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

Fractionated stereotactic radiotherapy for bilateral vestibular schwannomas associated with neurofibromatosis type 2: early experiences in Ramathibodi Hospital.

PURPOSE: To evaluate the rates of tumor control and useful hearing preservation in patients with bilateral vestibular schwannomas (VSs) associated with neurofibromatosis type 2 (NF-2) treated with fractionated stereotactic radiotherapy (FSRT). MATERIAL AND METHOD: From August 1998--December 2002 there were 5 patients with NF-2 who underwent FSRT (Linac-based system) for bilateral CP angle tumors. Median age was 28 (18-47) years. Median tumor volume was 5.4 (2.2-9.4) cc. Eight lesions received a marginal dose of 44.2-59.9 (median = 46.2) Gy in 25-33 fractions. The other 2 lesions received 4.4 and 4.9 Gy/fraction for 6 fractions in 3 and 2 weeks. Median follow-up was 19 (14-44) months. RESULTS : Radiographic and clinical tumor control rate was 90%. One lesion progressed at 7 months after FSRT and was completely resected Of the 5 lesions with Gardner-Robertson class I-II hearing before FSRT 2 (40%) retained useful hearing at the last follow-up. One patient had left facial spasm at 10 months after FSRT which gradually improved. No patient had facial palsy, facial numbness or pain. CONCLUSIONS : FSRT provided good tumor control and hearing preservation rate in NF-2 patients with minimal morbidity. However, a longer follow-up is needed to evaluate long term results.

Vestibular schwannomas: Clinical presentation, management and outcome

OBJECTIVE: To review the demographic trends clinical spectrum, diagnosis, management and out come of patients with vestibular Schwannoma and to identify areas where improvements are needed. METHODS: All patients with vestibular schwannoma admitted to the Aga Khan University Hospital over the past 11 years were reviewed retrospectively. The age range of majority of 22 patients analyzed, was 41-50 years [23%]. Hearing loss was the most common presenting symptom [96%]. Other clinical features included cranial nerve palsies [59%] and headache [55%]. Fifty% had signs of raised intracranial pressure. Neuroimaging revealed 'Stage IV b' [tumor distorting the brainstem and compressing the 4th ventricle] in 50% cases. Neurosurgical intervention was carried out in 86%; mainly using the retrosigmoid approach. Postoperative complications included facial nerve palsy in 13 [65%] and hydrocephalus in 5 [25%] patients. Hearing determined clinically was preserved in three patients [14%]. One patient died during the inpatient stay. Presentation of these patients is late and the outcome is poor