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Trakolis L, Bender B, Ebner FH, Ernemann U, Tatagiba M, Naros G. Cortical and subcortical gray matter changes in patients with chronic tinnitus sustaining after vestibular schwannoma surgery. Sci Rep 2021; 11:8411. [PMID: 33863965 PMCID: PMC8052351 DOI: 10.1038/s41598-021-87915-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/06/2021] [Indexed: 02/07/2023] Open
Abstract
Tinnitus is attributed to partial sensory deafferentation resulting in a central maladaptive neuroplasticity. Unfortunately, the agent of deafferentation is usually unknown or irreversible. In patients with unilateral vestibular schwannoma (VS), however, the auditory nerve is affected by a benign tumor. Hence, removal of the tumor can cease the tinnitus. In turn, sustaining complaints after surgery indicate cortical neuroplasticity. The present study is a cross sectional study which aims to track cortical structural changes by surface-based morphometry in 46 VS patients with sustained (i.e. centralized) or ceased (i.e. peripheral) tinnitus after surgery. A volumetric analysis of cortical and subcortical gray matter (GM) anatomy was performed on preoperative high-resolution MRI and related to the presence of hearing impairment, pre- and/or postoperative tinnitus. Patients with sustained (i.e. chronic) tinnitus showed an increased GM volume of the bilateral caudate nucleus, the contralateral superior colliculus, the middle frontal and middle temporal gyrus, the fusiform gyrus as well as the ipsilateral pars orbitalis when compared to those patients in whom tinnitus ceased postoperatively. Chronic tinnitus in VS patients is associated with characteristic structural changes in frontal, temporal and subcortical areas. Notably, a significant GM change of the caudate nucleus was detected providing further support for the striatal gaiting model of tinnitus.
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Affiliation(s)
- Leonidas Trakolis
- grid.411544.10000 0001 0196 8249Department of Neurosurgery and Neurotechnology, Eberhard Karls University Hospital, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
| | - Benjamin Bender
- grid.411544.10000 0001 0196 8249Department of Diagnostic and Interventional Neuroradiology, Eberhardt Karls University Hospital, Tuebingen, Germany
| | - Florian H. Ebner
- grid.476313.4Department of Neurosurgery, Alfried Krupp Hospital, Essen, Germany
| | - Ulrike Ernemann
- grid.411544.10000 0001 0196 8249Department of Diagnostic and Interventional Neuroradiology, Eberhardt Karls University Hospital, Tuebingen, Germany
| | - Marcos Tatagiba
- grid.411544.10000 0001 0196 8249Department of Neurosurgery and Neurotechnology, Eberhard Karls University Hospital, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
| | - Georgios Naros
- grid.411544.10000 0001 0196 8249Department of Neurosurgery and Neurotechnology, Eberhard Karls University Hospital, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
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Przepiórka Ł, Kunert P, Rutkowska W, Dziedzic T, Marchel A. Surgery After Surgery for Vestibular Schwannoma: A Case Series. Front Oncol 2020; 10:588260. [PMID: 33392082 PMCID: PMC7775645 DOI: 10.3389/fonc.2020.588260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/03/2020] [Indexed: 11/13/2022] Open
Abstract
Objective We retrospectively evaluated the oncological and functional effectiveness of revision surgery for recurrent or remnant vestibular schwannoma (rVS). Methods We included 29 consecutive patients with unilateral hearing loss (16 women; mean age: 42.2 years) that underwent surgery for rVS. Previous surgeries included gross total resections (GTRs, n=11) or subtotal resections (n=18); mean times to recurrence were 9.45 and 4.15 years, respectively. House–Brackmann (HB) grading of facial nerve (FN) weakness (grades II-IV) indicated that 22 (75.9%) patients had deep, long-lasting FN paresis (HB grades: IV-VI). The mean recurrent tumor size was 23.3 mm (range: 6 to 51). Seven patients had neurofibromatosis type 2. Results All patients received revision GTRs. Fourteen small- to medium-sized tumors located at the bottom of the internal acoustic canal required the translabyrinthine approach (TLA); 12 large and small tumors, predominantly in the cerebellopontine angle, required the retrosigmoid approach (RSA); and 2 required both TLA and RSA. One tumor that progressed to the petrous apex required the middle fossa approach. Fifteen patients underwent facial neurorrhaphy. Of these, 11 received hemihypoglossal–facial neurorrhaphies (HHFNs); nine with simultaneous revision surgery. In follow-up, 10 patients (34.48%) experienced persistent deep FN paresis (HB grades IV-VI). After HHFN, all patients improved from HB grade VI to III (n=10) or IV (n=1). No tumors recurred during follow-up (mean, 3.46 years). Conclusions Aggressive microsurgical rVS treatment combined with FN reconstruction provided durable oncological and neurological effects. Surgery was a reasonable alternative to radiosurgery, particularly in facial neurorrhaphy, where it provided a one-step treatment.
