Delaying this decision until the postoperative period is safe and avoids unnecessary shunting in the majority of patients.

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

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0040-1709162 ◽

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.

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Cerebellopontine Angle Epidermoids: Comparative Results of Microscopic and Endoscopic Excision Using the Retromastoid Approach”

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1722713 ◽

2021 ◽

Author(s):

Suyash Singh ◽

Kuntal Kanti Das ◽

Krishna Kumar ◽

Kamlesh Rangari ◽

Priyadarshi Dikshit ◽

...

Keyword(s):

Hospital Stay ◽

Cranial Nerve ◽

Cerebellopontine Angle ◽

Surgical Excision ◽

Csf Leak ◽

Tumor Extension ◽

Endoscopic Excision ◽

Endoscopic Assistance ◽

Comparative Results ◽

Neurovascular Structures

Abstract Background Densely packed neurovascular structures, often times inseparable capsular adhesions and sometimes a multicompartmental tumor extension, make surgical excision of cerebellopontine angle epidermoids (CPEs) a challenging task. A simultaneous or an exclusive endoscopic visualization has added a new dimension to the classical microscopic approaches to these tumors recently. Method Eighty-six patients (age: 31.6 ± 11.7 years, M:F = 1:1) were included. Nineteen patients (22.1%) had a multicompartmental tumor. Tumor extension was classified into five subtypes. Sixty-two patients underwent a pure microscopic approach (72%) out of which 10 patients (16%) underwent an endoscope-assisted surgery (11.6%) and 24 patients (28%) underwent an endoscope-controlled excision. Surgical outcomes were retrospectively analyzed. Results Headache (53.4%), hearing loss (46.5%), and trigeminal neuralgia (41.8%) were the leading symptoms. Interestingly, 21% of the patients had at least one preexisting cranial nerve deficit. Endoscopic assistance helped in removing an unseen tumor lobule in 3 of 10 patients (30%). Pure endoscopic approach significantly reduced the hospital stay from 9.2 to 7.3 days (p = 0.012), and had a statistically insignificant yet a clearly noticeable lesser incidence of subtotal tumor excision (0 vs. 10%, p = 0.18) with comparable cranial nerve deficits but with a higher postoperative cerebrospinal fluid (CSF) leak rate (29% vs. 4.8%, p = 0.004). Conclusion Endoscope assistance in CPE surgery is a useful addition to conventional microscopic retromastoid approach. Pure endoscopic excision in CPE is feasible, associated with a lesser duration of hospital stay, better extent of excision in selected cases, and it has a comparable cranial nerve morbidity profile albeit with a higher rate of CSF leak.

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Developmentally anomalous cerebellar encephalocele arising within the cerebellopontine angle and extending into the adjacent skull base in a pediatric patient

Child s Nervous System ◽

10.1007/s00381-020-05020-8 ◽

2021 ◽

Author(s):

Forrest A. Hamrick ◽

Michael Karsy ◽

Carol S. Bruggers ◽

Angelica R. Putnam ◽

Gary L. Hedlund ◽

...

Keyword(s):

Skull Base ◽

Pediatric Patient ◽

Cerebellopontine Angle ◽

Resonance Imaging ◽

Middle Cerebellar Peduncle ◽

Cerebellar Tissue ◽

Cerebellar Peduncle ◽

Histopathologic Analysis ◽

The Right ◽

Internal Acoustic Canal

AbstractLesions of the cerebellopontine angle (CPA) in young children are rare, with the most common being arachnoid cysts and epidermoid inclusion cysts. The authors report a case of an encephalocele containing heterotopic cerebellar tissue arising from the right middle cerebellar peduncle and filling the right internal acoustic canal in a 2-year-old female patient. Her initial presentation included a focal left 6th nerve palsy. Magnetic resonance imaging was suggestive of a high-grade tumor of the right CPA. The lesion was removed via a retrosigmoid approach, and histopathologic analysis revealed heterotopic atrophic cerebellar tissue. This report is the first description of a heterotopic cerebellar encephalocele within the CPA and temporal skull base of a pediatric patient.

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Meningiomas Of the Internal Auditory Canal

Neurosurgery ◽

10.1227/01.neu.0000126887.55995.e7 ◽

2004 ◽

Vol 55 (1) ◽

pp. 119-128 ◽

Cited By ~ 36

Author(s):

Makoto Nakamura ◽

Florian Roser ◽

Sharham Mirzai ◽

Cordula Matthies ◽

Peter Vorkapic ◽

...

