Surgery After Surgery for Vestibular Schwannoma: A Case Series

Abstract

ObjectiveWe retrospectively evaluated the oncological and functional effectiveness of revision surgery for recurrent or remnant vestibular schwannoma (rVS).MethodsWe included 29 consecutive patients with unilateral hearing loss (16 women; mean age: 42.2 years) that underwent surgery for rVS. Previous surgeries included gross total resections (GTRs, n=11) or subtotal resections (n=18); mean times to recurrence were 9.45 and 4.15 years, respectively. House–Brackmann (HB) grading of facial nerve (FN) weakness (grades II-IV) indicated that 22 (75.9%) patients had deep, long-lasting FN paresis (HB grades: IV-VI). The mean recurrent tumor size was 23.3 mm (range: 6 to 51). Seven patients had neurofibromatosis type 2.ResultsAll patients received revision GTRs. Fourteen small- to medium-sized tumors located at the bottom of the internal acoustic canal required the translabyrinthine approach (TLA); 12 large and small tumors, predominantly in the cerebellopontine angle, required the retrosigmoid approach (RSA); and 2 required both TLA and RSA. One tumor that progressed to the petrous apex required the middle fossa approach. Fifteen patients underwent facial neurorrhaphy. Of these, 11 received hemihypoglossal–facial neurorrhaphies (HHFNs); nine with simultaneous revision surgery. In follow-up, 10 patients (34.48%) experienced persistent deep FN paresis (HB grades IV-VI). After HHFN, all patients improved from HB grade VI to III (n=10) or IV (n=1). No tumors recurred during follow-up (mean, 3.46 years).ConclusionsAggressive microsurgical rVS treatment combined with FN reconstruction provided durable oncological and neurological effects. Surgery was a reasonable alternative to radiosurgery, particularly in facial neurorrhaphy, where it provided a one-step treatment.

Endoscope-Assisted Retrosigmoid Approach for Vestibular Schwannomas With Intracanalicular Extensions: Facial Nerve Outcomes

“…Most vestibular schwannomas have intracanalicular portions. One of the most common causes of vestibular schwannoma recurrence is remnants at the fundus of IAC ( 6 , 7 ). To achieve maximal resection for tumors with intracanalicular extension, care must be taken to prevent concomitant injuries to the posterior SCC, the endolymphatic duct, and a potential HJB ( 8 , 9 ).…”

Analysis of the effect of neuroendoscopy-assisted microscopy in the treatment of Large (Koos grade IV) vestibular schwannoma

“…Recurrence of acoustic neuromas is highly related to residual tumors in the internal auditory canal (12,13). McKennan et al were the first to use an endoscopic-assisted technique to explore the internal auditory canal, removing the portion of the VS in the internal auditory canal with preservation of facial nerve (17).…”

“…At present, an endoscopic-assisted technique for more complex cases of VS has been adopted widely by increasing numbers of neurosurgeons, due to the technological advancement of endoscopic-assisted microsurgery and improved intraoperative neurophysiological monitoring technology ( 10 , 11 ). Endoscopic-assisted microsurgery has greatly reduced postoperative complications, significantly improved the tumor resection rate, and notably has improved the quality of life of patients ( 12 , 13 ).…”

“…The vast majority of acoustic neuromas originate from the vestibular nerve in the internal auditory canal and then grow outward into the cerebellopontine angle. Recurrence of acoustic neuromas is highly related to residual tumors in the internal auditory canal ( 12 , 13 ). McKennan et al.…”

Repeat Surgery for Vestibular Schwannomas: An Institutional Case Series

“…This is consistent with prior studies by Perry et al and Przepiórka et al that reported no progression after mean follow-up times of 55 and 42 months, respectively. 15,16 Huang et al likewise reported a low progression rate of 6% at a median follow-up time of 74 months, highlighting the efficacy of repeat surgery but the importance of vigilant long-term follow-up in the management of VS. 13 There were several important limitations to this study. This is a retrospective study with a small sample size that is limited by selection bias.…”