Stereotactic radiosurgery for acoustic nerve tumors in patients with useful preoperative hearing: results at 2-year follow-up examination

1994 ◽  
Vol 80 (6) ◽  
pp. 1011-1017 ◽  
Author(s):  
Olusola K. Ogunrinde ◽  
L. Dade Lunsford ◽  
John C. Flickinger ◽  
Douglas Kondziolka
Keyword(s):  
Stereotactic Radiosurgery ◽  
Trigeminal Nerve ◽  
Cranial Nerve ◽  
Nerve Function ◽  
Content Type ◽  
Acoustic Neuromas ◽  
Cranial Nerve Function ◽  
Acoustic Nerve ◽  
Radiation Beams ◽  
Fine Print

✓ Twenty patients with acoustic nerve tumors (mean diameter ≤ 30 mm) and useful preoperative hearing were examined 2 years after stereotactic radiosurgery to determine the effectiveness of the surgery in the control of tumor growth and the preservation of cranial nerve function. Results showed tumor volume stabilization (12 cases) or reduction (seven cases) was achieved in a total of 19 patients (95%). Useful hearing (defined as Gardner and Robertson Class I or II) preservation was obtained in 100% of cases immediately postoperatively, 50% at 6 months, and 45% at both 1 and 2 years. Two years after stereotactic radiosurgery, facial nerve function was preserved in 90% of patients and 75% continued to have normal trigeminal nerve function. All patients returned to and maintained their preoperative functional status within 3 to 5 days after radiosurgery. These findings indicate that stereotactic radiosurgery with multiple isocenters and narrow radiation beams is a safe and effective management strategy for progressive acoustic nerve tumors. Auditory, facial, and trigeminal nerve function can be preserved in most patients. Prevention of further growth and preservation of cranial nerve function appear to be satisfactory goals in the current management of patients with acoustic neuromas.

Trigeminal schwannomas: removal of dumbbell-shaped tumors through the expanded Meckel cave and outcomes of cranial nerve function

2002 ◽  
Vol 96 (3) ◽  
pp. 453-463 ◽  
Author(s):  
Ossama Al-Mefty ◽  
Samer Ayoubi ◽  
Esam Gaber
Keyword(s):  
Cranial Nerve ◽  
Nerve Function ◽  
Middle Fossa ◽  
Total Removal ◽  
Content Type ◽  
Middle Fossa Approach ◽  
Cranial Nerve Function ◽  
Nerve Paresis ◽  
Abducent Nerve ◽  
Fine Print

Object. As in patients with vestibular schwannomas, advances in surgical procedures have markedly improved outcomes in patients with trigeminal schwannomas. In this article the authors address the function of cranial nerves in a series of patients with trigeminal schwannomas that were treated with gross-total surgical removal. The authors emphasize a technique they use to remove a dumbbell-shaped tumor through the expanded Meckel cave, and discuss the advantage of the extradural zygomatic middle fossa approach for total removal of tumor and preservation or improvement of cranial nerve function. Methods. Within an 11-year period (1989–2000), 25 patients (14 female and 11 male patients with a mean age of 44.4 years) with benign trigeminal schwannomas were surgically treated by the senior author (O.A.) with the aim of total removal of the tumor. Three patients had undergone previous surgery elsewhere. Trigeminal nerve dysfunction was present in all but two patients. Abducent nerve paresis was present in 40%. The approach in each patient was selected according to the location and size of the lesion. Nineteen tumors were dumbbell shaped and extended into both middle and posterior fossae. All 25 tumors involved the cavernous sinus. The zygomatic middle fossa approach was particularly useful and was used in 14 patients. The mean follow-up period was 33.12 months. In patients who had not undergone previous surgery, the preoperative trigeminal sensory deficit improved in 44%, facial pain decreased in 73%, and trigeminal motor deficit improved in 80%. Among patients with preoperative abducent nerve paresis, recovery was attained in 63%. Three patients (12%) experienced a persistent new or worse cranial nerve function postoperatively. Fifth nerve sensory deficit persisted in one of these patients, sensory and motor dysfunction in another, and motor trigeminal weakness in the third patient. In all patients a good surgical outcome was achieved. One patient died 2 years after treatment from an unrelated cause. In three patients the tumors recurred after an average of 22.3 months. Conclusions. Preservation or improvement of cranial nerve function can be achieved through total removal of a trigeminal schwannoma, and skull base approaches are better suited to achieving this goal. The zygomatic middle fossa approach is particularly helpful and safe. It allows extradural tumor removal from the cavernous sinus, the infratemporal fossa, and the posterior fossa through the expanded Meckel cave.