Keyword(s):

Cerebellopontine Angle ◽

Clinical Symptoms ◽

Management Strategies ◽

Internal Auditory Canal ◽

Signs And Symptoms ◽

Vestibular Schwannomas ◽

Additional Patient ◽

Surgical Removal ◽

Neurosurgical Department ◽

Vestibulocochlear Nerve

Abstract OBJECTIVE: Meningiomas arising primarily within the internal auditory canal (IAC) are notably rare. By far the most common tumors that are encountered in this region are neuromas. We report a series of eight patients with meningiomas of the IAC, analyzing the clinical presentations, surgical management strategies, and clinical outcomes. METHODS: The charts of the patients, including histories and audiograms, imaging studies, surgical records, discharge letters, histological records, and follow-up records, were reviewed. RESULTS: One thousand eight hundred meningiomas were operated on between 1978 and 2002 at the Neurosurgical Department of Nordstadt Hospital. Among them, there were 421 cerebellopontine angle meningiomas; 7 of these (1.7% of cerebellopontine angle meningiomas) were limited to the IAC. One additional patient underwent surgery at the Neurosurgical Department of the International Neuroscience Institute, where a total of 21 cerebellopontine angle meningiomas were treated surgically from 2001 to 2003. As a comparison, the incidence of intrameatal vestibular schwannomas during the same period, 1978 to 2002, was 168 of 2400 (7%). There were five women and three men, and the mean age was 49.3 years (range, 27–59 yr). Most patients had signs and symptoms of vestibulocochlear nerve disturbance at presentation. One patient had sought treatment previously for total hearing loss before surgery. No patient had a facial paresis at presentation. The neuroradiological workup revealed a homogeneously contrast-enhancing tumor on magnetic resonance imaging in all patients with hypointense or isointense signal intensity on T1- and T2-weighted images. Some intrameatal meningiomas showed broad attachment, and some showed a dural tail at the porus. In all patients, the tumor was removed through the lateral suboccipital retrosigmoid approach with drilling of the posterior wall of the IAC. Total removal was achieved in all cases. Severe infiltration of the facial and vestibulocochlear nerve was encountered in two patients. There was no operative mortality. Hearing was preserved in five of seven patients; one patient was deaf before surgery. Postoperative facial weakness was encountered temporarily in one patient. CONCLUSION: Although intrameatal meningiomas are quite rare, they must be considered in the differential diagnosis of intrameatal mass lesions. The clinical symptoms are very similar to those of vestibular schwannomas. A radiological differentiation from vestibular schwannomas is not always possible. Surgical removal of intrameatal meningiomas should aim at wide excision, including involved dura and bone, to prevent recurrences. The variation in the anatomy of the faciocochlear nerve bundle in relation to the tumor has to be kept in mind, and preservation of these structures should be the goal in every case.

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

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0040-1719026 ◽

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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Intratumoral Bleeding in a Vestibular Schwannoma

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0037-1615287 ◽

2017 ◽

Vol 37 (01) ◽

pp. 47-49

Author(s):

Emanuelle Braga ◽

Luiza Köhler ◽

Marcelo de Cesaro ◽

Tasso Barreto ◽

Richard Giacomelli ◽

...

Keyword(s):

Hearing Loss ◽

Case Report ◽

Cranial Nerve ◽

Cerebellopontine Angle ◽

Clinical Presentation ◽

Cranial Nerves ◽

Altered Consciousness ◽

Progressive Hearing Loss ◽

Asymptomatic Patients ◽

Intratumoral Bleeding

AbstractVestibular schwannomas (VSs) account for ∼ 70% of all tumors of the cerebellopontine angle (CPA). Their clinical presentation is often insidious, with progressive hearing loss and involvement of other cranial nerves. Spontaneous hemorrhage in those tumors is very unusual, and generally presents with acute clinical features such as nausea, vomiting, headache and altered consciousness, usually with marked dysfunction of the cranial nerve involved, and with new deficits of neighboring cranial nerves. Asymptomatic patients are extremely rare. We present a case report of an incidental VS with asymptomatic bleeding, which evolved to death after surgery.

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EVALUATION OF PATIENTS WITH SUBAXIAL CERVICAL FRACTURES BY THE NEW AOSPINE CLASSIFICATION

Coluna/Columna ◽

10.1590/s1808-185120191804193631 ◽

2019 ◽

Vol 18 (4) ◽

pp. 268-271

Author(s):

Pedro Augusto Celestino de Oliveira ◽

Alberto Gotfryd ◽

Maria Fernanda Cafaro ◽

Nelson Astur ◽

Rodrigo Mendonça ◽

...

Keyword(s):

Neurological Deficit ◽

Medical Records ◽

Tertiary Hospital ◽

Categorical Variables ◽

Neurological Involvement ◽

Chi Square ◽

Level Of Evidence ◽

Significance Level ◽

Cervical Fractures ◽

Type C

ABSTRACT Objective: To evaluate the profile of patients with fracture and / or dislocation of the subaxial cervical spine using the new AOSpine classification and to correlate it with the trauma mechanism and the type of neurological deficit. Methods: Analyses were performed of the medical records of patients admitted to a tertiary hospital with fracture and / or subaxial cervical dislocation during the period from 2009 to 2016. For the evaluation of the association between the two categorical variables, the Chi-square test was used with a significance level of p <0.05. Results: A total of 67 medical records were analyzed, in which a higher prevalence of type C fractures (49.3%) was observed. The neurological subclassification N4 (35.8%) was the most prevalent type found, followed by subtype N0 (26.9%). Among the main injury mechanisms found, the most prevalent was the motorcycle accident (29.9%). There was no statistically significant association between the injury mechanism and the AOSpine morphological classification (p> 0.05) or neurological deficit (p> 0.05). Conclusion: Cervical fractures of type C, due to automobile accidents were the most prevalent. It was not possible to determine an association between the degree of neurological involvement and the morphology of the injury. Level of Evidence II; Retrospective study.

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