-
The Laryngoscope Dec 2023In an era of vestibular schwannoma (VS) surgery where functional preservation is increasingly emphasized, persistent postoperative dizziness is a relatively understudied...
OBJECTIVE
In an era of vestibular schwannoma (VS) surgery where functional preservation is increasingly emphasized, persistent postoperative dizziness is a relatively understudied functional outcome. The primary objective was to develop a predictive model to identify patients at risk for developing persistent postoperative dizziness after VS resection.
METHODS
Retrospective review of patients who underwent VS surgery at our institution with a minimum of 12 months of postoperative follow-up. Demographic, tumor-specific, preoperative, and immediate postoperative features were collected as predictors. The primary outcome was self-reported dizziness at 3-, 6-, and 12-month follow-up. Binary and multiclass machine learning classification models were developed using these features.
RESULTS
A total of 1,137 cases were used for modeling. The median age was 67 years, and 54% were female. Median tumor size was 2 cm, and the most common approach was suboccipital (85%). Overall, 63% of patients did not report postoperative dizziness at any timepoint; 11% at 3-month follow-up; 9% at 6-months; and 17% at 12-months. Both binary and multiclass models achieved high performance with AUCs of 0.89 and 0.86 respectively. Features important to model predictions were preoperative headache, need for physical therapy on discharge, vitamin D deficiency, and systemic comorbidities.
CONCLUSION
We demonstrate the feasibility of a machine learning approach to predict persistent dizziness following vestibular schwannoma surgery with high accuracy. These models could be used to provide quantitative estimates of risk, helping counsel patients on what to expect after surgery and manage patients proactively in the postoperative setting.
LEVEL OF EVIDENCE
4 Laryngoscope, 133:3534-3539, 2023.
Topics: Humans; Female; Aged; Male; Neuroma, Acoustic; Dizziness; Treatment Outcome; Vertigo; Headache; Retrospective Studies
PubMed: 37092316
DOI: 10.1002/lary.30708 -
Neurosurgery Feb 2024Intratumoral hemorrhage (ITH) in vestibular schwannoma (VS) after stereotactic radiosurgery (SRS) is exceedingly rare. The aim of this study was to define its incidence...
BACKGROUND AND OBJECTIVES
Intratumoral hemorrhage (ITH) in vestibular schwannoma (VS) after stereotactic radiosurgery (SRS) is exceedingly rare. The aim of this study was to define its incidence and describe its management and outcomes in this subset of patients.
METHODS
A retrospective multi-institutional study was conducted, screening 9565 patients with VS managed with SRS at 10 centers affiliated with the International Radiosurgery Research Foundation.
RESULTS
A total of 25 patients developed ITH (cumulative incidence of 0.26%) after SRS management, with a median ITH size of 1.2 cm 3 . Most of the patients had Koos grade II-IV VS, and the median age was 62 years. After ITH development, 21 patients were observed, 2 had urgent surgical intervention, and 2 were initially observed and had late resection because of delayed hemorrhagic expansion and/or clinical deterioration. The histopathology of the resected tumors showed typical, benign VS histology without sclerosis, along with chronic inflammatory cells and multiple fragments of hemorrhage. At the last follow-up, 17 patients improved and 8 remained clinically stable.
CONCLUSION
ITH after SRS for VS is extremely rare but has various clinical manifestations and severity. The management paradigm should be individualized based on patient-specific factors, rapidity of clinical and/or radiographic progression, ITH expansion, and overall patient condition.
Topics: Humans; Middle Aged; Neuroma, Acoustic; Radiosurgery; Retrospective Studies; Microsurgery; Hemorrhage; Treatment Outcome; Follow-Up Studies
PubMed: 37581440
DOI: 10.1227/neu.0000000000002627 -
Neuro-oncology Advances 2023Both stereotactic radiosurgery () and microsurgical resection () are available as treatment options for sporadic vestibular schwannoma (VS). There are very few direct...
