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

scholarly journals Endoscopic-assisted microsurgical resection of giant vestibular schwannoma in semi-sitting position

2021 ◽  
Vol 5 (2) ◽  
pp. V3
Author(s):  
Gang Song ◽  
Liyong Sun ◽  
Yuhai Bao ◽  
Jiantao Liang
Keyword(s):  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Residual Tumor ◽  
Nerve Function ◽  
Tumor Removal ◽  
Function Preservation ◽  
Microsurgical Resection ◽  
Dissection Technique ◽  
Total Tumor Removal ◽  
Facial Function

The main objectives of microsurgery for vestibular schwannoma are total tumor removal and preservation of facial and cochlear nerve function. For giant tumors, total tumor removal and facial nerve function preservation are challenging. The semisitting position has some advantages. In this video the authors show the removal of a giant vestibular schwannoma with the patient in a semisitting position. They demonstrate the advantages of the semisitting technique, such as the two-handed microsurgical dissection technique and a clear operative field. Finally, a small residual tumor in the internal auditory canal was removed by endoscopy. The patient’s facial function was House-Brackmann grade I at discharge. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2176

Hearing preservation after translabyrinthine approach performed to remove a large vestibular schwannoma

2008 ◽  
Vol 266 (1) ◽  
pp. 147-150 ◽  
Author(s):  
Stéphane Tringali ◽  
Chantal Ferber-Viart ◽  
Stéphane Gallégo ◽  
Christian Dubreuil
Keyword(s):  
Vestibular Schwannoma ◽  
Hearing Preservation ◽  
Translabyrinthine Approach ◽  
Large Vestibular Schwannoma

Hearing Preservation Using the Middle Fossa Approach for the Treatment of Vestibular Schwannoma

Neurosurgery ◽  
2011 ◽  
Vol 70 (2) ◽  
pp. 334-341 ◽  
Author(s):  
Joe Walter Kutz ◽  
Tyler Scoresby ◽  
Brandon Isaacson ◽  
Bruce E. Mickey ◽  
Christopher J. Madden ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Academic Medical Center ◽  
Hearing Preservation ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Class A ◽  
Facial Function ◽  
Grade Iii

Abstract BACKGROUND: The incidence of small vestibular schwannomas in patients with serviceable hearing is increasing because of the widespread use of MRI. The middle fossa approach provides the patient with an opportunity for tumor removal with hearing preservation. OBJECTIVE: To determine the rate of hearing preservation and facial nerve outcomes after removal of a vestibular schwannoma with the use of the middle fossa approach. METHODS: A retrospective case review at a tertiary, academic medical center was performed identifying patients from 1998 through 2008 that underwent removal of a vestibular schwannoma by the middle fossa approach. Preoperative and postoperative audiograms were compared to determine hearing preservation rates. In addition, facial nerve outcomes at last follow-up were recorded. RESULTS: Forty-six patients underwent a middle fossa craniotomy for the removal of a vestibular schwannoma. Of the 38 patients that had class A or class B hearing preoperatively, 24 (63.2%) retained class A or B hearing and 29 (76.3%) retained class A, B, or C hearing. When tumors were 10 mm or less in patients with class A or B preoperative hearing, 22 of 30 patients (73.3%) retained class A or B hearing. When the tumor size was greater than 10 mm in patients with class A or B preoperative hearing, 2 of 8 patients (25%) retained class A or B hearing. At most recent follow-up, 76.1% of patients had House-Brackmann grade I facial function, 13.0% had House-Brackmann grade II facial function, and 10.9% had House-Brackmann grade III facial function. CONCLUSION: Hearing preservation rates are excellent using the middle fossa approach, especially for smaller tumors. No patient experienced long-term facial nerve function worse than House-Brackmann grade III.

