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Annayappa SKS, Prabhuraj AR, Arivazhagan A, Bhat DI, Shukla D, Srinivas D, Rao KVLN, Vikas V, Devi IB. Facial Nerve Preserving Subtotal Excision for Large Vestibular Schwannoma: An Institution-Based Functional Outcome Study. Neurol India 2024; 72:811-816. [PMID: 39216039 DOI: 10.4103/neurol-india.ni_951_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/04/2021] [Indexed: 09/04/2024]
Abstract
BACKGROUND The ideal goal of treatment for medium to large vestibular schwannoma is complete tumor removal with preservation of all cranial nerves. However, despite the advancements in microsurgery and intraoperative monitoring, the risk of facial nerve dysfunction following total resection varies between 31% and 57%. Currently, the goal of treatment for large tumors is shifting from total excision to facial nerve preservation. OBJECTIVE To evaluate the facial nerve outcome in patients who underwent subtotal excision with or without subsequent gamma knife radiosurgery for large vestibular schwannomas in our institute. METHODS AND MATERIAL All patients who underwent primary surgery for large vestibular schwannomas between January 2012 and December 2016 were analyzed retrospectively. Cases where total excision was not done and a residue was left behind to prevent facial nerve injury during surgery were included in the study. RESULTS A total of 52 patients who met the inclusion criteria were analyzed. At final follow-up, 70% of patients had good facial nerve function (H-B grade 1 and 2). In patients with normal facial nerve function preoperatively, 81% (25/31) of them had good facial nerve outcomes (H-B grade 1 and 2), whereas in patients with preexisting facial nerve deficits, nearly 62% (13/21) of them either maintained or had improvement in their facial nerve grades. CONCLUSION Good facial nerve outcomes and tumor control rate is obtained by subtotal excision of VS followed by upfront or delayed GKRS; however, there is a need for long-term follow-up to detect recurrences in these slow-growing tumors.
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Affiliation(s)
- Santhosh K S Annayappa
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Heman-Ackah SM, Blue R, Quimby AE, Abdallah H, Sweeney EM, Chauhan D, Hwa T, Brant J, Ruckenstein MJ, Bigelow DC, Jackson C, Zenonos G, Gardner P, Briggs SE, Cohen Y, Lee JYK. A multi-institutional machine learning algorithm for prognosticating facial nerve injury following microsurgical resection of vestibular schwannoma. Sci Rep 2024; 14:12963. [PMID: 38839778 PMCID: PMC11153496 DOI: 10.1038/s41598-024-63161-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/26/2024] [Indexed: 06/07/2024] Open
Abstract
Vestibular schwannomas (VS) are the most common tumor of the skull base with available treatment options that carry a risk of iatrogenic injury to the facial nerve, which can significantly impact patients' quality of life. As facial nerve outcomes remain challenging to prognosticate, we endeavored to utilize machine learning to decipher predictive factors relevant to facial nerve outcomes following microsurgical resection of VS. A database of patient-, tumor- and surgery-specific features was constructed via retrospective chart review of 242 consecutive patients who underwent microsurgical resection of VS over a 7-year study period. This database was then used to train non-linear supervised machine learning classifiers to predict facial nerve preservation, defined as House-Brackmann (HB) I vs. facial nerve injury, defined as HB II-VI, as determined at 6-month outpatient follow-up. A random forest algorithm demonstrated 90.5% accuracy, 90% sensitivity and 90% specificity in facial nerve injury prognostication. A random variable (rv) was generated by randomly sampling a Gaussian distribution and used as a benchmark to compare the predictiveness of other features. This analysis revealed age, body mass index (BMI), case length and the tumor dimension representing tumor growth towards the brainstem as prognosticators of facial nerve injury. When validated via prospective assessment of facial nerve injury risk, this model demonstrated 84% accuracy. Here, we describe the development of a machine learning algorithm to predict the likelihood of facial nerve injury following microsurgical resection of VS. In addition to serving as a clinically applicable tool, this highlights the potential of machine learning to reveal non-linear relationships between variables which may have clinical value in prognostication of outcomes for high-risk surgical procedures.
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Affiliation(s)
- Sabrina M Heman-Ackah
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 15th Floor, Philadelphia, PA, 19104, USA.