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Affiliation(s)
- Łukasz Przepiórka
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Wiktoria Rutkowska
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Harati A, Oni P, Schultheiß R, Deitmer T. Management von Patienten mit Vestibularisschwannomen Typ IV. Laryngorhinootologie 2020; 99:613-619. [DOI: 10.1055/a-1130-6321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Zusammenfassung
Hintergrund Vestibularisschwannome (VS) sind benigne Tumoren, die anhand der Hannover-Klassifikation bzw. der Koos-Klassifizierung eingeteilt werden. Trotz der umfangreichen Literatur sind die Klinik und die Behandlungskonzepte speziell bei großen VS selten beschrieben.
Material und Methoden Zwischen 2003 und 2018 wurden 61 Patienten mit VS Typ IV durch die Arbeitsgruppe Schädelbasischirurgie am Klinikum Dortmund behandelt. Die radiologischen und klinischen Daten wurden retrospektiv ausgewertet. Zudem erfolgte eine Subgruppenanalyse zwischen Patienten mit und ohne Kompression des IV. Ventrikels.
Ergebnisse Neben einer Hörminderung bei 55 Patienten (90 %) hatten die meisten Patienten multiple Symptome wie eine Trigeminusaffektion bei 16 (26 %), eine Fazialisparese bei 7 (12 %), eine Ataxie bei 27 (45 %) und Symptome eines Hirndruckanstiegs durch einen Hydrozephalus bei 4 Patienten (7 %). Bei Patienten mit einem VS Typ IVb wurde signifikant häufiger eine Ataxie, eine tonsilläre Herniation bzw. ein Hydrozephalus festgestellt. Eine komplette Resektion wurde in 48 Patienten (78 %) erreicht und eine weitestgehende Tumorentfernung in 12 Patienten (20 %). In der Langzeituntersuchung zeigten 90 % einen günstigen Outcome bezüglich des Nervus facialis (House-und-Brackman-Grad I–III). 6 Patienten (10 %) benötigten einen dauerhaften ventrikulo-peritonealen Shunt. Mehr als 90 % der Patienten erzielten einen Karnofsky-Index > 70 %.
Diskussion VS Typ IV sind häufig assoziiert mit Hydrozephalus, Ataxie, multiplen Hirnnervenausfällen und gelegentlich Zeichen eines intrakraniellen Druckanstiegs. Die primäre mikrochirurgische Resektion ist weiterhin eine entscheidende Therapieoption.
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Affiliation(s)
- Ali Harati
- Neurosurgical Department, Klinikum Dortmund, Germany
| | - Paul Oni
- Neurosurgical Department, Klinikum Dortmund, Germany
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Ochal-Choińska A, Lachowska M, Kurczak K, Niemczyk K. Interchangeability of three different methods of calculating Pure Tone Average in patients with vestibular schwannoma to assess the risk of surgery-related hearing loss. Otolaryngol Pol 2020; 74:11-16. [PMID: 34550091 DOI: 10.5604/01.3001.0014.1475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<b>Background:</b> Patients with vestibular schwannoma (VS) most commonly present with hearing threshold reduction for high frequencies and a falling type of audiometric curve. However, it is doubtful whether all Pure Tone Averages described in the literature characterize patients with VS correctly, as the type of PTA which comprises higher frequencies may be more appropriate for hearing status assessment in those patients. <br><b>Aim:</b> The aim of this study was to analyze 3 common methods of calculating Pure Tone Averages (PTA1 - 500, 1000, 2000 and 3000 Hz; PTA2 - 500, 1000, 2000 and 4000 Hz; PTA3 - 500, 1000 and 2000 Hz) and to determine which of them is the most reliable for the assessment of VS patients. <br><b>Material and Methods:</b> The study group included 86 patients operated on due to vestibular schwannoma accessed via the middle cranial fossa. <br><b>Results:</b> Regarding the method of calculating Pure Tone Averages (PTA1, PTA2 and PTA3) identical or similar correlations were found between the preoperative values of Pure Tone Averages (PTA1, PTA2 and PTA3) and surgery-related hearing loss, as well as individual parameters of audiologic tests. <br><b>Conclusions:</b> Pure Tone Averages calculated according to 3 different methods (PTA1, PTA2, PTA3) may be used interchangeably in the assessment of hearing in VS patients.
