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Vestibular schwannoma management

Part II. Failed radiosurgery and the role of delayed microsurgery

Bruce E. Pollock, L. Dade Lunsford, Douglas Kondziolka, Raymond Sekula, Brian R. Subach, Robert L. Foote and John C. Flickinger

S tereotactic radiosurgery is an important alternative to surgical resection for patients who have a vestibular schwannoma. 3–5, 11–13, 15 There is no incidence of mortality or major perioperative morbidity in patients undergoing radiosurgery. Hearing preservation and facial neuropathy rates are comparable to those of published microsurgical series. Hospitalization is minimal after radiosurgery and costs are reduced. Because patients do not require a convalescent period, they are immediately able to resume their preoperative level of functioning. There have

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Vestibular schwannoma management

Part I. Failed microsurgery and the role of delayed stereotactic radiosurgery

Bruce E. Pollock, L. Dade Lunsford, John C. Flickinger, Brent L. Clyde and Douglas Kondziolka

C urrently , surgical resection is the most frequently recommended management strategy for patients in whom vestibular schwannomas (acoustic neuromas) have been newly diagnosed. 24 Studies on the natural history of untreated vestibular schwannomas have shown that the majority of tumors will grow within 3 years 2, 4, 17, 27 and that the growth rate can vary from 0.1 to 3 cm per year. Consequently, observation with serial imaging is recommended only for elderly patients who experience no symptoms from mass effect. 5, 34–36, 38 The results of microsurgical

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Daniel T. Ginat and Robert L. Martuza

V estibular schwannomas are typically benign, slow-growing tumors that most commonly arise from the region of Scarpa's ganglion and comprise approximately 85% of cerebellopontine angle masses. 23 Patients with vestibular schwannomas can present with tinnitus, dizziness, unsteadiness, and vertigo, as well as symptoms due to compression effects, including hearing loss, facial and trigeminal nerve dysfunction, and hydrocephalus. 15 Management options include observation with serial imaging, stereotactic radiosurgery, fractionated radiotherapy, microsurgical

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Dheerendra Prasad, Melita Steiner and Ladislau Steiner

signs and two experienced an improvement following a decrease in tumor size. Lower cranial nerve involvement was present in six cases. One patient (who also had cerebellar signs) improved following GS. Discussion Despite providing the first systematic evidence that these tumors had their origin in Schwann cells, Henschen 26 continued to refer to them as acoustic neuromas in his seminal work on this subject. Almost 80 years later the National Institutes of Health issued a consensus statement: “the term vestibular schwannoma is preferred over acoustic neuroma as these

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Marc S. Schwartz, Gregory P. Lekovic, Mia E. Miller, William H. Slattery and Eric P. Wilkinson

T he translabyrinthine (TL) approach to the cerebellopontine angle was first described by Panse in the late nineteenth century. 38 This approach did not truly become technically feasible until it was reintroduced in the early 1960s by William House, who brought the operating microscope to otologic and skull base surgery. Soon after, House and Hitselberger demonstrated that use of the TL approach reduced the mortality of vestibular schwannoma (VS) surgery to under three percent. 27 , 28 Improvements in diagnostic techniques, including the development of MRI, led

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Michael E. Sughrue, Isaac Yang, Derick Aranda, Martin J. Rutkowski, Shanna Fang, Steven W. Cheung and Andrew T. Parsa

rates in patients surgically treated for VSs. We excluded CN VII or VIII complications to focus on what has been an understated issue in VS surgery, namely nonaudiofacial morbidities. Our goal was to summarize these reported morbidities separately from CN VII or VIII complications. Methods Article Selection Articles were identified via a PubMed search using the key words “vestibular schwannoma,” “microsurgery,” “facial nerve function,” “acoustic neuroma,” “surgery,” “morbidity,” “mortality,” “complication,” and “hearing preservation,” alone and in

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William A. Friedman, Patrick Bradshaw, Adam Myers and Frank J. Bova

, 1992 5 Flickinger JC , Kondziolka D , Niranjan A , Lunsford LD : Results of acoustic neuroma radiosurgery: an analysis of 5 years’ experience using current methods . J Neurosurg 94 : 1 – 6 , 2001 6 Foote KD , Friedman WA , Buatti JM , Bova FJ , Meeks SL : Linear accelerator radiosurgery in brain tumor management . Neurosurg Clin N Am 10 : 203 – 242 , 1999 7 Foote KD , Friedman WA , Buatti JM , Meeks SL , Bova FJ , Kubilis PS : Analysis of risk factors associated with radiosurgery for vestibular schwannoma

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Maurizio Falcioni, Paolo Fois, Abdelkader Taibah and Mario Sanna

preservation acoustic neuroma surgery . Arch Otolaryngol Head Neck Surg 127 : 543 – 546 , 2001 2 Bacciu A , Falcioni M , Pasanisi E , Di Lella F , Lauda L , Flanagan S , : Intracranial facial nerve grafting after removal of vestibular schwannoma . Am J Otolaryngol 30 : 83 – 88 , 2009 3 Bloch DC , Oghalai JS , Jackler RK , Osofsky M , Pitts LH : The fate of the tumor remnant after less-than-complete acoustic neuroma resection . Otolaryngol Head Neck Surg 130 : 104 – 112 , 2004 4 Brackmann DE , Cullen RD , Fisher LM

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Christian Strauss, Julian Prell, Stefan Rampp and Johann Romstöck

Department of Neurosurgery, University of Erlangen-Nuremberg, Germany, in honor of his 65th birthday. References 1 Anderson DE , Leonetti J , Wind JJ , Cribari D , Fahey K : Resection of large vestibular schwannomas: facial nerve preservation in the context of surgical approach and patient-assessed outcome . J Neurosurg 102 : 643 – 649 , 2005 2 Anonymous : Committee on Hearing and Equilibrium guidelines for the evaluation of hearing preservation in acoustic neuroma (vestibular schwannoma). American Academy of Otolaryngology-Head and Neck Surgery

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Leopoldo Casentini, Umberto Fornezza, Zeno Perini, Egle Perissinotto and Federico Colombo

tongue, and a trigeminal neuralgia—in 3 patients. In addition, 30 months after multisession SRS, a 77-year-old female patient developed polyneuritis causing paraparesis; 22 months after treatment a 67-year-old male patient suffered low-back pain, and MRI revealed spinal schwannomas at T-11 and L-2 that required surgery. Discussion A limited number of studies on radiosurgery as the primary treatment for large vestibular schwannomas have been conducted ( Table 3 ), and microsurgery is generally considered the first choice. 4 , 14 , 16 , 22 , 32 , 45 In a recent