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rachel Blue
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 15th Floor, Philadelphia, PA, 19104, USA
| | - Alexandra E Quimby
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Otolaryngology and Communication Sciences, SUNY Upstate Medical University Hospital, Syracuse, NY, USA
| | - Hussein Abdallah
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth M Sweeney
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Daksh Chauhan
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Tiffany Hwa
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Brant
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
| | - Michael J Ruckenstein
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas C Bigelow
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Jackson
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 15th Floor, Philadelphia, PA, 19104, USA
| | - Georgios Zenonos
- Center for Cranial Base Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Paul Gardner
- Center for Cranial Base Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Selena E Briggs
- Department of Otolaryngology, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Otolaryngology, Georgetown University, Washington, DC, USA
| | - Yale Cohen
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 15th Floor, Philadelphia, PA, 19104, USA
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
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Alomari AA, Eid SS, Fraschetti F, Michelini S, Mastronardi L. Comparative Analysis on Vestibular Schwannoma Surgery with and without Intraoperative Fluorescein Sodium Enhancement. Brain Sci 2024; 14:571. [PMID: 38928571 PMCID: PMC11202183 DOI: 10.3390/brainsci14060571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/01/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Vestibular schwannoma (VS), also known as acoustic neuroma, is a benign, well-encapsulated, and slow-growing tumor that originates from Schwann cells, which form the myelin sheath around the vestibulocochlear nerve (VIII cranial nerve). The surgical treatment of this condition presents a challenging task for surgeons, as the tumor's location and size make it difficult to remove without causing damage to the surrounding structures. In recent years, fluorescein sodium (FS) has been proposed as a tool to enhance surgical outcomes in VS surgery. This essay will provide an analytical comparison of the use of FS in VS surgery, evaluating its benefits and limitations and comparing surgical outcomes with and without FS-assisted surgery. METHODS In a retrospective study conducted at San Filippo Neri Hospital, we examined VS cases that were operated on between January 2017 and December 2023. The patients were divided into two groups: group A, which consisted of patients who underwent surgery without the use of FS until January 2020 (102 cases), and group B, which included patients who underwent surgery with FS after January 2020 (55 cases). All operations were performed using the retrosigmoid approach, and tumor size was classified according to the Koos, et al. classification system. The extent of surgical removal was evaluated using both the intraoperative surgeon's opinion and postoperative MRI imaging. Preoperatively and postoperatively, facial nerve function and hearing were assessed. In group B, FS was used to assist the surgical procedures, which were performed using a surgical microscope equipped with an integrated fluorescein filter. Postoperative clinical and MRI controls were performed at six months and annually, with no patients lost to follow-up. RESULTS This study investigated the impact of intraoperative fluorescein exposure on tumor resection and clinical outcomes in patients with VS. The study found a statistically significant difference in the tumor resection rates between patients who received fluorescein intraoperatively (p = 0.037). Further analyses using the Koos classification system revealed a significant effect of fluorescein exposure, particularly in the Koos 3 subgroup (p = 0.001). Notably, no significant differences were observed in hearing loss or facial nerve function between the two groups. A Spearman correlation analysis revealed a positive correlation between tumor size and Koos, age, and size, but no significant correlation was found between facial nerve function tests. CONCLUSIONS FS-assisted surgery for VS may potentially enhance tumor resection, allowing for more comprehensive tumor removal.
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Affiliation(s)
- Amer A. Alomari
- Department of Neurosurgery, San Filippo Neri Hospital/ASLRoma1, 00135 Rome, Italy; (A.A.A.); (F.F.)
- Division of Neurosurgery, Department of Special Surgery, Faculty of Medicine, Mutah University, Al-Karak 61710, Jordan
| | - Sadeen Sameer Eid
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan;
| | - Flavia Fraschetti
- Department of Neurosurgery, San Filippo Neri Hospital/ASLRoma1, 00135 Rome, Italy; (A.A.A.); (F.F.)
| | - Silvia Michelini
- Department of Neurosurgery, University of Tor Vergata, 00133 Rome, Italy;
| | - Luciano Mastronardi
- Department of Neurosurgery, San Filippo Neri Hospital/ASLRoma1, 00135 Rome, Italy; (A.A.A.); (F.F.)