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Affiliation(s)
- Aleksandra Ochal-Choińska
- Chair and Clinic of Otorhinolaryngology, Head and Neck Surgery, Medical University of Warsaw, Poland
| | - Magdalena Lachowska
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Warsaw, Poland
| | - Katarzyna Kurczak
- Department of Foreign Languages at the Medical University of Warsaw, Poland
| | - Kazimierz Niemczyk
- Chair and Clinic of Otorhinolaryngology, Head and Neck Surgery, Medical University of Warsaw, Poland
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Harati A, Scheufler KM, Schultheiss R, Tonkal A, Harati K, Oni P, Deitmer T. Clinical features, microsurgical treatment, and outcome of vestibular schwannoma with brainstem compression. Surg Neurol Int 2017; 8:45. [PMID: 28480107 PMCID: PMC5402336 DOI: 10.4103/sni.sni_129_16] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 01/25/2017] [Indexed: 11/06/2022] Open
Abstract
Background: Presenting symptoms, treatment considerations, and outcome are strongly related to the extension of vestibular schwannomas (VS). The aim of the current retrospective study was to analyze the clinical features, microsurgical treatment, and outcome of VS with brainstem compression. Methods: Forty-nine patients presented with VS (Hannover grading scale T4a or T4b) in our department. A subgroup analysis was performed among patients without (T4a) and with (T4b) compression and dislocation of the fourth ventricle. Results: Patients with type T4b VS presented significantly more often with long tract signs/ataxia (P < 0.05), tonsillar herniation (P < 0.001), and preoperative hydrocephalus (P < 0.01). No significant difference was found between the groups regarding hearing loss and facial nerve, trigeminal nerve, and lower cranial nerve function. Gross total resection was achieved in 83% of the cases, near total resection was achieved in 15% of the cases, and subtotal resection was performed in 2% of the cases. One patient died after massive postoperative bleeding caused by a coagulopathy. At last follow-up, 69% of the patients had excellent facial nerve function (Grade I–II) and the remaining 31% a fair outcome. Six patients (12%) required permanent ventriculoperitoneal shunting. Hearing was preserved in two patients. Forty-six patients (94%) were independent without occasional assistance (Karnofsky scale 70–100%). Conclusions: VS with brainstem compression is frequently associated with hydrocephalus, ataxia, long tract signs, multiple cranial nerve disorders, and occasionally, signs of intracranial hypertension. Primary microsurgical resection is an appropriate management option for large VS.
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Affiliation(s)
- Ali Harati
- Neurosurgical Department, Klinikum Dortmund, Germany
| | | | | | - Albaraa Tonkal
- Department for Head and Neck Surgery, Klinikum Dortmund, Germany
| | - Kamran Harati
- Department of Plastic Surgery, Bergmannsheil Bochum, Ruhr-University, Bochum, Germany
| | - Paul Oni
- Neurosurgical Department, Klinikum Dortmund, Germany
| | - Thomas Deitmer
- Department for Head and Neck Surgery, Klinikum Dortmund, Germany
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Microsurgical resection of vestibular schwannomas: complication avoidance. J Neurooncol 2016; 130:367-375. [DOI: 10.1007/s11060-016-2260-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/27/2016] [Indexed: 10/21/2022]
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Blakeley JO, Evans DG, Adler J, Brackmann D, Chen R, Ferner RE, Hanemann CO, Harris G, Huson SM, Jacob A, Kalamarides M, Karajannis MA, Korf BR, Mautner VF, McClatchey AI, Miao H, Plotkin SR, Slattery W, Stemmer-Rachamimov AO, Welling DB, Wen PY, Widemann B, Hunter-Schaedle K, Giovannini M. Consensus recommendations for current treatments and accelerating clinical trials for patients with neurofibromatosis type 2. Am J Med Genet A 2011; 158A:24-41. [PMID: 22140088 DOI: 10.1002/ajmg.a.34359] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 09/23/2011] [Indexed: 12/24/2022]
Abstract
Neurofibromatosis type 2 (NF2) is a tumor suppressor syndrome characterized by bilateral vestibular schwannomas (VS) which often result in deafness despite aggressive management. Meningiomas, ependymomas, and other cranial nerve and peripheral schwannomas are also commonly found in NF2 and collectively lead to major neurologic morbidity and mortality. Traditionally, the overall survival rate in patients with NF2 is estimated to be 38% at 20 years from diagnosis. Hence, there is a desperate need for new, effective therapies. Recent progress in understanding the molecular basis of NF2 related tumors has aided in the identification of potential therapeutic targets and emerging clinical therapies. In June 2010, representatives of the international NF2 research and clinical community convened under the leadership of Drs. D. Gareth Evans (University of Manchester) and Marco Giovannini (House Research Institute) to review the state of NF2 treatment and clinical trials. This manuscript summarizes the expert opinions about current treatments for NF2 associated tumors and recommendations for advancing therapies emerging from that meeting. The development of effective therapies for NF2 associated tumors has the potential for significant clinical advancement not only for patients with NF2 but for thousands of neuro-oncology patients afflicted with these tumors.
