-
Journal of Neurosurgery Feb 2023Vestibular schwannomas (VSs) are benign tumors of the cerebellopontine angle that are typically managed with stereotactic radiosurgery (SRS). Intratumoral hemorrhage... (Review)
Review
OBJECTIVE
Vestibular schwannomas (VSs) are benign tumors of the cerebellopontine angle that are typically managed with stereotactic radiosurgery (SRS). Intratumoral hemorrhage (ITH) of VSs is a rare occurrence that results in worsening vestibular and new cranial nerve deficits. Few reports have described the management and outcomes of this entity after SRS. To further delineate the incidence and impact of this event, the authors performed a retrospective review of their VS SRS patients at a single center.
METHODS
Between 1987 and 2022, 2058 patients with VSs underwent Gamma Knife radiosurgery (GKRS) at the University of Pittsburgh Medical Center. The authors performed a review of the prospectively maintained VS database at their center to identify patients with ITH. The presentation, management, and clinical and imaging outcomes of the patients are reported.
RESULTS
A total of 1902 VS patients had sufficient clinical and imaging follow-up data. Five Koos grade III (n = 1) and IV (n = 4) VS patients developed ITH after GKRS, resulting in a cumulative incidence rate of 0.26%. The age at presentation ranged from 62 to 79 years, and 3 patients were male. The time from VS diagnosis to GKRS ranged from 1 to 13 months, and the time from GKRS to ITH ranged from 2 to 130 months. Three patients had bleeding risk factors. One patient required urgent surgical intervention due to the ITH volume, while the other 4 patients were initially observed. Three patients remained stable and required no delayed intervention; 1 patient required delayed resection because of symptom progression and hemorrhagic expansion. Histopathological analysis revealed multiple fragments of S-100-positive cells, hemorrhage, and hemosiderin-laden macrophages. At last follow-up, 4 patients had clinically improved and 1 patient remained stable.
CONCLUSIONS
ITH after VS radiosurgery is a rare phenomenon with a cumulative incidence rate of 0.26% in this series. Patient-tailored management in the form of observation or resection is based on patient presentation, acuity, and ITH size.
Topics: Humans; Male; Middle Aged; Aged; Female; Neuroma, Acoustic; Radiosurgery; Retrospective Studies; Risk Factors; Hemorrhage; Treatment Outcome; Follow-Up Studies
PubMed: 35901754
DOI: 10.3171/2022.5.JNS22935 -
Neurosurgery Jun 2023Stereotactic radiosurgery (SRS) is one of the main treatment options in the management of small to medium size vestibular schwannomas (VSs), because of high tumor... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Stereotactic radiosurgery (SRS) is one of the main treatment options in the management of small to medium size vestibular schwannomas (VSs), because of high tumor control rate and low cranial nerves morbidity. Series reporting long-term hearing outcome (>3 years) are scarce.
OBJECTIVE
To perform a systematic review of the literature and meta-analysis, with the aim of focusing on long-term hearing preservation after SRS.
METHODS
Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we reviewed articles published between January 1990 and October 2020 and referenced in PubMed or Embase. Inclusion criteria were peer-reviewed clinical study or case series of VSs treated with SRS (single dose), reporting hearing outcome after SRS with a median or mean audiometric follow-up of at least 5 years. Hearing preservation, cranial nerves outcomes, and tumor control were evaluated.
RESULTS
Twenty-three studies were included. Hearing preservation was found in 59.4% of cases (median follow-up 6.7 years, 1409 patients). Main favorable prognostic factors were young age, good hearing status, early treatment after diagnosis, small tumor volume, low marginal irradiation dose, and maximal dose to the cochlea. Tumor control was achieved in 96.1%. Facial nerve deficit and trigeminal neuropathy were found in 1.3% and 3.2% of patients, respectively, both significantly higher in Linear Accelerator series than Gamma Knife series ( P < .05).
CONCLUSION
Long-term hearing preservation remains one of the main issues after SRS, with a major impact on health-related quality of life. Our meta-analysis suggests that hearing preservation can be achieved in almost 60% of patients after a median follow-up of 6.7 years, irrespective of the technique.