BACKGROUND
Both stereotactic radiosurgery () and microsurgical resection () are available as treatment options for sporadic vestibular schwannoma (VS). There are very few direct comparative studies comparing both treatment modalities in large cohorts allowing detailed subgroup analysis. This present study aimed to compare the nuances in the treatment of VS by and in 2 highly specialized neurosurgical centers.
METHODS
This is a retrospective bicentric cohort study. Data from patients treated between 2005 and 2011 were collected retrospectively. Recurrence-free survival (RFS) was assessed radiographically by contrast-enhanced magnetic resonance imaging.
RESULTS
The study population included = 901 patients with a mean follow-up of 7 years. Overall, the incidence of recurrence was 7% after , and 11% after with superior tumor control in in the Kaplan-Meier-analysis ( = 0.031). In small tumors (Koos I and II), tumor control was equivalent in both treatment arms. In large VS (Koos III and IV), however, RFS was superior in . The extent of resection correlated with RFS ( < .001). Facial and hearing deterioration was similar in both treatment arms in small VS, but more pronounced in of large VS. Tinnitus, vertigo, imbalance, and trigeminal symptoms were more often improved by than .
CONCLUSIONS
can achieve similar tumor control compared to in smaller VS (Koos I and II)-with similar postinterventional morbidities. In large VS (Koos III and IV), long-term tumor control of is inferior to . Based on these results, we suggest that if combination therapy is chosen, the residual tumor should not exceed the size of Koos II.
PubMed: 38024239
DOI: 10.1093/noajnl/vdad146 -
Otolaryngology--head and Neck Surgery :... Sep 2023Intracochlear schwannoma is very rare, and complete loss of hearing is inevitable after the removal of this tumor. Here, we discuss cochlear implantation (CI) performed...
OBJECTIVE
Intracochlear schwannoma is very rare, and complete loss of hearing is inevitable after the removal of this tumor. Here, we discuss cochlear implantation (CI) performed simultaneously with the removal of an intracochlear schwannoma.
STUDY DESIGN
Retrospective single-center study.
SETTING
Tertiary medical institute.
METHODS
Simultaneous CI and intracochlear schwannoma removal were performed in 4 subjects. After subtotal cochleostomy, the tumors were removed meticulously, with preservation of the modiolus. A new slim modiolar electrode (Nucleus CI632) was placed in a manner that hugged the modiolus. The surgical outcomes of functional gain, word recognition score (WRS), sound localization, and hearing in noise and speech intelligibility tests were investigated.
RESULTS
Intracochlear schwannomas were removed successfully from the 4 patients, with no remnant tumor. The mean aided hearing threshold 6 months after surgery was 25.0 ± 1.8 dB, and the mean-aided WRS with a 60 dB stimulus was 36.0 ± 18.8% (range 16%-60%). The Categorical Auditory Performance (CAP) score of the 3 single-sided deafness patients under contralateral ear masking was 7. The CAP score of the patient with bilateral sensorineural hearing loss was 6, which improved from a preoperative score of 0.
CONCLUSION
When an intracochlear schwannoma does not completely invade the modiolus, CI with simultaneous tumor removal can be performed successfully, resulting in good hearing performance. A slim modiolar electrode can be placed stably at the modiolus after schwannoma removal.
Topics: Humans; Cochlear Implantation; Cochlear Implants; Neuroma, Acoustic; Retrospective Studies; Neurilemmoma; Treatment Outcome
PubMed: 36807253
DOI: 10.1002/ohn.300 -
Medical Physics Aug 2023Radiosurgery is a well-established treatment for various intracranial tumors. In contrast to other established radiosurgery platforms, the new ZAP-X allows for...