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Palavani LB, Batista S, Andreão FF, de Barros Oliveira L, Silva GM, Koester S, Barbieri JF, Bertani R, da Silva VTG, Acioly M, Paiva WS, De Andrade EJ, Rassi MS. Retrosigmoid versus middle fossa approach for hearing and facial nerve preservation in vestibular schwannoma surgery: A systematic review and comparative meta-analysis. J Clin Neurosci 2024; 124:1-14. [PMID: 38615371 DOI: 10.1016/j.jocn.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Vestibular schwannomas (VS) are benign tumors arising from vestibular nerve's Schwann cells. Surgical resection via retrosigmoid (RS) or middle fossa (MF) is standard, but the optimal approach remains debated. This meta-analysis evaluated RS and MF approaches for VS management, emphasizing hearing preservation and Cranial nerve seven (CN VII) outcomes stratified by tumor size. METHODS Systematic searches across PubMed, Cochrane, Web of Science, and Embase identified relevant studies. Hearing and CN VII outcomes were gauged using the American Academy of Otolaryngology-Head and Neck Surgery, Gardner Robertson, and House-Brackmann scores. RESULTS Among 7228 patients, 56 % underwent RS and 44 % MF. For intracanalicular tumors, MF recorded 38 % hearing loss, compared to RS's 54 %. In small tumors (<1.5 cm), MF showed 41 % hearing loss, contrasting RS's lower 15 %. Medium-sized tumors (1.5 cm-2.9 cm) revealed 68 % hearing loss in MF and 55 % in RS. Large tumors (>3cm) were only reported in RS with a hearing loss rate of 62 %. CONCLUSION Conclusively, while MF may be preferable for intracanalicular tumors, RS demonstrated superior hearing preservation for small to medium-sized tumors. This research underlines the significance of stratified outcomes by tumor size, guiding surgical decisions and enhancing patient outcomes.
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Affiliation(s)
| | - Sávio Batista
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, RJ, Brazil
| | - Filipi Fim Andreão
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, RJ, Brazil.
| | | | - Guilherme Melo Silva
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, RJ, Brazil
| | - Stefan Koester
- Vanderbilt University School of Medicine, Nashville, TN, the United States of America
| | | | - Raphael Bertani
- Department of Neurosurgery, University of Sao Paulo Medical School, SP, Brazil
| | | | - Marcus Acioly
- Division of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Wellingson S Paiva
- Department of Neurosurgery, University of Sao Paulo Medical School, SP, Brazil
| | - Erion J De Andrade
- Division of Neurosurgery, Section of Skull Base Surgery, Emory University, Atlanta, GA, the United States of America
| | - Marcio S Rassi
- Division of Neurosurgery, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, SP, Brazil
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Riedy LN, Shanker RM, Sloane DC, Heiferman DM, Rezaii EG, Finucane SE, Veras P, Leonetti JP, Anderson DE. Long-term quality of life outcomes in patients undergoing microsurgical resection of vestibular schwannoma. World Neurosurg X 2024; 22:100294. [PMID: 38450247 PMCID: PMC10914591 DOI: 10.1016/j.wnsx.2024.100294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 02/20/2024] [Indexed: 03/08/2024] Open
Abstract
Background While previous studies have assessed patient reported quality of life (QOL) of various vestibular schwannoma (VS) treatment modalities, few studies have assessed QOL as related to the amount of residual tumor and need for retreatment in a large series of patients. Objective: To assess patient reported QOL outcomes following VS resection with a focus on extent of resection and retreatment. Methods A retrospective chart review was performed using single-center institutional data of adult patients who underwent VS resection by the senior authors between 1989-2018 at Loyola University Medical Center. The Penn Acoustic Neuroma Quality of Life (PANQOL) survey was sent to all patients via postal mail. Results Fifty-five percent of 367 total patients were female with a mean age of 61.6 years (SD 12.63). The mean period between surgery and PANQOL response was 11.4 years (IQR: 4.74-7.37). The median tumor size was 2 cm (IQR: 1.5-2.8). The mean total PANQOL score was 70 (SD 19). Patients who required retreatment reported lower overall scores (μdiff = -10.11, 95% CI: -19.48 to -0.74; p = 0.03) and face domain scores (μdiff = -20.34, 95% CI: -29.78 to -10.91; p < .001). There was no association between extent of resection and PANQOL scores in any domain. Conclusion In an analysis of 367 patients who underwent microsurgical resection of VS, extent of resection did not affect PANQOL scores in contrast to previous reports in the literature, while the need for retreatment and facial function had a significant impact on patient-reported outcomes.
