Hypervascularized Large Vestibular Schwannomas: Single-Center Experience in a Series of Forty Cases.

Background: Vestibular schwannomas (VS) are usually hypovascularized benign tumors. Large VS (Koos grade IV) with unusual vascular architecture are defined as hypervascular (HVVS); the excessive bleeding during microsurgery has a negative impact on results. Methods: Forty consecutive patients were operated on for HVVS (group A). A tendency to bleed and adherence of capsule to nervous structures were evaluated by reviewing intraoperative video records. The cisternal facial nerve (FN) position was reported. Microsurgical removal was classified as total, near-total, subtotal, or partial and the MIB-1 index was evaluated in all. FN results were classified according to the House-Brackmann scale. Results: Results of Group A were compared with those of 45 patients operated on for large low-bleeding VS (group B). Mean tumor diameter was 3.81 cm in group A and 3.58 cm in group B; the mean age was 42.4 and 56.3 years, respectively. The mean American Society of Anesthesiologists Physical Status Scale class of group A was 1.67 versus 2.31 of group B (P < 0.01). Total or near-total resection was accomplished in 76.5% of group A versus 73.3% of group B. Tight capsule adhesion was observed in 67.5% of group A versus 57.8% of group B. Mean MIB-1 was 1.25% and 1.08%, respectively.FN anatomic preservation was possible in 84.6% of group A versus 95.5% of group B; 67.5% of group A had HB grade I or II FN outcome versus 93.3% of group B (P < 0.001). In group A, 8 patients (20.0%) experienced transient postoperative complications versus 4.4% of group B. Recurrence/regrowth was observed in 4 patients in group A versus 1 in group B. Conclusions: Intraoperative video for classification of HVVS was used. Microsurgery of large HVVS was associated with higher (usually transient) complications and recurrence/regrowth rates and poorer FN outcome, especially in patients with tight capsule adhesion.

Microsurgical treatment of symptomatic vestibular schwannomas in patients under 40: different results before and after age of 30.

In 10-15% of cases of vestibular schwannoma (VS), age at diagnosis is 40 years or less. Little is known about the differences in natural history, surgical findings, and postoperative outcomes of such younger patients as compared to those of greater age. To analyze clinical and surgical and imaging data of a consecutive series of n = 50 patients with unilateral sporadic VS, aged 40 years or younger - separated in a very young group (15-30 years) and a moderately young group (31-40 years). Retrospective case series. Fifty consecutive patients under 40 years of age underwent microsurgical resection of unilateral sporadic VS via the retrosigmoid approach. The study cohort was subdivided into two groups according to the age range: group A, age range 15-30 years (n = 23 patients), and group B, age range 31-40 years (n = 27 patients). The adherence of VS capsule to surrounding nervous structures and the tendency of the tumors to bleed were evaluated by reviewing video records; the course of the FN in relation to the tumor's surface was assessed in each case. Microsurgical removal of tumor was classified as total (T), near total (residual tumor volume < 5%), subtotal (residual tumor volume 5-10%), or partial (residual tumor volume > 10%). Mean tumor size of entire cohort was 2.53 (range: 0.6-5.8) cm: 2.84 cm in group A and 2.36 cm in group B (p = NS). Facial nerve course and position within the cerebellopontine angle did not differ significantly between the two groups. At 6-month follow-up, FN functional outcome was HBI-II in 69.5% in group A, versus 96.3% in group B (p < .001). Hearing preservation was achieved in 60.0% of patients of group A and in 58.3% of group B (p = NS). Total and near-total resection was feasible in 95.6% of cases of group A and in 88.9% of group B (p = NS). Tumor capsule was tightly adherent to nervous structures in 69.6% patients of group A and in 22.2% of group B (p < .05). Significant bleeding was encountered in 56.5% of group A tumors, and in 29.6% of group B tumors (p < .01). Microsurgery of VS in patients aged 40 or less is associated with good functional results, and with high rates of total and near total tumor removal. Patients < 30 years of age have more adherent tumor capsules. Furthermore, their tumors exhibit a tendency to larger sizes, to hypervascularization, to profuse intraoperative bleeding and they present worse long-term functional FN results when compared to patients in their fourth decade of life. Our limited experience seems to suggest that a near total resection in very young VS patients with large tumors should be preferred in adherent and hypervascularized cases, in order to maximize resection and preserve function.

Safeness and efficacy of 2-µm handheld thulium laser during microsurgical resection of supratentorial and infratentorial meningiomas: Experience of a single center.

Aims: We performed a retrospective nonrandomized study to analyze the results of a microsurgery of intracranial meningiomas using 2-µm thulium flexible handheld laser fiber (Revolix jr). Methods: From February 2014 to December 2021, 75 nonconsecutive patients suffering from intracranial meningiomas, admitted in our department, have been operated on with microsurgical technique assisted by 2-µm thulium flexible handheld laser. We have reviewed demographic and clinical data to evaluate safety and efficacy of the technique. Results: There were no complications related to the use of the 2-µm thulium laser. We operated on a high percentage of cranial base and tentorial and posterior fossa meningioma in our series. The neurological outcome and degree of resection did not differ from previous series. The neurosurgical team found the laser easy to use and practical for avoiding bleeding and traction. Conclusion: The use of 2-µm thulium fiber handheld flexible laser in microsurgery of intracranial meningiomas seems to be safe and to facilitate tumor resection, especially in "difficult" conditions (e.g., deep seated, highly vascularized, and hard tumors). Even if in this limited retrospective trial the good functional outcome following conventional microsurgery had not further improved, nor the surgical time was reduced by laser, focusing its use on "difficult" (large and vascularized) cases may lead to different results in the future.