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de Ribaupierre S, Vernet O, Vinchon M, Rilliet B. [Phacomatosis and genetically determined tumors: the transition from childhood to adulthood]. Neurochirurgie 2008; 54:642-53. [PMID: 18752812 DOI: 10.1016/j.neuchi.2008.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Phacomatoses, or neurocutaneous disorders, are a group of congenital and hereditary diseases characterized by developmental lesions of the neuroectoderm, leading to pathologies affecting the skin and the central nervous system. There is a wide range of pathologies affecting individuals at different moments of life. The genetics is variable: while neurofibromatosis 1 and 2, tuberous sclerosis and von Hippel-Lindau disease are all inherited as autosomal dominant traits, Sturge-Weber syndrome is sporadic. Other neurocutaneous disorders can be inherited as autosomal recessive traits (i.e., ataxia-telangiectasia), X-linked (i.e., incontinentia pigmenti) or explained by mosaicism (i.e., hypomelanosis of Ito, McCune-Albright syndrome). In this review, we discuss the major types of neurocutaneous disorders most frequently encountered by the neurosurgeon and followed beyond childhood. They include neurofibromatosis types 1 and 2, tuberous sclerosis, Sturge-Weber syndrome and von Hippel-Lindau disease. In each case, a review of the literature, including diagnosis, genetics and treatment will be presented. The lifespan of the disease with the implications for neurosurgeons will be emphasized. A review of cases, including both pediatric and adult patients, seen in neurosurgical practices in the Lille, France and Lausanne, Switzerland hospitals between 1961 and 2007 is presented to illustrate the pathologies seen in different age-groups. Because the genes mutated in most phacomatoses are involved in development and are activated following a timed schedule, the phenotype of these diseases evolves with age. The implication of the neurosurgeon varies depending on the patient's age and pathology. While neurosurgeons tend to see pediatric patients affected with neurofibromatosis type 1, tuberous sclerosis and Sturge-Weber syndrome, there will be a majority of adult patients with von Hippel-Lindau disease or neurofibromatosis type 2.
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Affiliation(s)
- S de Ribaupierre
- Département de neurochirurgie, CHUV, rue du Bugnon-46, 1011 Lausanne, Suisse.
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Inoue HK. Low-dose radiosurgery for large vestibular schwannomas: long-term results of functional preservation. J Neurosurg 2005. [DOI: 10.3171/jns.2005.102.s_supplement.0111] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object.The author conducted a study to assess the long-term results obtained in patients who underwent GKS for large vestibular schwannomas (> cochlear nerve functions were evaluated.Methods.Twenty consecutive large tumors in 18 patients (including two cases of neurofibromatosus Type 2 [NF2]) were followed for more than 6 years. There were eight tumors that were more than 4 cm in maximum diameter. Microsurgery had already been performed prior to GKS in 11 patients (nine recurrent and two residual tumors).Four patients (including one with NF2) died during the follow-up period of other diseases or by accident. Fourteen of 15 tumors were stable or decreased in size. Microsurgery was performed in one patient 2 years after radiosurgery. Facial nerve function was preserved in all patients and hearing preserved in four of five patients with cochlear nerve function prior to radiosurgery. No adverse effects of radiosurgery have been observed to date.Conclusions.Gamma knife surgery seems to have a place in the low-dose treatment of selected large vestibular schwannoma in patients with a reasonable chance of retaining facial function and pretreatment hearing level. Patients with severe brainstem compression should first be undergo microsurgery.