BACKGROUND
Radiosurgery is a well-established treatment for various intracranial tumors. In contrast to other established radiosurgery platforms, the new ZAP-X allows for self-shielding gyroscopic radiosurgery. Here, treatment beams with variable beam-on times are targeted towards a small number of isocenters. The existing planning framework relies on a heuristic based on random selection or manual selection of isocenters, which often leads to a higher plan quality in clinical practice.
PURPOSE
The purpose of this work is to study an improved approach for radiosurgery treatment planning, which automatically selects the isocenter locations for the treatment of brain tumors and diseases in the head and neck area using the new system ZAP-X .
METHODS
We propose a new method to automatically obtain the locations of the isocenters, which are essential in gyroscopic radiosurgery treatment planning. First, an optimal treatment plan is created based on a randomly selected nonisocentric candidate beam set. The intersections of the resulting subset of weighted beams are then clustered to find isocenters. This approach is compared to sphere-packing, random selection, and selection by an expert planner for generating isocenters. We retrospectively evaluate plan quality on 10 acoustic neuroma cases.
RESULTS
Isocenters acquired by the method of clustering result in clinically viable plans for all 10 test cases. When using the same number of isocenters, the clustering approach improves coverage on average by 31 percentage points compared to random selection, 15 percentage points compared to sphere packing and 2 percentage points compared to the coverage achieved with the expert selected isocenters. The automatic determination of location and number of isocenters leads, on average, to a coverage of 97 ± 3% with a conformity index of 1.22 ± 0.22, while using 2.46 ± 3.60 fewer isocenters than manually selected. In terms of algorithm performance, all plans were calculated in less than 2 min with an average runtime of 75 ± 25 s.
CONCLUSIONS
This study demonstrates the feasibility of an automatic isocenter selection by clustering in the treatment planning process with the ZAP-X system. Even in complex cases where the existing approaches fail to produce feasible plans, the clustering method generates plans that are comparable to those produced by expert selected isocenters. Therefore, our approach can help reduce the effort and time required for treatment planning in gyroscopic radiosurgery.
Topics: Humans; Radiosurgery; Retrospective Studies; Brain Neoplasms; Algorithms; Cluster Analysis
PubMed: 37099483
DOI: 10.1002/mp.16436 -
Otology & Neurotology : Official... Oct 2023Metformin and aspirin reduce vestibular schwannoma (VS) growth.
HYPOTHESIS
Metformin and aspirin reduce vestibular schwannoma (VS) growth.
BACKGROUND
There have been reported associations between patients with VS prescribed metformin and decreased tumor volumetric growth. Aspirin has also been associated with decreased VS growth in animal studies.
METHODS
Rat schwannoma cell lines were grown and implanted into 50 athymic nude mice. Tumors were grown to 5 mm, and then mice were injected with either low- or high-dose metformin, aspirin, or saline daily. Tumors were measured until 14 days elapsed or mice demonstrated symptoms such as ulceration, inability to walk, or passed away.
RESULTS
There were no significant differences in day 0 tumor sizes between the control and the treatment groups ( p = 0.73). In the low-dose, but not high-dose groups, day 7 volumes were significantly different for both metformin ( p = 0.04) and aspirin ( p = 0.02) compared with placebo. Mean tumor growth rates were 126.6 ± 65.6 mm 3 /day for saline compared with 73.7 ± 29.5 mm 3 /day for low-dose metformin ( p = 0.03) and 68.7 ± 34.8 mm 3 /day for low-dose aspirin ( p = 0.016). There were no significant differences in tumor sizes ( p = 0.59) or growth rates ( p = 0.75) between low-dose metformin and aspirin groups. Low-dose groups had treatment stopped at 14 days, with continued monitoring demonstrating significant increases in tumor growth off treatment for both aspirin ( p = 0.006) and metformin ( p = 0.048).
CONCLUSIONS
Metformin treatment significantly reduced VS growth to a similar level as aspirin. Furthermore, when removing both metformin and aspirin treatment, tumor growth significantly increased.
