Functional outcome after complete surgical removal of giant vestibular schwannomas

Samii, M.; Gerganov, Venelin; Samii, Amir

doi:10.3171/2009.7.jns0989

Cited by 223 publications

(239 citation statements)

References 42 publications

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“…Variations in surgical approach, staging of tumor resection, and postoperative radiosurgery have been proposed to achieve superior results while respecting the need for maximal tumor resection, brainstem decompression, facial nerve preservation, and long-term tumor remission. 1,9,14,30,34 The literature clearly demonstrates the superiority of the standard retrosigmoid or translabyrinthine approaches in preserving facial nerve function.…”

Section: Discussionmentioning

confidence: 99%

“…36 Studies have shown that the best strategy for tumor control is to achieve a high level of tumor resection while being mindful of facial nerve function. 41 A single-institution series from Samii et al 34 showed that of 50 patients with large vestibular schwannomas treated with gross-total resection, 92% had anatomical preservation of the facial nerve. At their last follow-up, 75% of patients had excellent or good facial nerve function, 19% had fair function, and 6% had poor function.…”

Section: Discussionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

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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“…25,26,28 In addition to CN involvement, larger tumors compress and displace the brainstem, distorting the usual view of the brain-tumor interface; draining veins in large and giant tumors may be unusually distended and fragile, increasing the risk of hemorrhage. 25 When tumors are stratified by size, those larger than 3 cm (20%-22%) are associated with higher complication rates and longer hospital stays than those under 3 cm (6%-9.6%). 28 In our series, no mortality or unexpected adverse neurological events were encountered.…”

Section: Sizementioning

confidence: 99%

Medial acoustic neuromas: clinical and surgical implications

Dunn

Erkmen³

et al. 2014

JNS

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Object Medial acoustic neuroma is a rare entity that confers a distinct clinical syndrome. It is scarcely discussed in the literature and is associated with adverse features. This study evaluates the clinical and imaging features, pertinent surgical challenges, and treatment outcome in a large series of this variant. The authors postulate that the particular pathological anatomy with its arachnoidal rearrangement has a profound implication on the surgical technique and outcome. Methods The authors conducted a retrospective analysis of 52 cases involving 33 women and 19 men who underwent resection of medial acoustic neuromas performed by the senior author (O.A.) over a 20-year period (1993–2013). Clinical, radiological, and operative records were reviewed, with a specific focus on the neurological outcomes and facial nerve function and hearing preservation. Intraoperative findings were analyzed with respect to the effect of arachnoidal arrangement on the surgeon's ability to resect the lesion and the impact on postoperative function. Results The average tumor size was 34.5 mm (maximum diameter), with over 90% of tumors being 25 mm or larger and 71% being cystic. Cerebellar, trigeminal nerve, and facial nerve dysfunction were common preoperative findings. Hydrocephalus was present in 11 patients. Distinguishing intraoperative findings included marked tumor adherence to the brainstem and frequent hypervascularity, which prompted intracapsular dissection resulting in enhancement on postoperative MRI in 18 cases, with only 3 demonstrating growth on follow-up. There was no mortality or major postoperative neurological deficit. Cerebrospinal fluid leak was encountered in 7 patients, with 4 requiring surgical repair. Among 45 patients who had intact preoperative facial function, only 1 had permanent facial nerve paralysis on extended follow-up. Of the patients with preoperative Grade I–II facial function, 87% continued to have Grade I–II function on follow-up. Of 10 patients who had Class A hearing preoperatively, 5 continued to have Class A or B hearing after surgery. Conclusions Medial acoustic neuromas represent a rare subgroup whose site of origin and growth patterns produce a distinct clinical presentation and present specific operative challenges. They reach giant size and are frequently cystic and hypervascular. Their origin and growth pattern lead to arachnoidal rearrangement with marked adherence against the brainstem, which is critical in the surgical management. Excellent surgical outcome is achievable with a high rate of facial nerve function and attainable hearing preservation. These results suggest that similar or better results may be achieved in less complex tumors.

