Treatment of large vestibular schwannomas: towards a compromise between recurrence and facial function preservation

Ideal treatment of large vestibular schwannomas [VS] is complete removal without significant morbidity. The aim of this study is to assess the long-term outcome of surgery, focusing on factors influencing facial function and recurrence. Large VS were removed from 76 consecutive patients, through the retrosigmoid approach, from 1990-2004. Prognostic factors evaluated were age, size hydrocephalus, IX[th] and X[th] nerve signs, extent of surgical removal, and tumours's consistency. Statistics were taken by assessment of Chi-square, Fisher, student t-test. The mean age was 40 +/- 14 years, and the mean diameter was 45 +/- 9 mm. Preoperatively, 93% had significant hearing loss, 74% had cerebellar ataxia, 77% had high intracranial pressure and 40% had IX[th] and X[th] nerve signs. The perioperative mortality dramatically decreased from 17.6% in the earlier period [1990-1996] to 4.5% in the latter period [1997-2004]. At long-term follow-up, 84% of the patients had a Karnofsky score superior to 80%. Mean facial function was better for solid tumours [mean House-Brackmann [HB] standard deviation [SD], 3.7 [1.7] vs. 4.5 [1.7], p = 0.035]. Facial anatomical continuity was preserved in 76% of the cases [n = 58] and was correlated with a better facial function [mean HB [sd], 3.1 [0.7] vs. 5.8 [1.3], p < 0.001]. Excluding patients with a preoperative facial palsy, good facial function was achieved in 58% of the patients, without statistical difference between gross total and subtotal resection [mean HB [SD], 4.3 [1.4] vs. 4.8 [1.9], p=0.229]. The method resulted in improved outcome. Subtotal resection is a good strategy with high likelihood of preserving facial nerve function, without significantly increasing the risk of recurrence. New strategies associating subtotal resection and radiosurgery must be evaluated

Intraventricular cavernoma

Intraventricular cavernoma is rare; only 45 cases have been reported in the literature. Magnetic resonance imaging has wildly contributed in the diagnosis and the surgical approach. Case file: We report a 45-year-old man presenting with syndrome of intracranial hypertesion and retrograde amnesia for one year. CT scan and MRI revealed an intraventricular tumour, which was responsible for active hydrocephalus. A ventriculo-peritoneal shunt was performed and a stereotactic biopsy allowed the diagnosis of cavernoma. Post operative follow-up was uneventful, the patient rests asymptomatic. Ventricular cavernoma is rare and should be suspected in atypical localisations in order to chosse the best surgical approach. The author attack the attention to that rare localisation of cavernoma and for its hemorrhagic risles

Exophthalmos as a presenting sign of extradural haematoma

A conscious 14-year old boy admitted to hospital with progressive right exophthalmos, decreased visual acuity and headache 9 days after head trauma, with neurological deficit. Computerized tomography [CT] scan demonstrated intracranial and intraorbital cystic mass. At craniotomy, a subacute extradural haematoma was found which communicated with an orbital subperiosteal haematoma through an orbital roof fracture. Postoperative outcome was marked by complete recovery of exophthalmos and visual acuity. This case demonstrated the rare diagnosis of epidural and subperiosteal orbital haematoma. The literature is reviewed and surgical management is discussed