Topics: Rats; Animals; Mice; Mice, Nude; Neurilemmoma; Neuroma, Acoustic; Aspirin; Metformin
PubMed: 37641199
DOI: 10.1097/MAO.0000000000004001 -
PloS One 2024Vestibular schwannoma can cause vestibular dysfunction; however, conflicting evidence exists regarding whether this affects the incidence of fall-related injuries in...
Vestibular schwannoma can cause vestibular dysfunction; however, conflicting evidence exists regarding whether this affects the incidence of fall-related injuries in this patient population. This matched cross-sectional and cohort study assess the risk of fall-related injuries in patients with vestibular schwannoma. The study included patients with vestibular schwannoma treated at a tertiary referral hospital in Sweden between 1988 and 2014. Information on fall-related injuries was obtained from the National Patient Register, and matched population comparisons were randomly selected in a 1:25 ratio. Fall-related injuries occurring pre- (within 5 years before the diagnosis of vestibular schwannoma) and post-diagnostically (up to 3 years after diagnosis or intervention) were registered. The association between vestibular schwannoma and fall-related injuries was estimated using logistic regression and Cox proportional hazards analyses. We identified 1153 patients with vestibular schwannoma (569 [49%] women and 584 [51%] men), and 28815 population comparisons. Among the patients, 9% and 7% had pre- and post-diagnostic fall-related injuries, respectively, and among the comparisons, 8% and 6% had pre- and post-diagnostic fall-related injuries, respectively. There was no increased risk of pre- (OR 1.14; CI 0.92-1.41) or post-diagnostic 1 year (HR 1.16; CI 0.87-1.54) or 3 years (HR 1.11; CI 0.89-1.29) fall-related injury among the total patient cohort. In age-stratified analyses, we found an increased risk of pre-diagnostic fall-related injury among patients aged 50-69 years (OR 1.42; CI 1.10-1.88). Patients who underwent middle fossa surgery, regardless of age, had an increased risk of post-surgery fall-related injury within 3 years of follow-up (HR 2.68; CI 1.06-6.81). We conclude that patients with vestibular schwannoma have a low risk of enduring fall-related injuries. Middle-aged patients with dizziness and fall-related injuries should be considered for a vestibular clinical evaluation. Our results highlight the importance of rehabilitation in avoiding future fall-related injuries among patients undergoing middle fossa surgery.
Topics: Humans; Neuroma, Acoustic; Female; Male; Middle Aged; Aged; Accidental Falls; Sweden; Adult; Cross-Sectional Studies; Risk Factors; Cohort Studies
PubMed: 38875269
DOI: 10.1371/journal.pone.0304184 -
Acta Oto-laryngologica 2023Acute audiovestibular deficits may be a harbinger of vestibular schwannoma (VS).
BACKGROUND
Acute audiovestibular deficits may be a harbinger of vestibular schwannoma (VS).
OBJECTIVE
To investigate clinical and laboratory features of 25 consecutive patients with VS presenting with acute audiovestibular deficits.
METHODS
A symptomatic combination of acute audiovestibular deficits was investigated. Audiometric and vestibular function tests, and internal auditory canal magnetic resonance imaging (IAC MRI) results were evaluated.
RESULTS
Varying combinations of symptoms may develop in VS patients with acute audiovestibular deficits, of whom sudden hearing loss (HL) without acute vertigo or acute facial nerve palsy (FNP) was most common. The most common audiometric configuration was high-tone hearing loss, and no patient showed low-tone hearing loss. IAC MRI demonstrated that the tumor had an intracanalicular portion and attachment to the bony IAC wall in all patients and widened the IAC wall in some patients.
CONCLUSION
Different symptomatic combinations of acute audiovestibular deficits may develop in patients with VS. Awareness about the possibility of VS as a cause of sudden HL, acute vertigo, and acute FNP, as well as subsequent IAC MRI scanning is vital to earlier diagnosis of VS in these patients.