Stereotactic radiosurgery in the management of acoustic neuromas associated with neurofibromatosis Type 2

1999 ◽  
Vol 90 (5) ◽  
pp. 815-822 ◽  
Author(s):  
Brian R. Subach ◽  
Douglas Kondziolka ◽  
L. Dade Lunsford ◽  
David J. Bissonette ◽  
John C. Flickinger ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Neurofibromatosis Type ◽  
Tumor Control ◽  
Nerve Function ◽  
Content Type ◽  
Acoustic Neuromas ◽  
The Mean ◽  
Fine Print

Object. Stereotactically guided radiosurgery is one of the primary treatment modalities for patients with acoustic neuromas (vestibular schwannomas). The goal of radiosurgery is to arrest tumor growth while preserving neurological function. Patients with acoustic neuromas associated with neurofibromatosis Type 2 (NF2) represent a special challenge because of the risk of complete deafness. To define better the tumor control rate and long-term functional outcome, the authors reviewed their 10-year experience in treating these lesions.Methods. Forty patients underwent stereotactic radiosurgery at the University of Pittsburgh, 35 of them for solitary tumors. The other five underwent staged procedures for bilateral lesions (10 tumors, 45 total). Thirteen patients (with 29% of tumors) had undergone a median of two prior resections. The mean tumor volume at radiosurgery was 4.8 ml, and the mean tumor margin dose was 15 Gy (range 12–20 Gy).The overall tumor control rate was 98%. During the median follow-up period of 36 months, 16 tumors (36%) regressed, 28 (62%) remained unchanged, and one (2%) grew. In the 10 patients for whom more than 5 years of clinical and neuroimaging follow-up results were available (median 92 months), five tumors were smaller and five remained unchanged. Surgical resection was performed in three patients (7%) after radiosurgery; only one showed radiographic evidence of progression. Useful hearing (Gardner—Robertson Class I or II) was preserved in six (43%) of 14 patients, and this rate improved to 67% after modifications made in 1992. Normal facial nerve function (House—Brackmann Grade 1) was preserved in 25 (81%) of 31 patients. Normal trigeminal nerve function was preserved in 34 (94%) of 36 patients.Conclusions. Stereotactically guided radiosurgery is a safe and effective treatment for patients with acoustic tumors in the setting of NF2. The rate of hearing preservation may be better with radiosurgery than with other available techniques.

Stereotactic radiotherapy for the treatment of acoustic neuromas

2004 ◽  
Vol 101 (Supplement3) ◽  
pp. 362-372 ◽  
Author(s):  
Michael T. Selch ◽  
Alessandro Pedroso ◽  
Steve P. Lee ◽  
Timothy D. Solberg ◽  
Nzhde Agazaryan ◽  
...  
Keyword(s):  
Stereotactic Radiotherapy ◽  
Tumor Size ◽  
Cranial Nerve ◽  
Target Volume ◽  
Tumor Control ◽  
Content Type ◽  
Seventh Cranial Nerve ◽  
Acoustic Neuromas ◽  
Fine Print

