Vestibular Schwannomas

Carlson, Matthew L.; Link, Michael J.

doi:10.1056/nejmra2020394

Cited by 137 publications

(152 citation statements)

References 64 publications

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“…Clinically apparent VII nerve palsy is rarely a feature of compression from the VS tumor itself but is a common cause of morbidity following microsurgical resection. 1,7,[11][12][13] The principal factor determining VII nerve damage at the time of surgical resection is the size of the VS itself, with tumor vascularity, the tumour micro-environment and tumour consistency also playing a part. [14][15][16][17][18][19][20] Patients with VSs associated with neurofibromatosis type-2 also seem to be at risk of adverse VII nerve outcomes following surgical resection.…”

Section: Facial (Vii) Nerve Weaknessmentioning

confidence: 99%

“…The incidence of them is around 4 per 100,000 person-years and they make up approximately 8% of all primary adult intracranial neoplasms. 1 , 2 VSs typically present with alterations in hearing and tinnitus due to compression of the VIII nerve at the internal acoustic meatus. However, smaller tumors often present incidentally on neuro-imaging 2 , 3 and larger, more proximal tumors involving the cerebello-pontine angle may present with consequences of brainstem compression such as poor balance and vertigo.…”

Section: Introductionmentioning

confidence: 99%

“…Choice of treatment is largely driven by tumor size and rate of growth, but also by patient factors as well as provider experience and expertise. 1 , 6 …”

Section: Introductionmentioning

confidence: 99%

“…Choice of treatment is largely driven by tumor size and rate of growth, but also by patient factors as well as provider experience and expertise. 1,6 The neuro-ophthalmic consequences following VS resection are neither infrequent nor innocuous and need to be considered carefully when making management choices. In one study of patient perceptions following neurosurgical management for VS, 90% of the 1651 respondents to a questionnaire reported eye problems following their VS surgery 7 and eye problems were the third most common response to the question "What did you find was the one most difficult problem to deal with during the whole VS experience?"…”

Section: Introductionmentioning

confidence: 99%

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Neuro-Ophthalmic Complications of Vestibular Schwannoma Resection: Current Perspectives

Chiu¹,

Hickman²,

Pepper³

et al. 2021

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Vestibular schwannomas (VSs), also called acoustic neuromas, are benign intracranial neoplasms of the vestibulocochlear (VIII) cranial nerve. Management options include “wait-and-scan,” stereotactic radiosurgery and surgical resection. Due to the proximity of the VIII nerve to the facial (VII) nerve in the cerebello-pontine angle, the VII nerve is particularly vulnerable to the effects of surgical resection. This can result in poor eye closure, lagophthalmos and resultant corneal exposure post VS resection. Additionally, compression from the tumor or resection can cause trigeminal (V) nerve damage and a desensate cornea. The combination of an exposed and desensate cornea puts the eye at risk of serious ocular complications including persistent epithelial defects, corneal ulceration, corneal vascularization, corneal melting and potential perforation. The abducens (VI) nerve can be affected by a large intracranial VS causing raised intracranial pressure (a false localizing sign) or as a result of damage to the VI nerve at the time of resection. Other types of neurogenic strabismus are rare and typically transient. Contralaterally beating nystagmus as a consequence of vestibular dysfunction is common post-operatively. This generally settles to pre-operative levels as central compensation occurs. Ipsilaterally beating nystagmus post-operatively should prompt investigation for post-operative cerebrovascular complications. Papilledema (and subsequent optic atrophy) can occur as a result of a large VS causing raised intracranial pressure. Where papilledema follows surgical resection of a VS, it can indicate that cerebral venous sinus thrombosis has occurred. Poor visual function following VS resection can result as a combination of all these potential complications and is more likely with larger tumors.

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Section: Facial (Vii) Nerve Weaknessmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…Choice of treatment is largely driven by tumor size and rate of growth, but also by patient factors as well as provider experience and expertise. 1 , 6 …”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Neuro-Ophthalmic Complications of Vestibular Schwannoma Resection: Current Perspectives

Chiu¹,

Hickman²,

Pepper³

et al. 2021

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“…21 Tumors <2.5 cm in diameter are preferred for treatment using Gamma Knife radiosurgery to minimize the risk of radiation-induced edema, trigeminal neuropathy, hydrocephalus, and diminished long-term tumor control. 22 We initially chose surgical resection to preserve the hearing status because the tumor size seemed too large for Gamma Knife radiosurgery to preserve functional hearing.…”

Section: Treatment Options For Patients With the Rare Anomalous Veinmentioning

confidence: 99%

An aberrant venous channel mimicking the perilabyrinthine cells in the petrous bone of a patient with vestibular schwannoma: illustrative case