Topics: Humans; Neuroma, Acoustic; Ear, Inner; Vertigo; Magnetic Resonance Imaging; Hearing Loss, Sudden; Syndrome; Facial Paralysis; Cerebellopontine Angle
PubMed: 38108643
DOI: 10.1080/00016489.2023.2290202 -
Acta Oto-laryngologica Jan 2024There is no comprehensive and up-to-date overview of audiovestibular approach to the posterior fossa tumors in the literature. (Review)
Review
BACKGROUND
There is no comprehensive and up-to-date overview of audiovestibular approach to the posterior fossa tumors in the literature.
OBJECTIVE
This paper reviewed the literature relating to tumors at the posterior cranial fossa to find red flags alerting a posterior fossa lesion from audiovestibular perspectives.
METHODS
This review was developed from articles published in those journals listed on the journal citation reports. Through the PubMed database, Embase, Google Scholar, and Cochrane library, 60 articles were finally obtained based on the PRISMA guidelines for reporting reviews.
RESULTS
The presence of one red flag indicates a positive predictive value of 33% for detecting a posterior fossa lesion. Clinical features, namely, 1) mid-frequency sudden sensorineural hearing loss (SNHL), 2) bilateral sudden SNHL, and 3) rebound nystagmus may indicate a posterior fossa lesion, representing one, two, and three red flags, respectively.
CONCLUSION
Those with 1) mid-frequency sudden SNHL, 2) bilateral sudden SNHL, and 3) rebound nystagmus trigger one, two, and three red flags, respectively, alerting clinicians the possibility of a posterior fossa lesion, which warrant MR imaging to exclude life-threatening or treatable conditions.
SIGNIFICANCE
Patients with posterior fossa tumors may have potential life-threatening outcome.
Topics: Humans; Hearing Loss, Sensorineural; Nystagmus, Pathologic; Infratentorial Neoplasms; Cranial Fossa, Posterior; Hearing Loss, Sudden
PubMed: 38461404
DOI: 10.1080/00016489.2024.2316262 -
European Archives of... Nov 2023To highlight the changes in the management of vestibular schwannoma (VS) since 2004 with a focus on small- to middle-size VS.
PURPOSE
To highlight the changes in the management of vestibular schwannoma (VS) since 2004 with a focus on small- to middle-size VS.
METHODS
Retrospective analysis of the decisions made in skull base tumor board between 2004 and 2021.
RESULTS
1819 decisions were analyzed (average age 59.25, 54% females). Overall, 850 (47%) cases were allocated to a Wait and Scan (WS) approach, 416 (23%) received radiotherapy and 553 (30%) were treated surgically (MS). All stages considered WS increased from 39% before 2010 to 50% after 2010. Similarly, Stereotactic Radio Therapy (SRT) increased from 5 to 18%. MS decreased from 46 to 25%. It was more commonly proposed to younger patients and larger tumors, p < 0.001. For Koos stages 1, 2, and 3 there was a statistically significant increase in SRT, and a decrease in MS, p < 0.001. WS also increased for stages 1 and 2. However, such a trend was not observed for stage 3. MS remained the primary treatment modality for stage 4 tumors throughout the study period, p = 0.057. The significance of advanced age as a factor favoring SRT decreased over time. The opposite is true for serviceable hearing. There was also a decrease in the percentage of the justification "young age" in the MS category.
CONCLUSION
The is a continuing trend towards non-surgical treatment. Small- to medium-sized VS witnessed an increase in both WS and SRT. There is only an increase in SRT for moderately large VS. Physicians are less and less considering young age as a factor favoring MS over SRT. There is a tendency towards favoring SRT when hearing is serviceable.
Topics: Female; Humans; Middle Aged; Male; Neuroma, Acoustic; Retrospective Studies; Treatment Outcome; Hearing; Dose Fractionation, Radiation; Follow-Up Studies
PubMed: 37195345
DOI: 10.1007/s00405-023-08009-6