Management of large vestibular schwannoma. Part II. Primary Gamma Knife surgery: radiological and clinical aspects

Clinical article

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Object

In large vestibular schwannomas (VSs), microsurgery is the main treatment option. A wait-and-scan policy or radiosurgery are generally not recommended given concerns of further lesion growth or increased mass effect due to transient swelling. Note, however, that some patients do not present with symptomatic mass effect or may still have serviceable hearing. Moreover, others may be old, suffer from severe comorbidity, or refuse any surgery. In this study the authors report the results in patients with large, growing VSs primarily treated with Gamma Knife surgery (GKS), with special attention to volumetric growth, control rate, and symptoms.

Methods

The authors retrospectively analyzed 33 consecutive patients who underwent GKS for large, growing VSs, which were defined as > 6 cm3 and at least indenting the brainstem. Patients with neurofibromatosis Type 2 were excluded from analysis, as were patients who had undergone previous treatment. Volume measurements were performed on contrast-enhanced T1-weighted MR images at the time of GKS and during follow-up. Medical charts were analyzed for clinical symptoms.

Results

Radiological growth control was achieved in 88% of cases, clinical control (that is, no need for further treatment) in 79% of cases. The median follow-up was 30 months, and the mean VS volume was 8.8 cm3 (range 6.1–17.7 cm3). No major complications occurred, although ventriculoperitoneal shunts were placed in 2 patients. The preservation of serviceable hearing and facial and trigeminal nerve function was achieved in 58%, 91%, and 86% of patients, respectively, with any facial and trigeminal neuropathy being transient. In 92% of the patients presenting with trigeminal hypesthesia before GKS, the condition resolved during follow-up. No patient- or VS-related feature was correlated with growth.

Conclusions

Primary GKS for large VSs leads to acceptable radiological growth rates and clinical control rates, with the chance of hearing preservation. Although a higher incidence of clinical control failure and postradiosurgical morbidity is noted, as compared with that for smaller VSs, primary radiosurgery is suitable for a selected group of patients. The absence of symptomatology due to mass effect on the brainstem or cerebellum is essential, as are close clinical and radiological follow-ups, because there is little reserve for growth or swelling.

Abbreviations used in this paper: GKS = Gamma Knife surgery; HB = House-Brackmann; VS = vestibular schwannoma.

Article Information

Address correspondence to: Rick van de Langenberg, M.D., Maastricht University Medical Center, Department of Otolaryngology, Head and Neck Surgery, PO Box 5800, 6202 AZ Maastricht, The Netherlands. email: rickvandelangenberg@hotmail.com.

Please include this information when citing this paper: published online August 12, 2011; DOI: 10.3171/2011.6.JNS101963.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial contrast-enhanced T1-weighted MR images (A and B) obtained in a 47-year-old patient with a large (17.7 cm3) VS, Koos Grade IV. The patient reported complete unilateral hearing loss and hypesthesia of the maxillary branch of the trigeminal nerve (A). The patient specifically chose treatment with primary GKS. Twenty-four months after radiosurgery the tumor volume was reduced to 4.6 cm3 (B). Sensibility in the maxillary branch recovered completely, and the patient is functioning well. Axial contrast-enhanced T1-weighted MR images (C and D) obtained in an 83-year-old patient with a large cystic VS (12.9 cm3, Koos Grade IV, C). Surgical intervention was not recommended because of severe comorbidity. Therefore, primary GKS was initiated. Preoperative symptoms consisted of unilateral deafness and hypesthesia of the maxillary branch of the trigeminal nerve. After a follow-up of 24 months a significant volume reduction occurred (last volume 2.5 cm3, D). The patient is functioning well, and sensibility in the trigeminal nerve is fully recovered.

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    Kaplan-Meier analysis of clinical control during follow-up after primary GKS in large VSs.

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    Kaplan-Meier analysis of radiological growth control during follow-up after primary GKS in large VSs.

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