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Inoue HK. Low-dose radiosurgery for large vestibular schwannomas: long-term results of functional preservation. J Neurosurg 2005. [DOI: 10.3171/sup.2005.102.s_supplement.0111] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The author conducted a study to assess the long-term results obtained in patients who underwent GKS for large vestibular schwannomas (> cochlear nerve functions were evaluated.
Methods. Twenty consecutive large tumors in 18 patients (including two cases of neurofibromatosus Type 2 [NF2]) were followed for more than 6 years. There were eight tumors that were more than 4 cm in maximum diameter. Microsurgery had already been performed prior to GKS in 11 patients (nine recurrent and two residual tumors).
Four patients (including one with NF2) died during the follow-up period of other diseases or by accident. Fourteen of 15 tumors were stable or decreased in size. Microsurgery was performed in one patient 2 years after radiosurgery. Facial nerve function was preserved in all patients and hearing preserved in four of five patients with cochlear nerve function prior to radiosurgery. No adverse effects of radiosurgery have been observed to date.
Conclusions. Gamma knife surgery seems to have a place in the low-dose treatment of selected large vestibular schwannoma in patients with a reasonable chance of retaining facial function and pretreatment hearing level. Patients with severe brainstem compression should first be undergo microsurgery.
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Litvack ZN, Norén G, Chougule PB, Zheng Z. Preservation of functional hearing after gamma knife surgery for vestibular schwannoma. Neurosurg Focus 2003; 14:e3. [PMID: 15669814 DOI: 10.3171/foc.2003.14.5.4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThe goal of this retrospective study was to define the rates of preservation of functional hearing and growth control of vestibular schwannomas (VS) treated by gamma knife surgery (GKS) involving a consistent 12-Gy prescription dose.MethodsOne hundred thirty-four patients with unilateral VS underwent GKS between 1994 and 2000. The mean magnetic resonance (MR) imaging follow-up period was 31.7 months (maximum 72 months), and the mean audiometry follow-up interval was 26.3 months (maximum 60 months). The mean marginal dose was 12 ± 0.6 Gy. The mean maximum dose delivered to the tumor center was 25.4 Gy (range 17.4–34.3 Gy). The tumor control rate, defined as no change or a reduction in size at last follow up, was 96.7%. Of the patients studied, 97.7% remained free from the need to undergo tumor resection. Overall functional hearing preservation was 61.7%; the preservation rate for intra-canalicular tumors was 63.6%, for those with an intracranial diameter less than 1.5 cm it was 54.5%, for those between 1.5 and 3 cm it was 68.2%, and for those larger than 3 cm it was 33.3%. Early in the series, three patients (2.2%) developed temporary facial weakness (House–Brackmann Grade II–III) in the posttreatment period, but this resolved within a few weeks. No case of facial weakness occurred after 1996.ConclusionsThe authors demonstrated the efficacy, safety, and in many ways, the advantage of GKS over microsurgery for VS. Patients harboring tumors 3 cm or smaller in intracranial diameter, regardless of their age and medical condition, should be given the option of undergoing GKS as primary treatment.
