Staged resection of large vestibular schwannomas

Clinical article

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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.


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.


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.


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:

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.



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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.



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