Brain Tumor Res Treat.  2022 Apr;10(2):108-112. 10.14791/btrt.2021.0028.

Surgical Outcomes After Total or Subtotal Resection of Large Vestibular Schwannoma: A Single-Institution Experience

• Rujimethapass S
• Ananthanandorn A
• Karnchanapandh K
• Wongsirisuwan M
• Gunnarat I
• Segkhaphant N

• KMID: 2529442
• DOI: http://doi.org/10.14791/btrt.2021.0028

Abstract

Background
Patients with large vestibular schwannomas have various surgical outcomes. The aim of this study is to evaluate facial nerve outcome and surgical complications in patients who underwent total and subtotal resection.
Methods
Between October 2008 and September 2020, 72 patients underwent surgery in Rajavithi Hospital. Of these, 48 had total or subtotal resection. We classified these participants into two groups: VS ≥3 cm (Group A, n=30); and VS <3 cm (Group B, n=18). Both groups were compared in terms of clinical presentation, imaging data, facial nerve outcomes, and surgical complications. The retrosigmoid approach was used in each case, and all patients had follow-up for at least 1 year. Chisquare and Fisher’s exact test were used for statistical analysis.
Results
The mean tumor size in Group A was 3.8 cm compared with 1.5 cm in Group B. In Group A, clinical signs of hearing dysfunction, gait ataxia, and facial paresthesia were present in 96.7%, 66.7%, 50% of patients respectively, compared with 100%, 5.6%, and 11.1% respectively in Group B. Radiographic signs of hydrocephalus were observed in 56.7% of Group A subjects, and 5.6% of those in Group B. At 1 year follow-up, 40% of patients with large VS and 94.4% of patients with small to medium size VS had good facial nerve outcomes (House-Brackmann [HB] facial grading scale grade I-III). Significant differences between the two groups were found only in gait ataxia (p<0.001), facial paresthesia (p=0.006), radiographic signs of hydrocephalus (p=0.002), facial nerve outcome 1 month (p<0.001) and facial nerve outcome 1 year (p<0.001).
Conclusion
In patients with large size VS, microsurgical resection had poor facial nerve outcomes compared with those of their counterparts with small to medium size VS. Planned subtotal resection with postoperative radiosurgery might attain superior facial nerve outcomes and result in better quality of life in subjects with large VS.

Keyword

Schwannoma; Facial nerve; Outcome

Figure

• 

  Fig. 1 Contrast-enhanced T1-weighted MR images showing surgically treated vestibular schwannomas patient in Group A (size ≥3 cm) and Group B (size <3 cm). A: Images obtained from a patient with size ≥3 cm who underwent total resection. B: Images obtained from a patient with size ≥3 cm who had subtotal resection. C: Images obtained from a patient with size <3 cm who underwent near total resection.

Reference

1. Delong M, Kirkpatrick J, Cummings T, Adamson DC. Vestibular schwannomas: lessons for the neurosurgeon: part II: molecular biology and histology. Contemp Neurosurg. 2011; 33:1–3.

2. Gal TJ, Shinn J, Huang B. Current epidemiology and management trends in acoustic neuroma. Otolaryngol Head Neck Surg. 2010; 142:677–681. PMID: 20416455.

3. Propp JM, McCarthy BJ, Davis FG, Preston-Martin S. Descriptive epidemiology of vestibular schwannomas. Neuro Oncol. 2006; 8:1–11. PMID: 16443943.

4. Stangerup SE, Tos M, Thomsen J, Caye-Thomasen P. True incidence of vestibular schwannoma? Neurosurgery. 2010; 67:1335–1340. PMID: 20871439.

5. Tos M, Stangerup SE, Cayé-Thomasen P, Tos T, Thomsen J. What is the real incidence of vestibular schwannoma? Arch Otolaryngol Head Neck Surg. 2004; 130:216–220. PMID: 14967754.

6. Chen Z, Prasad SC, Di Lella F, Medina M, Piccirillo E, Taibah A, et al. The behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas. J Neurosurg. 2014; 120:1278–1287. PMID: 24724851.

7. Nair S, Baldawa SS, Gopalakrishnan CV, Menon G, Vikas V, Sudhir JB. Surgical outcome in cystic vestibular schwannomas. Asian J Neurosurg. 2016; 11:219–225. PMID: 27366248.

8. Anderson DE, Leonetti J, Wind JJ, Cribari D, Fahey K. Resection of large vestibular schwannomas: facial nerve preservation in the context of surgical approach and patient-assessed outcome. J Neurosurg. 2005; 102:643–649. PMID: 15871506.