Tumor origin and hearing preservation in vestibular schwannoma surgery

2011 ◽  
Vol 115 (5) ◽  
pp. 900-905 ◽  
Author(s):  
Jens Rachinger ◽  
Stefan Rampp ◽  
Julian Prell ◽  
Christian Scheller ◽  
Alex Alfieri ◽  
...  
Keyword(s):  
Vestibular Schwannoma ◽  
Tumor Size ◽  
Hearing Preservation ◽  
Vestibular Nerve ◽  
Cochlear Nerve ◽  
Nerve Function ◽  
Nerve Preservation ◽  
Tumor Origin ◽  
Inferior Vestibular Nerve ◽  
Vs Removal

Object Preservation of cochlear nerve function in vestibular schwannoma (VS) removal is usually dependent on tumor size and preoperative hearing status. Tumor origin as an independent factor has not been systematically investigated. Methods A series of 90 patients with VSs, who underwent surgery via a suboccipitolateral route, was evaluated with respect to cochlear nerve function, tumor size, radiological findings, and intraoperatively confirmed tumor origin. All patients were reevaluated 12 months after surgery. Results Despite comparable preoperative cochlear nerve status and larger tumor sizes, hearing preservation was achieved in 42% of patients with tumor originating from the superior vestibular nerve, compared with 16% of those with tumor originating from the inferior vestibular nerve. Conclusions Tumor origin is an important prognostic factor for cochlear nerve preservation in VS surgery.

Contemporary Surgical Management of Vestibular Schwannomas: Analysis of Complications and Lessons Learned Over the Past Decade

2012 ◽  
Vol 72 (2) ◽  
pp. ons103-ons115 ◽  
Author(s):  
Yoichi Nonaka ◽  
Takanori Fukushima ◽  
Kentaro Watanabe ◽  
Allan H. Friedman ◽  
John H. Sampson ◽  
...  
Keyword(s):  
Vestibular Schwannoma ◽  
Clinical Status ◽  
Neurological Complication ◽  
Tumor Resection ◽  
Hearing Preservation ◽  
Lessons Learned ◽  
Vestibular Schwannomas ◽  
Consecutive Series ◽  
Lower Cranial Nerve

Abstract BACKGROUND: Despite advanced microsurgical techniques, more refined instrumentation, and expert team management, there is still a significant incidence of complications in vestibular schwannoma surgery. OBJECTIVE: To analyze complications from the microsurgical treatment of vestibular schwannoma by an expert surgical team and to propose strategies for minimizing such complications. METHODS: Surgical outcomes and complications were evaluated in a consecutive series of 410 unilateral vestibular schwannomas treated from 2000 to 2009. Clinical status and complications were assessed postoperatively (within 7 days) and at the time of follow-up (range, 1–116 months; mean, 32.7 months). RESULTS: Follow-up data were available for 357 of the 410 patients (87.1%). Microsurgical tumor resection was performed through a retrosigmoid approach in 70.7% of cases. Thirty-three patients (8%) had intrameatal tumors and 204 (49.8%) had tumors that were <20 mm. Gross total resection was performed in 306 patients (74.6%). Hearing preservation surgery was attempted in 170 patients with tumors <20 mm, and good hearing was preserved in 74.1%. The main neurological complication was facial palsy (House-Brackmann grade III-VI), observed in 14% of patients (56 cases) postoperatively; however, 59% of them improved during the follow-up period. Other neurological complications were disequilibrium in 6.3%, facial numbness in 2.2%, and lower cranial nerve deficit in 0.5%. Nonneurological complications included cerebrospinal fluid leaks in 7.6%, wound infection in 2.2%, and meningitis in 1.7%. CONCLUSION: Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed.

scholarly journals Emerging Indications for Fractionated Gamma Knife Radiosurgery

Neurosurgery ◽  
2017 ◽  
Vol 80 (2) ◽  
pp. 210-216 ◽  
Author(s):  
Emory McTyre ◽  
Corbin A. Helis ◽  
Michael Farris ◽  
Lisa Wilkins ◽  
Darrell Sloan ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Vestibular Schwannoma ◽  
Gamma Knife Radiosurgery ◽  
Hearing Preservation ◽  
Vestibular Schwannomas ◽  
Previously Treated ◽  
Immobilization Device ◽  
Gamma Knife Perfexion ◽  
High Degree