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Affiliation(s)
- Zachary N Litvack
- New England Gamma Knife Center and Department of Clinical Neurosciences (Neurosurgery), Brown Medical School /Rhode Island Hospital, Providence, Rhode Island 02903, USA
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Matthies C, Samii M. Direct brainstem recording of auditory evoked potentials during vestibular schwannoma resection: nuclear BAEP recording. Technical note and preliminary results. J Neurosurg 1997; 86:1057-62. [PMID: 9171191 DOI: 10.3171/jns.1997.86.6.1057] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The usefulness of intraoperative monitoring in cerebellopontine angle surgery should be improved by obtaining faster and stronger brainstem auditory evoked potential (BAEP) responses. A new technique of direct recording at the brainstem has been developed, which is applicable to all tumor sizes. By placing a retractor with electrodes attached to its tip at the cerebellomedullary junction, the authors have recorded BAEP amplitudes that are 10 times greater than those recorded using the conventional technique. Only small sampling numbers (64-256 recordings) are required and are obtained in 5 to 15 seconds. The technique has been applied successfully in 34 patients who underwent vestibular schwannoma resections. It has also been tested in patients with intrameatal-extrameatal meningiomas and in those with vascular compressive disorders; there have been no false results. The advantages of this new technique are: 1) identification of BAEP components is easier and faster; 2) reliable BAEP responses are obtained in some cases in which conventional BAEP responses are lost or severely deformed; and 3) BAEP response deterioration and improvement are recognized earlier than would occur using the conventional technique. This last advantage provides the surgeon with a useful warning at a stage of surgery at which BAEP changes are still temporary and can be reversed. This method is different from other trials of intradural BAEP recordings in three respects: its use is not limited to particular tumor sizes; there is no interference with the surgical process; and, most important, the obtained responses correlate well with those of conventional BAEP responses, probably because the recording site is in the vicinity of the anterior cochlear nucleus. In conclusion, the chances of useful monitoring feedback with adequate adaptation of the microsurgical strategy are improved considerably.
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Affiliation(s)
- C Matthies
- Department of Neurosurgery, Nordstadt Hospital, Hannover, Germany
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Samii M, Matthies C. Management of 1000 vestibular schwannomas (acoustic neuromas): the facial nerve--preservation and restitution of function. Neurosurgery 1997; 40:684-94; discussion 694-5. [PMID: 9092841 DOI: 10.1097/00006123-199704000-00006] [Citation(s) in RCA: 291] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Although the rate of reported facial nerve preservation after surgery for vestibular schwannomas continuously increases, facial nerve paresis or paralysis is a frequent postsurgical sequelae of major concern. The major goal of this study was to define criteria for the right indication, timing, and type of therapy for patients with palsies despite anatomic nerve continuity and those with loss of anatomic continuity. METHODS One thousand vestibular schwannomas were surgically treated at the Department of Neurosurgery at Nordstadt Hospital from 1978 to 1993. Of 979 cases of complete removal and 21 cases of deliberately partial removal, the facial nerve was anatomically preserved in 929 cases (93%). The rate of preservation is increasing, as is evidenced in the most recent cases, and preservation is supported by special electrophysiological monitoring. The facial nerve was anatomically severed in 60 cases (6%). It was anatomically lost in previous operations that were performed elsewhere in 11 cases (1%). In case of nerve discontinuity (42 cases), immediate nerve reconstruction by one of three available intracranial procedures (within the cerebellopontine angle, intracranial-intratemporal, intracranial-extracranial) was performed in the same surgical setting. In case of loss of the proximal facial nerve stump at the brain stem, early reanimation by combination with the hypoglossal nerve was achieved in most patients within weeks after tumor surgery. In a few patients with anatomic nerve continuity but absence of reinnervation for 10 to 12 months, a hypoglossal-facial combination was applied. All the patients with partial or with complete palsies were treated in a special follow-up program of regular controls and of modulation of physiotherapeutic treatment every 3 to 6 months. RESULTS In intracranial nerve reconstruction at the cerebellopontine angle, 61 to 70% of patients regained complete eye closure and an overall result equivalent to House-Brackmann Grade 3. Hypoglossal-facial reanimation led to Grade 3 in 79%. The duration between the onset of paralysis and the reconstructive procedure is decisive for the quality of the outcome. These data are discussed in view of other treatment options and certain parameters influencing outcome. CONCLUSIONS This management contains three major principles as follows: 1) preservation of facial nerve continuity in function by the aid of intraoperative monitoring, 2) early nerve reconstruction in case of lost continuity, and 3) scheduled follow-up program for all patients with incomplete or complete palsies.
