Differential Impact of Advanced Age on Clinical Outcomes After Vestibular Schwannoma Resection in the Very Elderly: Cohort Study

Abstract

BACKGROUND Vestibular schwannomas (VS) have a peak incidence in the sixth and seventh decades of life. Stereotactic radiosurgery is often the preferred treatment for VS among patients of advanced age. The fraction of elderly patients potentially requiring consideration for surgical treatment is anticipated to expand, mandating an update to management paradigms in this population. OBJECTIVE To describe our experience with surgical management of VS in patients aged 75 yr and older. METHODS Cohort study of all patients aged ≥75 yr with sporadic VS requiring surgical treatment at our institution between 1999 and 2020. Data included preoperative baseline characteristics and outcome data including extent of resection, facial nerve and hearing status, functional outcome, length of stay, and complications. RESULTS A total of 24 patients were included, spanning an age range of 75 to 90 yr. Average tumor size was 2.76 ± 1.04 cm, and average baseline Modified 5-item Frailty Index (mFI-5) score was 1.08 ± 0.93. Extent of resection was gross total in 5 (20.8%), near total in 3 (12.5%), and sub-total resection in the remaining 16 (66.7%). One patient died in the postoperative period because of an acute sub-dural hematoma. Favorable facial nerve function (HB1-2) was preserved in 12 patients (75%) between 75 and 79 yr and 2 patients (28.6%) aged ≥ 80 yr. No cerebrospinal fluid leak or surgical site infection was observed; 3 patients developed hydrocephalus requiring ventriculo-peritoneal shunt placement. Nine patients required out-of-home disposition; all patients eventually returned to independent living. CONCLUSION Microsurgical resection of VS can be safely undertaken in patients greater than 75 y/o but may carry an increased risk of poor facial function.

Factors Influencing Personalized Management of Vestibular Schwannoma: A Systematic Review

“…The analysis found that the frail group had statistically significant higher rates of readmission, postoperative infection, facial paralysis, urinary tract infection, and hydrocephalus [ 75 ]. If elderly patients are more prone to develop general complications after surgery (including acute cardiac events, stroke, bleeding, postoperative delirium, prolonged inpatient stays as well as mortality), complications specific to VS and its removal, including cerebrospinal fluid leak or FN dysfunction, were not shown to be significantly higher, as shown on a population of 452 patients divided by age cutoff > 70 years [ 76 , 77 ]. sRS results proved particularly favorable in elderly patients in terms of overall outcome and reliable tumor control.…”

Life Expectancy After Diagnosis of a Vestibular Schwannoma in Patients 70 Years and Older

“…The middle fossa approach, usually preferred in small intrameatal tumors, was used once, since most of these were nongrowing and many of the patients had stable hearing with 100% discrimination score. Studies also comment that radiotherapy often is a consideration in this group . While stereotactic radiosurgery (SRS) worldwide may be a more frequently used treatment modality in the older adult population with increased complication risk, it was not a popular treatment modality in Denmark in the study period.…”

“…Only 10 patients with a growing VS in Denmark (3 of whom had previous VS surgery) were treated with radiation treatment in the study period, and the group was, for that reason, excluded from the study; however, it would be logical to count in the SRS group as well. Studies have reported SRS to be an appealing option due to its capability to diminish tumor growth, minimal threat to the facial nerve, and lower risk of hearing loss, and underline furthermore that comorbidities and dizziness are prevalent in older adult patients, yet no significant differences exist after surgery in hard parameters, such as facial nerve weakness, hearing impairment, or general surgical complications . Furthermore, regarding radiotherapy, gamma knife is not an option in Copenhagen, and the aforementioned patients received conventional fractionated or hypofractionated stereotactic radiotherapy, which timewise obviously is inferior to the onetime gamma knife treatment.…”

“…That being said, other studies on VS in older adult patients have concluded that surgery is safe in patients older than 70 years, regarding surgical complications specific to VS removal, and reported no higher risk of stroke, bleeding, cardiac events, or mortality . Furthermore, studies have underlined that comorbidities and dizziness are prevalent in older adult patients, yet no significant differences exist after surgery in hard parameters, such as cranial nerve damage or general surgical complications . The aim of this study was to evaluate the postdiagnostic survival of conservatively and surgically treated patients 70 years and older and to compare these findings with the expected life span of an age-matched population in Denmark.…”

“…11 Furthermore, studies have underlined that comorbidities and dizziness are prevalent in older adult patients, yet no significant differences exist after surgery in hard parameters, such as cranial nerve damage or general surgical complications. [12][13][14] The aim of this study was to evaluate the postdiagnostic survival of conservatively and surgically treated patients 70 years and older and to compare these findings with the expected life span of an age-matched population in Denmark.…”