Staged resection of large vestibular schwannomas

Clinical article

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Object

Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection.

Methods

A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors' institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications.

Results

Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2–7 cm) in the 2-stage group and 3.9 cm (range 3.1–5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4%) of 28 patients in the 2-stage group and 15 (79%) of 19 patients in the single-stage group (p < 0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7%), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82%) of 28 patients in the 2-stage group and 10 (53%) of 19 patients in the single-stage group (p < 0.01). Cerebrospinal fluid leak–related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group.

Conclusions

The authors' results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections.

Abbreviations used in this paper:CPA = cerebellopontine angle; GTR = gross-total resection; IAC = internal auditory canal; VS = vestibular schwannoma.

Article Information

Address correspondence to: Johnny B. Delashaw Jr., M.D., Department of Neurological Surgery, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, Oregon 97239. email: delashaw@ohsu.edu.

Please include this information when citing this paper: published online February 24, 2012; DOI: 10.3171/2012.1.JNS111402.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Illustration depicting the tumor prior to resection in the CPA angle, with brainstem and facial nerve compression. B: Illustration of the exposure of tumor–facial nerve interface and cerebellar retraction in the retrosigmoid approach, partial tumor resection, and decompression of the brainstem. C: Illustration of the exposure of the tumor–facial nerve interface from a presigmoid angle, completed tumor resection with removal of the IAC portion. Illustrations printed with permission from Oregon Health & Science University.

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    Illustration demonstrating the differences in trajectory and surgical angle between the retrosigmoid and translabyrinthine approaches that allow for a different perspective of the tumor–facial nerve interface. Illustration printed with permission from Oregon Health & Science University.

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    Good (House-Brackmann Grade I or II) versus poor (House-Brackmann Grade III–IV) facial nerve function in the 2-stage and single-stage groups at the last documented follow-up. A statistically significant difference between groups is noted. HB = House-Brackmann.

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    Bar graph showing the progress of facial nerve functional outcome after each component of the 2-stage and the single-stage approach. FU = follow-up; RS = retrosigmoid; TL = translabyrinthine.

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    Bar graph showing GTR in the 2-stage versus single-stage groups. STR = subtotal resection.

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    Case 1. Preoperative (A), postretrosigmoid (B), and posttranslabyrinthine (C) MRI studies showing 2-stage resection of a VS that was larger than 3 cm. Gross-total resection is evident on the postoperative MRI study.

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    Case 2. Preoperative (A), postretrosigmoid (B), and posttranslabyrinthine (C) MRI studies showing near-total resection of a VS after 2-stage resection.

References

1

Briggs RJLuxford WMAtkins JS JrHitselberger WE: Translabyrinthine removal of large acoustic neuromas. Neurosurgery 34:7857911994

2

Comey CHJannetta PJSheptak PEJoh HDBurkhart LE: Staged removal of acoustic tumors: techniques and lessons learned from a series of 83 patients. Neurosurgery 37:9159211995

3

Committee on Hearing and Equilibrium: 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 Foundation, INC. Otolaryngol Head Neck Surg 113:1791801995

4

Godefroy WPvan der Mey AGde Bruine FTHoekstra ERMalessy MJ: Surgery for large vestibular schwannoma: residual tumor and outcome. Otol Neurotol 30:6296342009

5

Iwai YYamanaka KIshiguro T: Surgery combined with radiosurgery of large acoustic neuromas. Surg Neurol 59:2832912003

6

Kaylie DMGilbert EHorgan MADelashaw JBMcMenomey SO: Acoustic neuroma surgery outcomes. Otol Neurotol 22:6866892001

7

Lanman THBrackmann DEHitselberger WESubin B: Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach. J Neurosurg 90:6176231999

8

Mamikoglu BWiet RJEsquivel CR: Translabyrinthine approach for the management of large and giant vestibular schwannomas. Otol Neurotol 23:2242272002

9

Myrseth EMøller PPedersen PHVassbotn FSWentzel-Larsen TLund-Johansen M: Vestibular schwannomas: clinical results and quality of life after microsurgery or gamma knife radiosurgery. Neurosurgery 56:9279352005

10

Naguib MBSaleh ECokkeser YAristegui MLandolfi MTaibah AK: The enlarged translabyrinthine approach for removal of large vestibular schwannomas. J Laryngol Otol 108:5455501994

11

Nicoucar KMomjian SVader JPDe Tribolet N: Surgery for large vestibular schwannomas: how patients and surgeons perceive quality of life. J Neurosurg 105:2052122006

12

Patni AHKartush JM: Staged resection of large acoustic neuromas. Otolaryngol Head Neck Surg 132:11192005

13

Rigby PLShah SBJackler RKChung JHCooke DD: Acoustic neuroma surgery: outcome analysis of patient-perceived disability. Am J Otol 18:4274351997

14

Samii MGerganov VMSamii A: Functional outcome after complete surgical removal of giant vestibular schwannomas. Clinical article. J Neurosurg 112:8608672010

15

Sluyter SGraamans KTulleken CAVan Veelen CW: Analysis of the results obtained in 120 patients with large acoustic neuromas surgically treated via the translabyrinthine-transtentorial approach. J Neurosurg 94:61662001

16

Wu HSterkers J: Translabyrinthine removal of large acoustic neuromas in young adults. Auris Nasus Larynx 27:2012052000

17

Yamakami IUchino YKobayashi EYamaura AOka N: Removal of large acoustic neurinomas (vestibular schwannomas) by the retrosigmoid approach with no mortality and minimal morbidity. J Neurol Neurosurg Psychiatry 75:4534582004

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