Intracanalicular vestibular schwannomas presenting with facial nerve paralysis.

BACKGROUND: To describe the surgical management and postoperative course of two patients presenting with facial nerve (FN) paralysis as one of the presenting symptoms of small intracanalicular vestibular schwannomas (VS). METHODS: Among 153 patients operated for VS since September 2010 to August 2017, two adult female patients presented with rapidly progressive hearing decrease, vestibular symptoms, and FN paralysis (House-Brackmann grades III and IV, respectively). In both cases, c.e. T1-weighted magnetic resonance imaging revealed an enhancing tumor within the internal auditory canal without lateral extension beyond the fundus. RESULTS: Retrosigmoid approach and excision of tumor showed that the origin of tumor was from the superior vestibular nerve, extrinsic to FN. Gross total tumor resection was obtained, with FN preservation. In the first case, a millimetric fragment of capsule was left because of tight adhesion on FN itself. Histopathology confirmed schwannoma. After surgery, both patients improved FN motor function. CONCLUSIONS: Although very rarely, VS may start clinically with FN palsy, mimicking FN schwannomas and other less common pathologies. This presentation is exceptional in patients with small intracanalicular VS. Early surgical resection is the only reliable treatment for decompression of nerve, avoiding a complete and not-reversible damage, with possible postoperative FN function improvement or complete recovery.

How I Do It: The Role of Flexible Hand-held 2µ-Thulium Laser Fiber in Microsurgical Removal of Acoustic Neuromas.

Aims We performed a retrospective nonrandomized study to analyze the results of microsurgery of acoustic neuromas (AN) using 2µ-thulium flexible hand-held laser fiber (Revolix jr). Methods From September 2010 to September 2015, 89 patients suffering from AN have been operated on with microsurgical technique via retrosigmoid approach. In 37 cases, tumor resection was performed with the assistance of 2µ-thulium flexible hand-held laser fiber (L-group). Eight cases operated on with the assistance of CO 2 hand-held flexible laser fiber were excluded from this study. A total of 44 patients, operated on without laser assistance during the same period, were used as comparison group (C-group) (matched pair technique). Facial nerve function was assessed with the House-Brackmann (HB) scale preoperatively, and 1 week and 6 months postoperatively. Results Overall time from incision to skin suture changed in relation to size of tumor (165-575 minutes) and was not affected by the use of laser. In 7 out of 81 cases, a preoperative facial nerve palsy HB2 and in 1 case, HB4 (permanent) were observed. In the remaining 80 cases, at 6-month follow-up, facial nerve preservation rate (HB1) was 92.5%. Hearing preservation rate (AAO-HNS A/B classes) was 68.2% (26 out of 36). Adopting a 0 to 3 scale, the mean surgeon satisfaction rate of usefulness of laser fiber was 2.7. Conclusion The use of 2µ-thulium hand-held flexible laser fiber in AN microsurgery seems to be safe and subjectively facilitates tumor resection especially in "difficult" conditions (e.g., highly vascularized and hard tumors). In this limited retrospective trial, the good functional outcome following conventional microsurgery had not further improved, nor the surgical time reduced by laser. Focusing its use on "difficult" (large and vascularized) cases may lead to different results in future.

Surgical treatment of pituitary tumors in the elderly: clinical outcome and long-term follow-up.

Pituitary adenomas in the elderly represent an increasing proportion of pituitary tumors, making the surgical management of these patients of special importance. We therefore decided to review our experience with transsphenoidal surgery (TSS) in this age group, in order to better evaluate its efficacy, safety and outcome. A retrospective study was performed on 39 patients aged more than 70 years at the time of surgery (mean age 74.1 +/- 2.9 years) and with a minimum follow-up duration of 4 years at the time of the study. Thirty-one had a nonfunctioning pituitary adenoma, 5 had a GH-secreting adenoma and 3 a macroprolactinoma, respectively. The commonest presenting symptom was visual deterioration (60%), whereas hypopituitarism were present in 41% of patients. All patients underwent TSS without any major peri- and post-operative complications. Visual fields improved in 74% of patients. Post-operative radiotherapy was performed in 17 patients with partial surgical resection and/or persistent hormonal hypersecretion, whereas 22 patients with subtotal or total surgical resection were treated by surgery only. Long-term follow-up (mean 9.1 +/- 2.7 years) showed evidence for tumor regrowth in one irradiated (5.9%) and 3 non-irradiated patients (13.6%), respectively. A noticeable complication of radiotherapy was progressive hypopituitarism, which worsened or developed in 65% of patients. We conclude that TSS is safe and well tolerated even in elderly patients, with a low incidence of minor complications. The indications for post-operative radiotherapy in patients with incomplete tumor resection should be better defined.