Object. The authors sought to assess the safety and efficacy of stereotactic radiotherapy when using a linear accelerator equipped with a micromultileaf collimator for the treatment of patients with acoustic neuromas. Methods. Fifty patients harboring acoustic neuromas were treated with stereotactic radiotherapy between September 1997 and June 2003. Two patients were lost to follow-up review. Patient age ranged from 20 to 76 years (median 59 years), and none had neurofibromatosis. Forty-two patients had useful hearing prior to stereotactic radiotherapy. The fifth and seventh cranial nerve functions were normal in 44 and 46 patients, respectively. Tumor volume ranged from 0.3 to 19.25 ml (median 2.51 ml). The largest tumor dimension varied from 0.6 to 4 cm (median 2.2 cm). Treatment planning in all patients included computerized tomography and magnetic resonance image fusion and beam shaping by using a micromultileaf collimator. The planning target volume included the contrast-enhancing tumor mass and a margin of normal tissue varying from 1 to 3 mm (median 2 mm). All tumors were treated with 6-MV photons and received 54 Gy prescribed at the 90% isodose line encompassing the planning target volume. A sustained increase greater than 2 mm in any tumor dimension was defined as local relapse. The follow-up duration varied from 6 to 74 months (median 36 months). The local tumor control rate in the 48 patients available for follow up was 100%. Central tumor hypodensity occurred in 32 patients (67%) at a median of 6 months following stereotactic radiotherapy. In 12 patients (25%), tumor size increased 1 to 2 mm at a median of 6 months following stereotactic radiotherapy. Increased tumor size in six of these patients was transient. In 13 patients (27%), tumor size decreased 1 to 14 mm at a median of 6 months after treatment. Useful hearing was preserved in 39 patients (93%). New facial numbness occurred in one patient (2.2%) with normal fifth cranial nerve function prior to stereotactic radiotherapy. New facial palsy occurred in one patient (2.1%) with normal seventh cranial nerve function prior to treatment. No patient's pretreatment dysfunction of the fifth or seventh cranial nerve worsened after stereotactic radiotherapy. Tinnitus improved in six patients and worsened in two. Conclusions. Stereotactic radiotherapy using field shaping for the treatment of acoustic neuromas achieves high rates of tumor control and preservation of useful hearing. The technique produces low rates of damage to the fifth and seventh cranial nerves. Long-term follow-up studies are necessary to confirm these findings.

Targeting the cranial nerve: microradiosurgery for trigeminal neuralgia with CISS and 3D-Flash MR imaging sequences

2005 ◽  
Vol 102 ◽  
pp. 107-110 ◽  
Author(s):  
Vasilios A. Zerris ◽  
Georg C. Noren ◽  
William A. Shucart ◽  
Jeff Rogg ◽  
Gerhard M. Friehs
Keyword(s):  
Mr Imaging ◽  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Trigeminal Nerve ◽  
Cranial Nerve ◽  
Fusion Imaging ◽  
Vascular Compression ◽  
Content Type ◽  
History Of ◽  
Fine Print

Object.The authors undertook a study to identify magnetic resonance (MR) imaging techniques that can be used reliably during gamma knife surgery (GKS) to identify the trigeminal nerve, surrounding vasculature, and areas of compression.Methods.Preoperative visualization of the trigeminal nerve and surrounding vasculature as well as targeting the area of vascular compression may increase the effectiveness of GKS for trigeminal neuralgia. During the past years our gamma knife centers have researched different MR imaging sequences with regard to their ability to visualize cranial nerves and vascular structures. Constructive interference in steady-state (CISS) fusion imaging with three-dimensional gradient echo sequences (3D-Flash) was found to be of greatest value in the authors' 25 most recent patients.In 24 (96%) out of the 25 patients, the fifth cranial nerve, surrounding vessels, and areas of compression could be reliably identified using CISS/3D-Flash. The MR images were acceptable despite patients' history of microvascular decompression, radiofrequency (RF) ablation, or concomitant disease. In one of 25 patients with a history of multiple RF lesions, the visualization was inadequate due to severe trigeminal nerve atrophy.Conclusions.The CISS/3D-Flash fusion imaging has become the preferred imaging method at the authors' institutions during GKS for trigeminal neuralgia. It affords the best visualization of the trigeminal nerve, surrounding vasculature, and the precise location of vascular compression.

