Staged resection of large vestibular schwannomas

Clinical article

Ahmed Raslan, James K. Liu, Sean O. McMenomey, Johnny B. Delashaw

Research output: Contribution to journalArticle

20 Citations (Scopus)

Abstract

Object. Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection. Methods. A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors' institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications. Results. Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2-7 cm) in the 2-stage group and 3.9 cm (range 3.1-5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4%) of 28 patients in the 2-stage group and 15 (79%) of 19 patients in the single-stage group (p <0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7%), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82%) of 28 patients in the 2-stage group and 10 (53%) of 19 patients in the single-stage group (p <0.01). Cerebrospinal fluid leak-related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group. Conclusions. The authors' results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections.

Original languageEnglish (US)
Pages (from-to)1126-1133
Number of pages8
JournalJournal of Neurosurgery
Volume116
Issue number5
DOIs
StatePublished - May 2012

Fingerprint

Acoustic Neuroma
Facial Nerve
Brain Stem
Neoplasms
Intracranial Hypotension
Morbidity
Recurrence
Postoperative Hemorrhage
Edema
Stroke

Keywords

  • Acoustic neuroma
  • Facial nerve
  • Retrosigmoid
  • Staged resection
  • Translabyrinthine
  • Vestibular schwannoma

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Staged resection of large vestibular schwannomas : Clinical article. / Raslan, Ahmed; Liu, James K.; McMenomey, Sean O.; Delashaw, Johnny B.

In: Journal of Neurosurgery, Vol. 116, No. 5, 05.2012, p. 1126-1133.

Research output: Contribution to journalArticle

Raslan, Ahmed ; Liu, James K. ; McMenomey, Sean O. ; Delashaw, Johnny B. / Staged resection of large vestibular schwannomas : Clinical article. In: Journal of Neurosurgery. 2012 ; Vol. 116, No. 5. pp. 1126-1133.
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abstract = "Object. Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection. Methods. A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors' institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications. Results. Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2-7 cm) in the 2-stage group and 3.9 cm (range 3.1-5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4{\%}) of 28 patients in the 2-stage group and 15 (79{\%}) of 19 patients in the single-stage group (p <0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7{\%}), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82{\%}) of 28 patients in the 2-stage group and 10 (53{\%}) of 19 patients in the single-stage group (p <0.01). Cerebrospinal fluid leak-related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group. Conclusions. The authors' results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections.",
keywords = "Acoustic neuroma, Facial nerve, Retrosigmoid, Staged resection, Translabyrinthine, Vestibular schwannoma",
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N2 - Object. Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection. Methods. A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors' institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications. Results. Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2-7 cm) in the 2-stage group and 3.9 cm (range 3.1-5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4%) of 28 patients in the 2-stage group and 15 (79%) of 19 patients in the single-stage group (p <0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7%), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82%) of 28 patients in the 2-stage group and 10 (53%) of 19 patients in the single-stage group (p <0.01). Cerebrospinal fluid leak-related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group. Conclusions. The authors' results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections.

AB - Object. Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection. Methods. A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors' institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications. Results. Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2-7 cm) in the 2-stage group and 3.9 cm (range 3.1-5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4%) of 28 patients in the 2-stage group and 15 (79%) of 19 patients in the single-stage group (p <0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7%), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82%) of 28 patients in the 2-stage group and 10 (53%) of 19 patients in the single-stage group (p <0.01). Cerebrospinal fluid leak-related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group. Conclusions. The authors' results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections.

KW - Acoustic neuroma

KW - Facial nerve

KW - Retrosigmoid

KW - Staged resection

KW - Translabyrinthine

KW - Vestibular schwannoma

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