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Vestibular Schwannoma Surgical management and outcomes

Vestibular Schwannoma Surgical management and outcomes. Ching-Jen (Jared) Chen Visiting Sub-Intern University of Virginia. Patient MM. 48yo M w/ L-sided tinnitus and dysequilibrium since 2009. MRI 2010 revealed 5mm L vestibular schwannoma (purely intracanalicular).

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Vestibular Schwannoma Surgical management and outcomes

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  1. Vestibular SchwannomaSurgical management and outcomes Ching-Jen (Jared) Chen Visiting Sub-Intern University of Virginia

  2. Patient MM • 48yo M w/ L-sided tinnitus and dysequilibrium since 2009. • MRI 2010 revealed 5mm L vestibular schwannoma (purely intracanalicular). • No intervention, followed with serial scans. • MRI 2012 revealed schwannoma had extended to just outside the IAC. • Audiogram showed mild L sensorineural hearing loss. • Referred to MGH for surgical consideration.

  3. Patient MM (cont’d) • PMH: • Hx of Afib w/ spontaneous conversion to NSR • Viral pericarditis • S/p R knee surgery • S/p R shoulder surgery • SH: Denies tobacco and illicits, rare EtOH. • FH: Non-contributory, no hx of vestibular schwannomas. • MEDS: ASA 81 QDaily • ALL: NKDA • EXAM: NI, except slightly decreased hearing in L ear • Decided to undergo microsurgical resection via retrosigmoid approach

  4. T1-PostGad 2010 2012 2013 5mm L Vestibular Schwannoma, purely intracanalicular. Enlarging L VestibularSchwannoma, 11mm. Projects just beyond medial aspect of porous acusticus. 6 mo s/p microsurgical GTR, via retrosigmoid approach. W/o evidence of residual/recurrent tumor.

  5. Vestibular Schwannoma • Usually arise from the superior division of vestibular n. • Histology: Antoni A, Antoni B, and Verocay Bodies. • Comprising 8-10% of intracranial tumors. • Annual incidence ~1.5 cases/100,000. • Typically become symptomatic after age 30. • Most common symptoms: hearing loss, tinnitus, and dysequilibrium. • >95% are unilateral. B A Wippold FJ et al.

  6. Treatment options • Microsurgery • Middle Fossa approach • Translabyrinthine approach • Retrosigmoid approach • Radiosurgery Mayfield clinic

  7. Middle Fossa Approach • Usually selected for smaller (<25mm) and laterally place tumors. • Potential damage to temporal lobe w/ risk of seizures. Gonzalez LF et al.

  8. Retrospective review; 46 patients, middle fossa approach. • Mean follow-up time: 1.8 yr. • Mean tumor size 8.3mm. • Facial n. • Excellent/good (House-Brackmann Grade I-II)functional preservation: 89.1%. • Not correlated w/ tumor size. • Cochlear n. • Functional hearing (AAO-HNS Class A-B) preservation: 63.2% • Hearing preservation related to tumor size.

  9. Translabyrinthine Approach • Allows resection of tumors of different sizes. • Disadvantage: • Sacrifices hearing • Longer procedure Gonzalez LF et al.

  10. Retrospective review, 1244 patients, translabyrinthine approach. • All patients at least 12mo of f/u. • Gross total resection 84%, near-total 13.7%, subtotal 2.2%. • Facial n. • Excellent/good (House-Brackmann Grade I-II)functional preservation: 70.3% • Tumor size significantly correlates w/ post-op facial n. function.

  11. Retrosigmoid Approach • Most commonly used approach. • Allows resection of tumors of different sizes and wide view of cisternal component of tumor. • Disadvantage: • Cerebellar retraction (not a problem for smaller tumors, <40mm) • Less access to facial/cochlear n. in distal IAC • Headaches Gonzalez LF et al.

  12. Retrospective review; 200 consecutive patients, retrosigmoid approach. • Mean follow-up time: 24 mo. • Gross total resection: 98%, Subtotal resection: 2%. • Tumor recurrence: 0.5%. • Facial n. • Excellent/good (House-Brackmann Grade I-II)functional preservation: 62%. • Tumor size significantly correlates w/ post-op facial n. function (p<0.05). • Cochlear n. • Functional hearing (New Hannover Classification Grade I-III) preservation: 51%. • Hearing preservation related to tumor size and extension, and pre-op hearing level (p<0.05).

  13. Radiosurgery • Alone or in conjunction with surgery. • Usually reserved for small to medium sized tumors, or patients who are poor surgical candidates.

  14. Retrospective review, 190 patients treated with GKRS. • Primary treatment 70.5% and adjunctive 29.5%. • Median margin dose 13Gy, tumor volume 3.6cm3, f/u 109mo. • Overall tumor control rate 89.5%. • Estimated 3-, 5-, 10- and 15-year tumor control rates: 95%, 93%, 86%, and 70%, respectively. • Hearing preservation rate 75%. • Estimated 3-, 5-, and 10-year tumor control rates:, 96%, 92%, and 70% respectively. • Facial n. function (House-Brackmann Grade I-II) preservation 98.6%. • Tumor control was significantly affected by tumor volume.

  15. Patient MM (cont’d) • At 6mo f/u, pt has been doing well. • Stable tinnitus and hearing loss. • Exam unchanged, incision c/d/i. • No specific complaints. • F/u visit in 6mo w/ MRI and audiogram.

  16. Conclusions • Microsurgery appears to offer better tumor control rates, whereas radiosurgery seems to have higher hearing preservation. • Treatment selection should be tailored to each individual patient and tumor characteristics. • Surgeon/institution experience should also be taken into consideration. Gonzalez LF et al.

  17. Acknowledgements • Mark E. Shaffrey, MD • John A. Jane Sr., MD PhD • Justin S. Smith, MD PhD • Christopher I. Shaffrey, MD • Jason P. Sheehan, MD PhD • Robert L. Martuza, MD • William T. Curry, MD • Department of Neurosurgery

  18. References • Samii M, Gerganov V, Samii A: Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients. J Neurosurg 105: 527-535. 2006. • Gonzalez LF, Lekovic GP, Porter RW, Syms MJ, Daspit CP, Spetzler RF: Surgical approaches for resection of acoustic neuromas. Barrow Quarterly 20(4): 22-32. 2004. • Wippold FJ, Lubner M, Perrin RJ, Lammle M, Perry A: Neuropathology for the neuroradiologist: antoni a and antoni b tissue patterns. AJNR 28: 1633-1638. 2007. • Sun S, Liu A: Long-term follow-up studies of gamma knife surgery with a low margin dose for vestibular schwannoma. J Neurosurg 117: 57-62. 2006. • Springborg JB, Fugleholm K, Poulsgaard L, Caye-Thomasen P, Thomsen J: Outcome after translabyrinthine surgery for vestibular schwannomas: report on 1244 patients. J Neurol Surg B 73: 168-174. 2012. • Kutz JW, Scoresby T, Isaacson B, Mickey BE, Madden CJ, Barnett SL, Coimbra C, Hynan LS, Roland PS: Hearing preservation using the middle fossa approach for the treatment of vestibular schwannoma. Neurosurgery 70: 334-341. 2012.

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