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Affiliation(s)
- M Samii
- Department of Neurosurgery, Nordstadt Hospital, Hannover, Germany
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Samii M, Matthies C, Tatagiba M. Management of vestibular schwannomas (acoustic neuromas): auditory and facial nerve function after resection of 120 vestibular schwannomas in patients with neurofibromatosis 2. Neurosurgery 1997; 40:696-705; discussion 705-6. [PMID: 9092842 DOI: 10.1097/00006123-199704000-00007] [Citation(s) in RCA: 161] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Vestibular schwannomas (VSs) affect young patients with Neurofibromatosis 2 (NF-2) and cause very serious problems for hearing, facial expression, and brain stem function. Our objective was to determine a therapy concept for the right timing and indication of neurosurgical therapy. METHODS In 1000 consecutive VS resections, 120 tumors in 82 patients with NF-2 were surgically treated by the same surgeon (MS) at the Department of Neurosurgery at Nordstadt Hospital from 1978 to 1993. The mean age of the patients was 27.5 years. Sixty tumors were surgically treated in 41 male patients, and 60 tumors were surgically treated in 41 female patients. Bilateral tumor resection was performed in 38 patients (76 operations, after previous partial surgery in 15 cases elsewhere), and unilateral operations were performed in 44 patients, 5 of whom had undergone ipsi- or contralateral surgery that was performed elsewhere. The operative and clinical findings are evaluated and compared with the data of patients without NF-2. RESULTS In 105 cases, complete tumor resections were achieved. In 15 cases, deliberate subtotal resections were performed. These were for brain stem decompression in 4 cases and for hearing preservation in the last hearing ear in 11 cases, with successful preservation in 8 of the 11. Pre- and postoperative hearing rates were higher in male than in female patients (70% in male versus 65% in female patients before surgery and 40.5 versus 31%, respectively, after surgery). Hearing was preserved in 29 of 81 ears (36%). The rate of preservation was 24% in cases of large tumors and 57% in cases of small tumors (<30 mm). Twenty-one of 82 patients (26%) were bilaterally deaf before surgery. Twenty-five patients had uni- or bilateral hearing after surgery (i.e., 41 % of those with preoperative hearing or 30.5% of the whole group). Anatomic facial nerve preservation was achieved in 85%. The facial nerve was reconstructed intracranially at the cerebellopontine angle by sural grafting in 17 cases and by hypoglossal-facial reanimation in 5. Two deaths occurred 1 and 3 months postsurgically as a result of malignant tumor growth with brain stem dysfunction and respiratory problems. In summary, for patients with NF-2, the presentation ages are lower, tumor progression is faster, the chances of anatomic and functional nerve preservation are lower, the chances of good outcomes are best when surgery is performed early and when there is good preoperative hearing function, and the danger of sudden hearing loss is higher. The chances and danger often differ from side to side among individual patients. CONCLUSION The indication and the timing of tumor resections are in some respects different from normal VS handling and are dependent on the tumor extension and related necessity of brain stem decompression and on the auditory function. As an optimal goal, completeness of resection with functional cochlear nerve preservation is formulated, and as an acceptable compromise, subtotal microsurgical resection with functional cochlear nerve preservation in the last hearing ear is suggested.
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Affiliation(s)
- M Samii
- Department of Neurosurgery, Nordstadt Hospital, Hannover, Germany
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Valentino V, Raimondi AJ. Tumour response and morphological changes of acoustic neurinomas after radiosurgery. Acta Neurochir (Wien) 1995; 133:157-63. [PMID: 8748759 DOI: 10.1007/bf01420067] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Twenty-seven of the 1560 patients treated by radiosurgery during the period 1984-1993 had acoustic neurinomas. Four cases were excluded from this study because they had a follow-up of less than 2 years. There were 24 neurinomas treated in 23 patients as one patient had a bilateral tumour. Seven patients underwent radiosurgery for a recurrent tumour (already operated on once or twice), while it was the first treatment for 16 patients. The tumour volume ranged from 1.99 cm3 to 18.30 cm3, and the patient follow-up was from 2 to 8 years. To determine the target on CT/NMR for linear accelerator stereotactic irradiation, the Greitz-Bergström non-invasive head fixation device was used. It was again adopted for subsequent serial imaging, and for repeat radiosurgery when necessary. The total peripheral tumour dose ranged from 12 to 45 Gy. In 9 patients there was a reduction in tumour volume varying from 39 to 100%, while 14 of the neurinomas appeared stable after an average follow-up of 3 years. In one patient there was an increase in size of the tumour. Variable morphological changes were present in 66% of the neurinomas treated. Radiosurgery is indicated as an alternative to microsurgery for inoperable patients and for those who refuse surgery, for recurrent tumours, and as a post-operative complementary treatment for partially removed tumours. A gradual approach to radiosurgery, depending on tumour response, allows a greater efficacy with minimal risk. In the present series no complications were observed. Hearing was preserved at almost the same level as that prior to radiosurgery in all patients.
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Affiliation(s)
- V Valentino
- Centro di Radiochirurgia, Clinica Flaminia, Rome, Italy
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