Ito

Higuchi

Horiguchi

et al. 2021

Journal of Neurosurgery: Case Lessons

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BACKGROUND Anatomical variations, such as high jugular bulbs and air cell development in the petrosal bone, should be evaluated before surgery. Most bone defects in the internal auditory canal (IAC) posterior wall are observed in the perilabyrinthine cells. An aberrant vascular structure passing through the petrous bone is rare. OBSERVATIONS A 48-year-old man presented with a right ear hearing disturbance. Magnetic resonance imaging revealed a 23-mm contrast-enhancing mass in the right cerebellopontine angle extending into the IAC, consistent with a right vestibular schwannoma. Preoperative bone window computed tomographic scans showed bone defects in the IAC posterior wall, which ran farther posteroinferiorly in the petrous bone, reaching the medial part of the jugular bulb. The tumor was accessed via a lateral suboccipital approach. There was no other major vein in the cerebellomedullary cistern, except for the vein running from the brain stem to the IAC posterior wall. To avoid complications due to venous congestion, the authors did not drill out the IAC posterior wall or remove the tumor in the IAC. LESSONS Several aberrant veins in the petrous bone are primitive head sinus remnants. Although rare, their surgical implication is critical in patients with vestibular schwannomas.

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Upfront Radiosurgery vs a Wait-and-Scan Approach for Small- or Medium-Sized Vestibular Schwannoma

Dhayalan,

Tveiten,

Finnkirk

et al. 2023

JAMA

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ImportanceCurrent guidelines for treating small- to medium-sized vestibular schwannoma recommend either upfront radiosurgery or waiting to treat until tumor growth has been detected radiographically.ObjectiveTo determine whether upfront radiosurgery provides superior tumor volume reduction to a wait-and-scan approach for small- to medium-sized vestibular schwannoma.Design, Setting, and ParticipantsRandomized clinical trial of 100 patients with a newly diagnosed (&lt;6 months) unilateral vestibular schwannoma and a maximal tumor diameter of less than 2 cm in the cerebellopontine angle as measured on magnetic resonance imaging. Participants were enrolled at the Norwegian National Unit for Vestibular Schwannoma from October 28, 2014, through October 3, 2017; 4-year follow-up ended on October 20, 2021.InterventionsParticipants were randomized to receive either upfront radiosurgery (n = 50) or to undergo a wait-and-scan protocol, for which treatment was given only upon radiographically documented tumor growth (n = 50). Participants underwent 5 annual study visits consisting of clinical assessment, radiological examination, audiovestibular tests, and questionnaires.Main Outcomes and MeasuresThe primary outcome was the ratio between tumor volume at the trial end at 4 years and baseline (V4:V0). There were 26 prespecified secondary outcomes, including patient-reported symptoms, clinical examinations, audiovestibular tests, and quality-of-life outcomes. Safety outcomes were the risk of salvage microsurgery and radiation-associated complications.ResultsOf the 100 randomized patients, 98 completed the trial and were included in the primary analysis (mean age, 54 years; 42% female). In the upfront radiosurgery group, 1 participant (2%) received repeated radiosurgery upon tumor growth, 2 (4%) needed salvage microsurgery, and 45 (94%) had no additional treatment. In the wait-and-scan group, 21 patients (42%) received radiosurgery upon tumor growth, 1 (2%) underwent salvage microsurgery, and 28 (56%) remained untreated. For the primary outcome of the ratio of tumor volume at the trial end to baseline, the geometric mean V4:V0 was 0.87 (95% CI, 0.66-1.15) in the upfront radiosurgery group and 1.51 (95% CI, 1.23-1.84) in the wait-and-scan group, showing a significantly greater tumor volume reduction in patients treated with upfront radiosurgery (wait-and-scan to upfront radiosurgery ratio, 1.73; 95% CI, 1.23-2.44; P = .002). Of 26 secondary outcomes, 25 showed no significant difference. No radiation-associated complications were observed.Conclusion and relevanceAmong patients with newly diagnosed small- and medium-sized vestibular schwannoma, upfront radiosurgery demonstrated a significantly greater tumor volume reduction at 4 years than a wait-and-scan approach with treatment upon tumor growth. These findings may help inform treatment decisions for patients with vestibular schwannoma, and further investigation of long-term clinical outcomes is needed.Trial RegistrationClinicalTrials.gov Identifier: NCT02249572

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Vestibular Schwannomas

Cited by 137 publications

References 64 publications

Neuro-Ophthalmic Complications of Vestibular Schwannoma Resection: Current Perspectives

Neuro-Ophthalmic Complications of Vestibular Schwannoma Resection: Current Perspectives

An aberrant venous channel mimicking the perilabyrinthine cells in the petrous bone of a patient with vestibular schwannoma: illustrative case

Upfront Radiosurgery vs a Wait-and-Scan Approach for Small- or Medium-Sized Vestibular Schwannoma

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