Abstract BACKGROUND: Gamma Knife radiosurgery (GKRS) allows for the treatment of intracranial tumors with a high degree of dose conformality and precision. There are, however, certain situations wherein the dose conformality of GKRS is desired, but single-session treatment is contraindicated. In these situations, a traditional pin-based GKRS head frame cannot be used, because it precludes fractionated treatment. OBJECTIVE: To report our experience in treating patients with fractionated GKRS using a relocatable, noninvasive immobilization system. METHODS: Patients were considered candidates for fractionated GKRS if they had 1 or more of the following indications: a benign tumor >10 cc in volume or abutting the optic pathway, a vestibular schwannoma with the intent of hearing preservation, or a tumor previously irradiated with single-fraction GKRS. The immobilization device used for all patients was the Extend system (Leksell Gamma Knife Perfexion, Elekta, Kungstensgatan, Stockholm). RESULTS: We identified 34 patients treated with fractionated GKRS between August 2013 and February 2015. There were a total of 37 tumors treated including 15 meningiomas, 11 pituitary adenomas, 6 brain metastases, 4 vestibular schwannomas, and 1 hemangioma. At last follow-up, all 21 patients treated for perioptic tumors had stable or improved vision and all 4 patients treated for vestibular schwannoma maintained serviceable hearing. No severe adverse events were reported. CONCLUSION: Fractionated GKRS was well tolerated in the treatment of large meningiomas, perioptic tumors, vestibular schwannomas with intent of hearing preservation, and reirradiation of previously treated tumors.

Type 2 neurofibromatosis: the need for supraregional care?

1993 ◽  
Vol 107 (5) ◽  
pp. 401-406 ◽  
Author(s):  
D. Gareth R. Evans ◽  
Richard Ramsden ◽  
Susan M. Huson ◽  
Rodney Harris ◽  
Richard Lye ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Acoustic Neuroma ◽  
Hearing Preservation ◽  
Definitive Treatment ◽  
Facial Nerve Function ◽  
Operative Results ◽  
Nerve Preservation ◽  
Quality Life

The results of a U.K. study of 145 cases of type 2 neurofibromatosis has shown generally very poor operative results in terms of hearing and facial nerve preservation. Only 9 out of 118 vestibular schwannoma (acoustic neuroma) operations resulted in any clinically detectable hearing preservation and only 32 left the patient with good or normal (House grade I or II) ipsilateral facial nerve function. Although operation is still the definitive treatment of vestibular schwannoma (acoustic neuroma) and may be a lifesaving procedure, it appears that the evidence in favour of early operation is only valid when carried out in highly specialized centres. The special problems of NF2 cases who may go on to develop multiple spinal and cranial tumours making them wheelchair bound and blind as well as deaf warrants a careful experienced approach. Timing of operations may be critical for the enhancement of useful years of quality life. We therefore propose the setting up of a national NF2 register, with the management of cases at a few supraregional centres.

scholarly journals Translabyrinthine resection of NF2 associated vestibular schwannoma with cochlear implant insertion

2021 ◽  
Vol 5 (2) ◽  
pp. V14
Author(s):  
Cathal John Hannan ◽  
Priya Sharma ◽  
Matthew Edward Smith ◽  
Laurence Johann Glancz ◽  
Martin O’Driscoll ◽  
...  
Keyword(s):  
Cochlear Implant ◽  
Vestibular Schwannoma ◽  
Neurofibromatosis Type ◽  
Cochlear Nerve ◽  
Csf Leak ◽  
Tumor Control ◽  
Nerve Preservation ◽  
A Minor ◽  
Facial Function

The authors present the case of a 24-year-old female with neurofibromatosis type 2. Growth of the left vestibular schwannoma and progressive hearing loss prompted the decision to proceed to translabyrinthine resection with cochlear nerve preservation and cochlear implant insertion. Complete resection with preservation of the facial and cochlear nerves was achieved. The patient had grade 1 facial function and was discharged on postoperative day 4 following suturing of a minor CSF leak. This case highlights the feasibility of cochlear nerve preservation and cochlear implant insertion in appropriately selected patients, offering a combination of effective tumor control and hearing rehabilitation. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21122

GAMMA KNIFE RADIOSURGERY IN YOUNGER PATIENTS WITH VESTIBULAR SCHWANNOMAS

Neurosurgery ◽  
2009 ◽  
Vol 65 (2) ◽  
pp. 294-301 ◽  
Author(s):  
Javier Lobato-Polo ◽  
Douglas Kondziolka ◽  
Oscar Zorro ◽  
Hideyuki Kano ◽  
John C. Flickinger ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Vestibular Schwannoma ◽  
Gamma Knife Radiosurgery ◽  
Hearing Preservation ◽  
Vestibular Schwannomas ◽  
Surgical Removal ◽  
Management Options ◽  
Younger Patients ◽  
Cranial Nerve Dysfunction