Topics: Humans; Neuroma, Acoustic; Radiosurgery; Treatment Outcome; Quality of Life; Hearing; Follow-Up Studies; Retrospective Studies
PubMed: 36735500
DOI: 10.1227/neu.0000000000002354 -
Acta Neurochirurgica Dec 2023Hydrocephalus (HC) is common in patients with vestibular schwannoma (VS). This can be managed with a cerebrospinal fluid (CSF) diversion procedure prior to VS resection...
BACKGROUND
Hydrocephalus (HC) is common in patients with vestibular schwannoma (VS). This can be managed with a cerebrospinal fluid (CSF) diversion procedure prior to VS resection or with VS resection, keeping CSF diversion in reserve unless required postoperatively. No clear consensus exists as to which approach is superior. This study identifies factors predictive of the development of HC, and analyses outcomes for those managed with primary CSF resection versus tumour resection.
METHODS
Single-centre retrospective cohort study of 204 consecutive adult patients with a unilateral VS from May 2009 to June 2021. Data was collected on patient and tumour demographics, management, and outcome.
RESULTS
204 patients, with a mean age at presentation of 59.5 (21-83), with 50% female, and a mean follow-up of 7.5 years (1.8-13.9) were included. 119 were managed conservatively, 36 with stereotactic radiosurgery only, and 49 with surgery. 30 (15%) patients had radiological HC, of which 23 (77%) were obstructive, and 7 (23%) were communicating. Maximum intracranial tumour diameter and Koos grade were higher in patients with HC. Of the patients with HC the majority (20, 67%) were managed initially with CSF diversion, with 12 patients undergoing subsequent tumour resection, and three patients avoiding primary resection. Nine (30%) were managed with primary surgical resection, of whom three required subsequent CSF diversion. Complication rates and Modified Rankin Scale (MRS) were comparable or lower in the CSF diversion group (8%, MRS ≤2 = 83%), versus the primary resection group (67%, MRS ≤2 = 67%), and the primary surgical resection without HC group (25%, MRS ≤2 = 86%).
CONCLUSIONS
CSF diversion prior to tumour resection is a safe and acceptable strategy compared to primary VS resection, with improved outcomes and reduced surgical complications. Randomized studies and national databases are needed to determine the long-term outcomes of patients treated with CSF diversion versus primary resection.
Topics: Adult; Humans; Female; Male; Retrospective Studies; Neuroma, Acoustic; Hydrocephalus; Brain Neoplasms; Ventriculoperitoneal Shunt
PubMed: 37935949
DOI: 10.1007/s00701-023-05866-2 -
Turkish Journal of Medical Sciences Oct 2021The study aims to evaluate the usage of gold weight implants and monitor complaints and comfort of patients.
BACKGROUND
The study aims to evaluate the usage of gold weight implants and monitor complaints and comfort of patients.
METHODS
A hundred and ninety-one implantations performed between January 2009 and January 2019 were analyzed. Seventy-eight patients included in this study The average age of the patients was 51.3 ± 14.5 years. Forty-five (57.7%) of them were male and 33 (42.3%) female. Patient satisfaction was measured with a questionnaire containing the most common complaints related to gold weight in the literature through telephone surveys.
RESULTS
The average follow-up time was 74.5 months. Ninety-three-point-five percent of subjects had operational causes, among which the most widespread was acoustic neuroma (44.9%). The average time between facial paralysis and implantation was 141.1 days. Implantation was performed 26.6 days on average after acoustic neuroma surgery and 3.2 days on average after temporal zone malignancy surgery. Thirty-eight patients had their implants removed over either complication (n = 14) or recovery (n = 24). Recovery was the fastest after facial nerve decompression (mean= 4.75 ± 3.6 (2-10) months) and the slowest after 7-12 cranial nerve transfer (mean= 18.3 ± 8.2 (3-31) months). Twenty-six-point-nine percent (n = 21) of patients had complications, of which the most common was extrusion (n = 10). The overall satisfaction rate was 88.5% with the highest in visual acuity and the lowest in continuous requirement for artificial tear.
DISCUSSION
The gold weight implantation is an effective, reversible, and easy procedure significantly reducing complaints regarding paralytic lagophthalmos. Early implementation may be beneficial for ocular complications. A dynamic facial reanimation could terminate need of implant.
