Conservative Management of Acoustic Neuroma: A Meta-Analysis and Proposed Treatment Algorithm

Smouha, Eric E.; Yoo, Michael J.; Mohr, Kristi; Davis, Raphael P.

doi:10.1097/00005537-200503000-00011

Cited by 242 publications

(229 citation statements)

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“…5,24,38,42 Interventions would be considered if tumor growth of ≥ 2 mm/year were detected. 23,39 Although microsurgical resection and radiation therapy are viable options, the outcomes of vestibular schwannomas treated by radiosurgery are rapidly improving, with 4 nonrandomized prospective studies demonstrating that radiosurgery outcomes were either better than or similar to those obtained with resection.…”

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confidence: 99%

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

Hoshide

Faulkner

Teo³

et al. 2018

Neurosurgical Focus

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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.

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confidence: 99%

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

Hoshide

Faulkner

Teo³

et al. 2018

Neurosurgical Focus

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“…Additionally, children frequently present with large tumors. In a meta-analysis of 1345 adult patients, the average size of the vestibular schwannomas was 1.18 cm (12), while the average diameter of the tumors in our series was 5.15 cm (range, 3-8 cm). A plausible explanation for this difference is that younger patients are unable to articulate the severity or characteristics of their symptoms in the same fashion as adults.…”

Section: █ Discussionmentioning

confidence: 54%

Unilateral acoustic neuromas in childhood without evidence of neurofibromatosis: experience in 10 patients at a single institute

Yin¹,

Ma²,

Li³

et al. 2015

Turkish Neurosurgery

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ABSTRACT(approximately 0.2% of all cases reported in the last 20 years in Beijing Tiantan Hospital). █ mATERIAl and mEThODS PatientsTen pediatric patients (6 male and 4 female patients) who were admitted from January 1994 to December 2014 and diagnosed with unilateral vestibular schwannomas were █ INTRODUCTION V estibular schwannomas, which originate from the vestibular division of cranial nerve VIII, occur more often in adults than children. Identification of a sporadic or non-neurofibromatosis type 2 vestibular schwannoma in a child is extremely rare (1-7). When a vestibular schwannoma is found in a child, neurofibromatosis should be the first differential diagnosis. We reviewed 10 cases involving <16-yearold patients without clinical evidence of neurofibromatosis AIm: We investigated the clinical presentation and management issues of unilateral vestibular schwannomas in childhood without evidence of neurofibromatosis. mATERIAl and mEThODS: Ten pediatric patients with unilateral vestibular schwannoma and no evidence of neurofibromatosis were treated by the senior author at Tiantan Hospital from January 1994 to December 2014. The clinical manifestations, neuroimaging findings, treatment methods, and therapeutic results were retrospectively reviewed. RESUlTS:The study included 6 male and 4 female patients. The mean age of the patients was 13.9 years (range, 11-15 years). Common clinical features included increased intracranial pressure, hearing loss, and ataxia. The median diameter of the tumors was 5.15 cm. Gross total resection was achieved in 9 of 10 patients via a suboccipital retrosigmoid approach, and the perioperative mortality rate was 10%. The follow-up period ranged from 1 to 12 years. One patient with facial nerve injury recovered to HouseBrackmann grade I postoperatively, 5 to grade II-III, and 2 to grade IV-V. Only 1 patient had preserved hearing. CONClUSION:The clinical features of pediatric vestibular schwannomas are different from those of adult vestibular schwannomas, and cranial nerve preservation in children is more difficult. When a child presents with hearing loss as well as cognitive disability, a vestibular schwannoma should be highly suspected. Hypervascular vestibular schwannomas in childhood should be managed by multistaged surgeries.

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“…19,20 Growth rate varies from 0.7 to 2 mm annually, there are plenty of long term follow up studies proposing that over 65% of ANs do not grow or even decrease in size, limiting the need for intervention between 20-35% of the cases. [21][22][23][24] In a meta-analysis by Smouha et al 57% of ANs did not seem to grow after a mean follow up period of more than 3 years, whereas failure rate of conservative management was 20%. 18,21 Overall mean AN growth was 1.9 mm per year.…”

Section: Discussionmentioning

confidence: 99%

“…[21][22][23][24] In a meta-analysis by Smouha et al 57% of ANs did not seem to grow after a mean follow up period of more than 3 years, whereas failure rate of conservative management was 20%. 18,21 Overall mean AN growth was 1.9 mm per year. These results are similar to the findings our study.…”

Section: Discussionmentioning

confidence: 99%

Predictive factors of acoustic neuroma growth

Kikidis

Xenellis

Kyrodimos

et al. 2016

Int J Otorhinolaryngol Head Neck Surg

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Background:Since the use of magnetic resonance imaging (MRI) as the gold standard for acoustic neuroma diagnosis, the size of the majority of newly diagnosed acoustic neuromas has decreased. Management strategy is challenging, especially in young patients with small tumors. Therefore, prognostic factors for tumor growth may facilitate physicians to optimize treatment choice.Methods:Patients diagnosed with acoustic neuromas were recruited in this study. Gender, age, side, presence of hearing loss, tinnitus, vertigo, unsteadiness, other symptoms, hearing level in the affected ear and tumor growth at the first follow up MRI were recorded. Two primary endpoints were set: overall acoustic neuroma (AN) growth and growth correlated to treatment plan change (clinically significant growth). Multivariate and survival analysis were conducted to this end. Results:85 patients were finally included in the study. The most prevalent presenting symptoms were hearing loss (76%), tinnitus (56%) and unsteadiness (46%). The tumour grew in size in less than 50% of the cases during the observation period. Clinically significant growth was observed in 27% of the cases. Mean initial diameter was 10.41mm and mean final follow-up diameter (diameter at the end of the observation period) 12.73 mm. Following binary logistic regression analysis, tumour growth during the initial follow up visit was found to be correlated in a statistically significant level to overall tumour growth (p-value 0.023). Regarding clinically significant growth, three factors were found to be statistically significant: growth at the initial visit (p-value 0.02), initial diameter (p-value 0.045) and existence of unsteadiness at diagnosis (p-value 0.02).Conclusions:Acoustic neuroma overall growth is not identical to clinically significant growth. Growth at first visit is a significant prognostic factor and intervention potential should be considered under this perspective.

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Conservative Management of Acoustic Neuroma: A Meta-Analysis and Proposed Treatment Algorithm

Cited by 242 publications

References 20 publications

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

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

Unilateral acoustic neuromas in childhood without evidence of neurofibromatosis: experience in 10 patients at a single institute

Predictive factors of acoustic neuroma growth

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