Contemporary Surgical Management of Vestibular Schwannomas

Nonaka, Yoichi; Fukushima, Takanori; Watanabe, Kentaro; Friedman, Allan H.; Sampson, John H.; McElveen, John T.; Cunningham, Calhoun D.; Zomorodi, Ali R.

doi:10.1227/neu.0b013e3182752b05

Cited by 61 publications

(75 citation statements)

References 72 publications

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“…The incidence of IVS is quite high (approximately 8%), which is primarily associated with the growing availability of good-quality radiological imaging. 3,4 Since most patients with IVS present with only TA B L E 1 Gardner-Robertson scale (GRS) before (pre-GKS) and at the last follow up (post-GKS) after radiosurgery (n = 136) Pre-GKS Post-GKS I 25 19 II 32 30 III 66 62 IV 13 25 minor clinical symptoms or are completely asymptomatic, the optimal strategy for the management of these tumors is still a matter of debate. Nowadays, three reasonable IVS management options exist, the conservative approach (wait-and-see strategy), surgical treatment, and radiosurgery/ fractionated radiation therapy.…”

Section: Discussionmentioning

confidence: 99%

“…Approximately 8% of vestibular schwannomas are intracanalicular VS (IVS). [1][2][3][4][5] The growing availability of high-resolution magnetic resonance (MR) imaging contributed to an increase in the IVS detection rate. However, the choice of an appropriate management strategy, whether a conservative wait-and-see approach, microsurgical resection, or gamma knife surgery (GKS), still constitutes a challenge, especially since the majority of IVS has only minor clinical symptoms or is asymptomatic.…”

Section: Introductionmentioning

confidence: 99%

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Gamma knife surgery in the treatment of intracanalicular vestibular schwannomas

Dzierzęcki

Czapski²,

Dyttus-Cebulok

et al. 2020

Acta Neurol Scand

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Objective According to the literature, gamma knife surgery (GKS) is a promising method for intracanalicular vestibular schwannoma (IVS) management, providing excellent tumor growth control rates (91%‐100%) and good hearing preservation rates (41%‐76%), but this evidence originates primarily from a small series of patients. The aim of this study was to present the outcomes of GKS in the largest group of patients with IVS studied to date, with particular emphasis on the long‐term outcomes of treatment. Methods The study included 136 consecutive patients with unilateral IVS, who underwent GKS in 2011‐2015. Mean age of the patients was 54 ± 12.6 years. All patients were operated on with a 192‐source cobalt‐60 gamma knife unit. All patients had complete follow‐up documentation and the mean duration of the follow‐up was 52 ± 13.8 months (6‐83 months). Neurological status (facial and trigeminal nerve), hearing and instability/dizziness presence were determined prior to GKS, immediately after the procedure, and during the follow‐up visits. Results Tumor growth control was obtained in 124/136 (~91.2%) patients. Hearing improvement was observed in 32/136 (23.5%) patients, and there was a distinct cluster of 9 patients (6.6%) regaining serviceable hearing after GKS, whereas in 36 patients (26.5%) was stable. Four patients developed facial nerve dysfunction, including 3 periodic hemifacial spasm and 1 partial paresis, which resolved spontaneously within 12 months of GKS. None of the operated patients showed new, debilitating neurological deficits, including trigeminal sensory disturbances or hydrocephalus. Conclusions GKS is a highly effective treatment for IVS, associated with low morbidity and good tumor growth control.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Gamma knife surgery in the treatment of intracanalicular vestibular schwannomas

Dzierzęcki

Czapski²,

Dyttus-Cebulok

et al. 2020

Acta Neurol Scand

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“…The diagnoses and procedures are reported as ICD-9-CM and CPT codes, which inherently fail to capture details of the complications. Information on the type of the institution (academic versus non-academic) and surgical load were not available (10,11). In addition, it is unclear whether the patients had surgery for sporadic or neurofibromatosis type 2 (NF2) as complications in the NF2 group is higher (22).…”

Section: Discussionmentioning

confidence: 99%

Postoperative Complications and Readmission Rates Following Surgery for Cerebellopontine Angle Schwannomas