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“…13,75 Tumor size is not correlated with the risk of CSF fistula, 69 although larger tumors approached through the translabyrinthine route may be associated with a higher CSF leak rate. 58,75 This could also be related to the approach itself, as meticulous dural closure is difficult, if not impossible, with this technique. The present analysis confirms the belief that the retrosigmoid approach may result in a greater risk of CSF leakage than the middle cranial fossa and translabyrinthine approaches, which we did not find to differ significantly from each other in this respect.…”

Section: Postoperative Csf Leakagementioning

confidence: 99%

“…11,75 Frequently cited predictors of facial nerve function include tumor size, surgical approach, and the use of intraoperative monitoring. 15,22,40,64,75 The length of contact of the tumor with the nerve has also been suggested as a potential prognostic factor. 18 Samii et al 74 believe that prior surgery or radiosurgery and the presence of an intratumoral cyst are negative predictors of postoperative facial nerve function.…”

Section: Facial Nerve Functionmentioning

confidence: 99%

Surgery for vestibular schwannomas: a systematic review of complications by approach

Ansari

Terry

Cohen-Gadol

2012

FOC

250

216

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Object Various studies report outcomes of vestibular schwannoma (VS) surgery, but few studies have compared outcomes across the various approaches. The authors conducted a systematic review of the available data on VS surgery, comparing the different approaches and their associated complications. Methods MEDLINE searches were conducted to collect studies that reported information on patients undergoing VS surgery. The authors set inclusion criteria for such studies, including the availability of follow-up data for at least 3 months, inclusion of preoperative and postoperative audiometric data, intraoperative monitoring, and reporting of results using established and standardized metrics. Data were collected on hearing loss, facial nerve dysfunction, persistent postoperative headache, CSF leak, operative mortality, residual tumor, tumor recurrence, cranial nerve (CN) dysfunction involving nerves other than CN VII or VIII, and other neurological complications. The authors reviewed data from 35 studies pertaining to 5064 patients who had undergone VS surgery. Results The analyses for hearing loss and facial nerve dysfunction were stratified into the following tumor categories: intracanalicular (IC), size (extrameatal diameter) < 1.5 cm, size 1.5–3.0 cm, and size > 3.0 cm. The middle cranial fossa approach was found to be superior to the retrosigmoid approach for hearing preservation in patients with tumors < 1.5 cm (hearing loss in 43.6% vs 64.3%, p < 0.001). All other size categories showed no significant difference between middle cranial fossa and retrosigmoid approaches with respect to hearing loss. The retrosigmoid approach was associated with significantly less facial nerve dysfunction in patients with IC tumors than the middle cranial fossa method was; however, neither differed significantly from the translabyrinthine corridor (4%, 16.7%, 0%, respectively, p < 0.001). The middle cranial fossa approach differed significantly from the translabyrinthine approach for patients with tumors < 1.5 cm, whereas neither differed from the retrosigmoid approach (3.3%, 11.5%, and 7.2%, respectively, p = 0.001). The retrosigmoid approach involved less facial nerve dysfunction than the middle cranial fossa or translabyrinthine approaches for tumors 1.5–3.0 cm (6.1%, 17.3%, and 15.8%, respectively; p < 0.001). The retrosigmoid approach was also superior to the translabyrinthine approach for tumors > 3.0 cm (30.2% vs 42.5%, respectively, p < 0.001). Postoperative headache was significantly more likely after the retrosigmoid approach than after the translabyrinthine approach, but neither differed significantly from the middle cranial fossa approach (17.3%, 0%, and 8%, respectively; p < 0.001). The incidence of CSF leak was significantly greater after the retrosigmoid approach than after either the middle cranial fossa or translabyrinthine approaches (10.3%, 5.3%, 7.1%; p = 0.001). The incidences of residual tumor, mortality, major non-CN complications, residual tumor, tumor recurrence, and dysfunction of other cranial nerves were not significantly different across the approaches. Conclusions The middle cranial fossa approach seems safest for hearing preservation in patients with smaller tumors. Based on the data, the retrosigmoid approach seems to be the most versatile corridor for facial nerve preservation for most tumor sizes, but it is associated with a higher risk of postoperative pain and CSF fistula. The translabyrinthine approach is associated with complete hearing loss but may be useful for patients with large tumors and poor preoperative hearing.

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Functional outcome after complete surgical removal of giant vestibular schwannomas

Cited by 223 publications

References 42 publications

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

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

Medial acoustic neuromas: clinical and surgical implications

Surgery for vestibular schwannomas: a systematic review of complications by approach

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