Topics: Humans; Female; Male; Adult; Middle Aged; Aged; Neuroma, Acoustic; Prostheses and Implants; Facial Paralysis; Eye; Gold
PubMed: 34174800
DOI: 10.3906/sag-2104-50 -
HNO May 2017The experience of the medical team, interdisciplinarity, quality of the physician-patient relationship, sensible use of modern technology, and a sound knowledge about... (Review)
Review
BACKGROUND
The experience of the medical team, interdisciplinarity, quality of the physician-patient relationship, sensible use of modern technology, and a sound knowledge about the long-term results of observation and interventions all influence treatment quality in patients with vestibular schwannomas.
OBJECTIVES
Compilation of findings regarding the results of observation and microsurgical treatment of patients with these tumors. Deduction of strategies for the medical management from these data.
MATERIALS AND METHODS
Review of the pertinent literature concerning the course of the disease with observational management and microsurgical treatment with respect to tumor growth and symptoms.
RESULTS
Reported annual growth rates of vestibular schwannoma vary between 0.3 and 4.8 mm. Vertigo is the symptom that is most influential on quality of life regardless of the medical management strategy. Up to 75 % of patients are treated within 5 years of the primary diagnosis. Independent of the approach, reported resection rates are higher than 95 %, even with preservation of function as the primary goal. Recurrence rates after subtotal removal are three times higher than after complete removal. Facial nerve preservation is accomplished in more than 90 % of cases. With functional hearing before surgery and small tumors, the chance of hearing preservation exceeds 50 %.
CONCLUSIONS
Quality of life is primarily defined by symptoms caused by the tumor itself and only secondarily by the medical interventions. Treatment should be directed towards the preservation of the patient's quality of life from the beginning. Results of medical treatment should be superior to the natural course of the disease.
Topics: Evidence-Based Medicine; Humans; Microsurgery; Neoplasm Recurrence, Local; Neuroma, Acoustic; Neurosurgical Procedures; Treatment Outcome
PubMed: 27742964
DOI: 10.1007/s00106-016-0252-5 -
Current Oncology Reports May 2023Neurofibromatosis 2 (NF2) is an autosomal-dominant genetic disorder characterized by bilateral vestibular schwannomas (VS), meningiomas, ependymomas, spinal and... (Review)
Review
PURPOSE OF REVIEW
Neurofibromatosis 2 (NF2) is an autosomal-dominant genetic disorder characterized by bilateral vestibular schwannomas (VS), meningiomas, ependymomas, spinal and peripheral schwannomas, optic gliomas, and juvenile cataracts. Ongoing studies provide new insight into the role of the NF2 gene and merlin in VS tumorigenesis.
RECENT FINDINGS
As NF2 tumor biology becomes increasingly understood, therapeutics targeting specific molecular pathways have been developed and evaluated in preclinical and clinical studies. NF2-associated VS are a source of significant morbidity with current treatments including surgery, radiation, and observation. Currently, there are no FDA-approved medical therapies for VS, and the development of selective therapeutics is a high priority. This manuscript reviews NF2 tumor biology and current therapeutics undergoing investigation for treatment of patients with VS.
Topics: Humans; Neurofibromatosis 2; Neuroma, Acoustic; Meningioma; Skin Neoplasms; Meningeal Neoplasms
PubMed: 36933171
DOI: 10.1007/s11912-023-01388-3 -
HNO May 2017Microsurgical resection of vestibular schwannomas is demanding, even if not all of these tumors represent a challenge for experienced surgeons. In order to make the... (Review)
Review
BACKGROUND
Microsurgical resection of vestibular schwannomas is demanding, even if not all of these tumors represent a challenge for experienced surgeons. In order to make the right decisions when it comes to balancing the extent of tumor resection with preservation of function, the surgeon must possess detailed knowledge of the surgical techniques and also have mastered these.
OBJECTIVE
The current article describes the state-of-the-art of the three major microsurgical techniques for resection of vestibular schwannomas, their pearls and their perils.
MATERIALS AND METHODS
The literature-based review of the three surgical techniques is complemented by a discussion of operative nuances and weighting of advantages and possible complications based on the authors' own experience.