Trigeminal schwannoma

1988 ◽  
Vol 69 (6) ◽  
pp. 850-860 ◽  
Author(s):  
Paul C. McCormick ◽  
Jacqueline A. Bello ◽  
Kalmon D. Post
Keyword(s):  
Trigeminal Nerve ◽  
Surgical Approach ◽  
Csf Leak ◽  
Symptom Duration ◽  
Consecutive Series ◽  
Nerve Function ◽  
Content Type ◽  
Trigeminal Schwannoma ◽  
Cranial Nerve Palsies ◽  
Fine Print

✓ A consecutive series of 14 patients with trigeminal schwannoma managed surgically at the Neurological Institute of New York since 1970 is reported. Nine women and five men (mean age 40 years) were diagnosed following a mean symptom duration of 33 months. Abnormalities of trigeminal nerve function were present in 11 patients on admission examination. Facial pain was a prominent feature in eight patients. Two patients, both with schwannomas arising from the trigeminal root, presented initially with typical trigeminal neuralgia. Additional cranial nerve palsies or cerebellar or pyramidal tract signs were noted in eight patients. The surgical approach to these tumors depends on their anatomical location. Four patients had tumors confined to the middle fossa, three patients had tumors limited to the posterior fossa, and seven patients had both supratentorial and infratentorial components of their tumors. Twenty operative procedures were performed on these patients, resulting in complete extirpation in six patients, nearly complete removal in seven patients, and partial removal in one patient. Adherence of the tumor to the lateral wall of the cavernous sinus or the brain stem precluded total removal. There was one postoperative death. In the immediate postoperative period, abnormalities of cranial nerves controlling the extraocular muscles were common. In general, these deficits were transient; however, some permanent loss of trigeminal nerve function occurred in nine patients. Two patients required tarsorrhaphy for neurotropic keratitis, and two patients underwent cerebrospinal fluid (CSF) shunting procedures for hydrocephalus or for a persistent CSF leak. The follow-up period ranged from 4 to 177 months (mean 47 months). The clinical features, anatomical considerations, and surgical approach to these rare tumors are discussed. A clinical review of 106 additional cases of trigeminal schwannoma, reported in the English literature since 1935, is also presented.

184 Cranial Nerve Function Before and After Stereotactic Radiosurgery for Cavernous Sinus Meningiomas

Neurosurgery ◽  
2012 ◽  
Vol 71 (2) ◽  
pp. E571-E572 ◽  
Author(s):  
Hideyuki Kano ◽  
Kyung-Jae Park ◽  
Aditya K. Iyer ◽  
Ajay Niranjan ◽  
John Flickinger ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Nerve Function ◽  
Cranial Nerve Function ◽  
Before And After

Meningiomas involving the cavernous sinus: histological factors affecting the degree of resection

1997 ◽  
Vol 87 (4) ◽  
pp. 535-543 ◽  
Author(s):  
Chandranath Sen ◽  
Karin Hague
Keyword(s):  
Cavernous Sinus ◽  
Internal Carotid ◽  
Skull Base Surgery ◽  
Complete Resection ◽  
Nerve Function ◽  
Content Type ◽  
Factors Affecting ◽  
Cranial Nerve Function ◽  
Histological Factors ◽  
Fine Print

✓ Despite advances in the surgical treatment of meningiomas located at the skull base, surgery for meningiomas involving the cavernous sinus remains controversial. The controversy centers on whether complete resection of such a meningioma is possible while preserving cranial nerve function. To evaluate this question, the authors examined six patients with benign meningiomas involving the cavernous sinus. The pathological features of these tumors were evaluated and compared with the normal histoarchitecture of the cavernous sinus. The tendency of these tumors to be infiltrative is evident and this seems to occur along connective tissue planes within the cavernous sinus. This invasiveness can be explained by the peculiar structure of this region. The trigeminal nerve and ganglion seem to be particularly prone to invasion; this does not correlate with the degree of preoperative impairment of nerve function. Internal carotid artery invasion occurs frequently and can be seen even when there is no narrowing of the artery on arteriography. The pituitary gland can also be invaded by the tumor, which penetrates the thin dural barrier.