Abstract OBJECTIVE Management options for patients with vestibular schwannoma include observation, surgical resection, stereotactic radiosurgery (SRS), and stereotactic radiation therapy. In younger patients, resection is often advocated because of concern regarding the long-term effects of radiation. We studied tumor response and clinical outcomes after SRS in such patients. METHODS We reviewed long-term outcomes in 55 patients with vestibular schwannomas. Patients were 40 years of age or younger, underwent gamma knife (GK) SRS between 1987 and 2003, and were followed up for a minimum of 4 years. The median patient age was 35 years (range, 13–40 years). Forty-one patients had Gardner-Robertson class 1 to 4 hearing. Thirteen patients (24%) had undergone surgical removal. The median tumor volume was 1.7 mm3. The median tumor margin dose was 13.0 Gy (range, 11–20 Gy). RESULTS At a median of 5.3 years, (range, 4–20 years), 2 of 55 patients underwent GK SRS for a second time; 1 of these patients had had a recurrence after initial resection. The 5-year rate of freedom from additional management was 96%. Hearing preservation rates (i.e., remaining within the same Gardner-Robertson hearing class) were 93%, 87%, and 87% at 3, 5, and 10 years, respectively. In patients with serviceable hearing before SRS, it was maintained in 100%, 93%, and 93% of patients at 3, 5, and 10 years, respectively. Hearing preservation was related to a margin dose lower than 13 Gy (P = 0.017). At the last assessment, facial and trigeminal nerve function was preserved in 98.2% and 96.4% of patients, respectively; the only facial deficit (House-Brackmann grade III) occurred in a patient who received a tumor dose of 20 Gy early in our experience (1988). None of the patients treated with doses lower than 13 Gy experienced facial or trigeminal neuropathy. All patients continued their previous level of activity or employment after GK SRS. No patient developed a secondary radiation-related tumor. CONCLUSION Our experience indicates that GK SRS is an effective management strategy for younger patients with vestibular schwannoma, most of whom have no additional cranial nerve dysfunction.

scholarly journals Surgical Strategy in Large Vestibular Schwannoma

2018 ◽  
Vol 80 (S 03) ◽  
pp. S272-S273
Author(s):  
Georgios Klironomos ◽  
Amir Reza Dehdashti
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Air Embolism ◽  
Patient Positioning ◽  
Skin Incision ◽  
Surgical Strategy ◽  
Vestibular Schwannomas ◽  
Magnetic Resonance Imaging Mri ◽  
Large Vestibular Schwannoma

Particular care to facial nerve function preservation should be the ultimate goal in surgery for large vestibular schwannomas. We present a 60-year-old patient who presented with an enlarging right vestibular schwannoma and nonserviceable hearing. The patient was operated in the semisitting position after a patent foramen ovale was ruled out. During the positioning, the feet were positioned at the level of the heart. Precordial Doppler was used to monitor for air embolism. Straight skin incision and retrosigmoid craniotomy was performed. Specific attention to venous bleeding was made during the approach. Meticulous arachnoid dissection of the capsule preserving the arachnoid plane at the surface of the brain stem and the facial nerve can be achieved more efficiently with the patient in the semisiting position and with bimanual microdissection technique. After drilling of the internal auditory canal (IAC), we were able to achieve near total removal of the tumor, leaving a tiny tumor carpet due to extreme adherence to the nerve. Water-tight dura closure and replacement of the bone flap was performed. The patient woke up with a House–Brackmann grade III facial weakness which improved to grade I at 6 weeks postoperatively. Postoperative magnetic resonance imaging (MRI) showed a tiny residual at the surface of the facial nerve at the entrance of the IAC. Near total (> 98%) resection of large vestibular schwannomas is an acceptable surgical strategy with excellent facial nerve outcome. With appropriate patient positioning in semisitting and proper anesthesiological and surgical management, the risk of air embolism is negligible.The link to video can be found at: https://youtu.be/ErG9VexbiGw.

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