9. Pollock BE, Driscoll CL, Foote RL, Link MJ, Gorman DA, Bauch CD, et al. Patient outcomes after vestibular schwannoma management: a prospective comparison of microsurgical resection and stereotactic radiosurgery. Neurosurgery. 2006; 59:77–85. PMID: 16823303.

10. Jain VK, Mehrotra N, Sahu RN, Behari S, Banerji D, Chhabra DK. Surgery of vestibular schwannomas: an institutional experience. Neurol India. 2005; 53:41–45. discussion 45. PMID: 15805654.

11. Samii M, Matthies C. Management of 1000 vestibular schwannomas (acoustic neuromas): the facial nerve--preservation and restitution of function. Neurosurgery. 1997; 40:684–694. discussion 694-5. PMID: 9092841.

12. Yamakami I, Uchino Y, Kobayashi E, Yamaura A, Oka N. Removal of large acoustic neurinomas (vestibular schwannomas) by the retrosigmoid approach with no mortality and minimal morbidity. J Neurol Neurosurg Psychiatry. 2004; 75:453–458. PMID: 14966164.

13. Samii M, Gerganov VM, Samii A. Functional outcome after complete surgical removal of giant vestibular schwannomas. J Neurosurg. 2010; 112:860–867. PMID: 19663543.

14. Wiet RJ, Mamikoglu B, Odom L, Hoistad DL. Long-term results of the first 500 cases of acoustic neuroma surgery. Otolaryngol Head Neck Surg. 2001; 124:645–651. PMID: 11391255.

15. Lanman TH, Brackmann DE, Hitselberger WE, Subin B. Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach. J Neurosurg. 1999; 90:617–623. PMID: 10193604.

16. Sluyter S, Graamans K, Tulleken CA, Van Veelen CW. Analysis of the results obtained in 120 patients with large acoustic neuromas surgically treated via the translabyrinthine-transtentorial approach. J Neurosurg. 2001; 94:61–66.

17. Mamikoglu B, Wiet RJ, Esquivel CR. Translabyrinthine approach for the management of large and giant vestibular schwannomas. Otol Neurotol. 2002; 23:224–227. PMID: 11875354.

18. Lee J, Fung K, Lownie SP, Parnes LS. Assessing impairment and disability of facial paralysis in patients with vestibular schwannoma. Arch Otolaryngol Head Neck Surg. 2007; 133:56–60. PMID: 17224525.

19. Magliulo G, Zardo F, Damico R, Varacalli S, Forino M. Acoustic neuroma: postoperative quality of life. J Otolaryngol. 2000; 29:344–347. PMID: 11770141.

20. Nakatomi H, Jacob JT, Carlson ML, Tanaka S, Tanaka M, Saito N, et al. Long-term risk of recurrence and regrowth after gross-total and subtotal resection of sporadic vestibular schwannoma. J Neurosurg. 2017; 19:1–7.

21. Chung WY, Pan DH, Lee CC, Wu HM, Liu KD, Yen YS, et al. Large vestibular schwannomas treated by Gamma Knife surgery: long-term outcomes. J Neurosurg. 2010; 113 Suppl:112–121. PMID: 21121793.

22. Yang HC, Kano H, Awan NR, Lunsford LD, Niranjan A, Flickinger JC, et al. Gamma Knife radiosurgery for larger-volume vestibular schwannomas. J Neurosurg. 2011; 114:801–807. PMID: 20799863.

23. van de Langenberg R, Hanssens PE, Verheul JB, van Overbeeke JJ, Nelemans PJ, Dohmen AJ, et al. Management of large vestibular schwannoma. Part II. Primary Gamma Knife surgery: radiological and clinical aspects. J Neurosurg. 2011; 115:885–893. PMID: 21838503.

24. van de Langenberg R, Hanssens PE, van Overbeeke JJ, Verheul JB, Nelemans PJ, de Bondt BJ, et al. Management of large vestibular schwannoma. Part I. Planned subtotal resection followed by Gamma Knife surgery: radiological and clinical aspects. J Neurosurg. 2011; 115:875–884. PMID: 21838510.

25. Pan HC, Sheehan J, Sheu ML, Chiu WT, Yang DY. Intracapsular decompression or radical resection followed by Gamma Knife surgery for patients harboring a large vestibular schwannoma. J Neurosurg. 2012; 117 Suppl:69–77. PMID: 23205792.