RESULTS
The translabyrinthine, retrosigmoidal, and subtemporal microsurgical approaches are well documented in the literature regarding their modifications and the achievable surgical results. Hearing preservation is possible with the latter two approaches. The choice of approach and the preservation of neural function depend primarily on the size of the tumor and pre-existing neurologic deficits. Preoperative diagnostics and preparation differ only for semi-sitting patient positioning, where transesophageal echocardiography is required. The classic surgical techniques have been supplemented by fine-tuned electrophysiologic monitoring, endoscopic views, special microinstruments, and intraoperative image guidance.
CONCLUSION
The choice of surgical approach often depends on the personal preference and experience of the surgeon. Preoperative hearing and tumor extension are the main objective selection criteria.
Topics: Clinical Decision-Making; Evidence-Based Medicine; Humans; Microsurgery; Neoplasm Recurrence, Local; Neuroma, Acoustic; Neurosurgical Procedures; Treatment Outcome
PubMed: 28409217
DOI: 10.1007/s00106-017-0353-9 -
Acta Oto-laryngologica Feb 2015Many patients with acoustic neuroma (AN) experience hearing loss and tinnitus. Time from first symptoms to diagnosis can be considerable. AN should be suspected, and MRI...
CONCLUSION
Many patients with acoustic neuroma (AN) experience hearing loss and tinnitus. Time from first symptoms to diagnosis can be considerable. AN should be suspected, and MRI scans performed, in patients with hearing loss accompanied by asymmetry, tinnitus, low speech discrimination score (SDS), and abnormal auditory brainstem response (ABR).
OBJECTIVES
To determine the otorhinolaryngological factors associated with AN by analyzing the clinical manifestations and diagnostic test results of patients with AN before MRI scanning.
METHODS
This study enrolled 114 patients definitively diagnosed with AN after visiting the Ear-Nose-and-Throat and Neurosurgery Departments of Kyung Hee University Medical Center from 2001 to 2013. Factors retrospectively analyzed included patient age, gender, major symptoms, accompanying symptoms, symptom duration, pure-tone audiometry, SDS, asymmetry, tinnitogram, ABR, and MRI scan results.
RESULTS
The main symptom of AN was hearing loss, and the most frequent accompanying symptom was tinnitus. More severe deafness correlated significantly with lower SDS (p < 0.05). Asymmetric hearing was observed in 75 of 116 patients (64.6%), and mean SDS was 73.1 ± 34.1%. Of patients with latencies of waves I, III, and V on ABR tests, 56.1%, 92.4%, and 92.4%, had interaural latency differences ≥0.2 ms. However, audiometry results did not correlate with lesion site or tumor size (p > 0.05).
Topics: Adult; Aged; Audiometry, Pure-Tone; Evoked Potentials, Auditory, Brain Stem; Female; Humans; Male; Middle Aged; Neuroma, Acoustic; Retrospective Studies; Speech Discrimination Tests
PubMed: 25578127
DOI: 10.3109/00016489.2014.952334 -
Neuroimaging Clinics of North America Feb 2019Vestibular schwannomas are the most common tumor of the cerebellopontine angle. The history of their management has driven advances in imaging, lateral skull base... (Review)
Review
Vestibular schwannomas are the most common tumor of the cerebellopontine angle. The history of their management has driven advances in imaging, lateral skull base surgery, as well as radiosurgery. With these advances, a shift has occurred from life-saving treatment for late-stage disease to quality of life focused management of smaller tumors. The complicated treatment paradigms involving observation, stereotactic radiosurgery and surgery require close communication between the treatment and neuroradiology teams.
Topics: Delivery of Health Care; Humans; Magnetic Resonance Imaging; Neuroma, Acoustic; Neurosurgical Procedures; Radiologists; Radiosurgery; Tomography, X-Ray Computed; Treatment Outcome; Vestibulocochlear Nerve
PubMed: 30466639
DOI: 10.1016/j.nic.2018.09.003 -
Acta Otorhinolaryngologica Italica :... Jun 2021
Review
Topics: Humans; Microsurgery; Neurilemmoma; Neuroma, Acoustic
PubMed: 34264923
DOI: 10.14639/0392-100X-N1443