Mahboubi

Haidar

Moshtaghi

et al. 2016

Otology &Amp; Neurotology

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Objective To investigate the 30-day postoperative complication, readmission, and reoperation rates following surgery for cerebellopontine angle (CPA) schwannomas. Study Design Cross-sectional analysis. Setting National surgical quality improvement program dataset (NSQIP) 2009 through 2013. Patients All surgical cases with an International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis code of 225.1, benign neoplasms of cranial nerves, and one of the following current procedural terminology (CPT) codes, were included: 61616, 61526, 61530, and 61520. Intervention(s) Surgical resection as indicated by the CPT codes above. Main Outcome Measure(s) Demographics, comorbidities, 30-day postoperative complications, readmission rate, and reoperation rate. Results Overall, 404 cases were identified, of which 42.6% were men. The average age was 51 years. Comorbidities were present in 45.3%. NSQIP-tracked complications occurred in 9.7% of patients. Most common complications were wound infections including surgical-site infection and wound dehiscence (11 patients, 2.7%), sepsis (10 patients, 2.5%), blood loss (nine patients, 2.2%), and deep vein thrombosis (DVT; seven patients, 1.7%). Mortality occurred in four patients (1.0%). The complication rate was statistically higher in patients with comorbidities versus those without (10.2% versus 4.1%, p = 0.04). Patients with complications were more likely to undergo reoperation (2.5% with versus 4.1% without, p = 0.001). Unplanned readmissions occurred in 41 cases (10.1%) and reoperations occurred in 23 patients (5.7%). Conclusions Most common NSQIP-tracked complications in excision of CPA neoplasms are infections, sepsis, blood loss, and deep vein thrombosis (DVT). Further, investigation of patients with unplanned readmission and reoperation are warranted. Neurotologists need to take an active role in the data to be gathered in the NSQIP database as it relates to vestibular schwannomas.

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“…However, the surgeon cannot predict when this will happen [23,24]. We observed this situation (or scenario) in our first illustrative case, in which the patient developed facial nerve function of III/VI postoperatively despite the absence of a significant change in facial nerve stimulation during surgery.…”

Section: Discussionmentioning

confidence: 82%

“…Hearing preservation was achieved in 7/8 (87.5%), which is in keeping with favorable reported rates that range from 21 to 90%. [23,33]. …”

Section: Discussionmentioning

confidence: 99%

Outcomes in Patients with Vestibular Schwannoma after Subtotal Resection and Adjuvant Radiosurgery

Radwan

Eisenberg²,

Knisely³

et al. 2016

Stereotact Funct Neurosurg

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Background: The debate continues with a limited number of publications describing outcomes in patients with vestibular schwannoma (VS) treated with planned subtotal resection (STR) plus stereotactic radiosurgery (SRS). Here we present our experience. Methods: This is a retrospective review of 22 patients with VS Koos grade III and IV who were treated with STR followed by SRS. Tumor volumes, facial nerve function, hearing preservation, and the presence of trigeminal neuropathy were noted. Spearman's rank test was used to correlate facial nerve grade with postoperative tumor residual tumor volume. Results: Tumor control was achieved in all patients with a mean follow-up of 28 months. No patient required other treatment beyond the original surgery and adjuvant SRS during this period. After a mean postoperative period of 28 months, 19/22 patients had excellent (House-Brackmann I or II) facial nerve function grading. Improved facial nerve function was positively correlated with larger residual tumor volume (r_s = 0.63). Kaplan-Meier curve showed around 80% probability for regaining facial nerve function after initial deterioration. Four patients reported postoperative facial numbness at the side of surgery, with 3 cases showing improvement within a month. Temporary postoperative caudal cranial nerve dysfunction was observed in 2 patients. Conclusion: Hybrid strategy of STR and adjuvant SRS provides patients with large VS excellent tumor control and a good clinical outcome.

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Contemporary Surgical Management of Vestibular Schwannomas

Abstract: Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed.

Cited by 61 publications

References 72 publications

Gamma knife surgery in the treatment of intracanalicular vestibular schwannomas

Gamma knife surgery in the treatment of intracanalicular vestibular schwannomas

Postoperative Complications and Readmission Rates Following Surgery for Cerebellopontine Angle Schwannomas

Outcomes in Patients with Vestibular Schwannoma after Subtotal Resection and Adjuvant Radiosurgery

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