The clinical application of plugging patterns for the Leksell gamma knife

2002 ◽  
Vol 97 ◽  
pp. 579-581 ◽  
Author(s):  
Paul Vaughan ◽  
Anna Hampshire ◽  
Tracy Soanes ◽  
Andras Kemeny ◽  
Matthias Radatz ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Trigeminal Neuralgia ◽  
Stereotactic Radiosurgery ◽  
Radiation Field ◽  
Gamma Knife ◽  
Clinical Application ◽  
Trigeminal Nerve ◽  
Conformity Index ◽  
Content Type ◽  
Fine Print

Object. In this report the authors explore the use of standardized plugging templates in formulating stereotactic radiosurgery dose plans for the Leksell gamma knife. Methods. Unplugged gamma knife dose plans previously used in the treatment of patients with trigeminal neuralgia (TN) and vestibular schwannoma (VS) were studied. Standardized plugging templates were then superimposed on these plans, and their effects on the conformity index of tumors and the transposition of the radiation field from the brainstem to the cerebrospinal fluid spaces for the trigeminal cases were examined. Conclusions. The standardized plugging templates significantly increased the conformity indices in cases of VS plans and for TN. Plugging significantly reduced the brainstem exposure to radiation while at the same time not altering the length of the trigeminal nerve being treated. Standardized plugging templates may therefore be a useful tool in optimizing dose plans.

Proton Beam Radiosurgery for Vestibular Schwannoma: Tumor Control and Cranial Nerve Toxicity

Neurosurgery ◽  
2003 ◽  
Vol 53 (3) ◽  
pp. 577-588 ◽  
Author(s):  
Damien C. Weber ◽  
Annie W. Chan ◽  
Marc R. Bussiere ◽  
Griffith R. Harsh ◽  
Marek Ancukiewicz ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Proton Beam ◽  
Trigeminal Nerve ◽  
Cranial Nerve ◽  
Univariate Analysis ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Transverse Diameter ◽  
Nerve Function ◽  
Function Preservation

Abstract OBJECTIVE We sought to determine the tumor control rate and cranial nerve function outcomes in patients with vestibular schwannomas who were treated with proton beam stereotactic radiosurgery. METHODS Between November 1992 and August 2000, 88 patients with vestibular schwannomas were treated at the Harvard Cyclotron Laboratory with proton beam stereotactic radiosurgery in which two to four convergent fixed beams of 160-MeV protons were applied. The median transverse diameter was 16 mm (range, 2.5–35 mm), and the median tumor volume was 1.4 cm3 (range, 0.1–15.9 cm3). Surgical resection had been performed previously in 15 patients (17%). Facial nerve function (House-Brackmann Grade 1) and trigeminal nerve function were normal in 79 patients (89.8%). Eight patients (9%) had good or excellent hearing (Gardner-Robertson [GR] Grade 1), and 13 patients (15%) had serviceable hearing (GR Grade 2). A median dose of 12 cobalt Gray equivalents (range, 10–18 cobalt Gray equivalents) was prescribed to the 70 to 108% isodose lines (median, 70%). The median follow-up period was 38.7 months (range, 12–102.6 mo). RESULTS The actuarial 2- and 5-year tumor control rates were 95.3% (95% confidence interval [CI], 90.9–99.9%) and 93.6% (95% CI, 88.3–99.3%). Salvage radiosurgery was performed in one patient 32.5 months after treatment, and a craniotomy was required 19.1 months after treatment in another patient with hemorrhage in the vicinity of a stable tumor. Three patients (3.4%) underwent shunting for hydrocephalus, and a subsequent partial resection was performed in one of these patients. The actuarial 5-year cumulative radiological reduction rate was 94.7% (95% CI, 81.2–98.3%). Of the 21 patients (24%) with functional hearing (GR Grade 1 or 2), 7 (33.3%) retained serviceable hearing ability (GR Grade 2). Actuarial 5-year normal facial and trigeminal nerve function preservation rates were 91.1% (95% CI, 85–97.6%) and 89.4% (95% CI, 82–96.7%). Univariate analysis revealed that prescribed dose (P = 0.005), maximum dose (P = 0.006), and the inhomogeneity coefficient (P = 0.03) were associated with a significant risk of long-term facial neuropathy. No other cranial nerve deficits or cancer relapses were observed. CONCLUSION Proton beam stereotactic radiosurgery has been shown to be an effective means of tumor control. A high radiological response rate was observed. Excellent facial and trigeminal nerve function preservation rates were achieved. A reduced prescribed dose is associated with a significant decrease in facial neuropathy.

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