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Affiliation(s)
- Loren N. Riedy
- Committee Neurobiology, University of Chicago, Hyde Park, IL, USA
| | - Rachyl M. Shanker
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Dayna C. Sloane
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Daniel M. Heiferman
- Department of Neurological Surgery, Edward-Elmhurst Health, Naperville, IL, USA
| | - Elhaum G. Rezaii
- Department of Neurological Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sarah E. Finucane
- Department of Otolaryngology, Loyola University Medical Center, Maywood, IL, USA
| | - Perry Veras
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - John P. Leonetti
- Department of Otolaryngology, Loyola University Medical Center, Maywood, IL, USA
| | - Douglas E. Anderson
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL, USA
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Shi X, Liu Y, Zhang Z, Tao B, Zhang D, Jiang Q, Chen G, Ma H, Feng Y, Xie J, Zheng X, Zhang J. The value of radiographic features in predicting postoperative facial nerve function in vestibular schwannoma patients: A retrospective study and nomogram analysis. CNS Neurosci Ther 2024; 30:e14526. [PMID: 37990346 PMCID: PMC11017437 DOI: 10.1111/cns.14526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVE The purpose of this study was to identify significant prognostic factors associated with facial paralysis after vestibular schwannoma (VS) surgery and develop a novel nomogram for predicting facial nerve (FN) outcomes. METHODS Retrospective data were retrieved from 355 patients who underwent microsurgery via the retrosigmoid approach for VS between December 2017 and December 2022. Univariate and multivariate logistic regression analysis were used to construct a radiographic features-based nomogram to predict the risk of facial paralysis after surgery. RESULTS Following a thorough screening process, a total of 185 participants were included. The univariate and multivariate logistic regression analysis revealed that tumor size (p = 0.005), fundal fluid cap (FFC) sign (p = 0.014), cerebrospinal fluid cleft (CSFC) sign (p < 0.001), and expansion of affected side of internal auditory canal (IAC) (p = 0.033) were independent factors. A nomogram model was constructed based on these indicators. When applied to the validation cohort, the nomogram demonstrated good discrimination and favorable calibration. Then we generated a web-based calculator to facilitate clinical application. CONCLUSION Tumor size, FFC and CSFC sign, and the expansion of the IAC, serve as good predictors of postoperative FN outcomes. Based on these factors, the nomogram model demonstrates good predictive performance.
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Affiliation(s)
- Xudong Shi
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Yuyang Liu
- Department of Neurosurgery920th Hospital of Joint Logistics Support ForceKunmingChina
| | - Zehan Zhang
- Department of Neurosurgerythe Air Force Hospital of Southern Theater CommandGuangzhouChina
| | - Bingyan Tao
- Department of Neurosurgery961th Hospital of Joint Logistics Support ForceQiqiharChina
| | - Ding Zhang
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Qingyu Jiang
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Guilin Chen
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Hengchao Ma
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Yaping Feng
- Department of Neurosurgery920th Hospital of Joint Logistics Support ForceKunmingChina
| | - Jiaxin Xie
- Department of Neurosurgery920th Hospital of Joint Logistics Support ForceKunmingChina
| | - Xuan Zheng
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
| | - Jun Zhang
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
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Nowacka A, Barker-Collo S, Miles A. Exploring the influence of appearance evaluation apprehension: How fear of negative evaluation affects quality of life in people with Vestibular Schwannoma. J Clin Neurosci 2024; 123:7-12. [PMID: 38508019 DOI: 10.1016/j.jocn.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
People diagnosed with Vestibular Schwannoma (VS) can experience several symptoms both pre and post-treatment. These, alongside the diagnosis experience, can significantly impact their daily life. The present research is a continuation of a larger study aiming to explore the impacts of symptomology and body image/fear of negative evaluation (FNAE) on the quality of life (QOL) for people with VS. The research design was exploratory and involved a nationwide survey with a total of 52 participants. FNAE was assessed using a measurement of the same name, and QOL was assessed using the Penn Acoustic Neuroma Quality of Life scale (PANQOL). Comparing management groups revealed a significant difference in FNAE with higher scores for surgery compared to radiation treatment. Regression analyses revealed that FNAE significantly accounted for 10.9% of the variance in QOL. However, no symptom was significantly predictive of FNAE. In conclusion, VS is associated with several symptoms that can persist post-treatment. Body satisfaction contributes to QOL and may differ between management types. However, due to inconclusive findings on the predictability of symptoms on FNAE, other moderator factors could influence these direct relationships. Future studies should evaluate the variables that could mitigate or protect from the impacts of FNAE for this population.
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Affiliation(s)
- Alicja Nowacka
- School of Psychology, The University of Auckland, Auckland, New Zealand.
| | - Suzanne Barker-Collo
- Clinical Training Programme, School of Psychology, The University of Auckland, Auckland, New Zealand
| | - Anna Miles
- Speech Science, School of Psychology, The University of Auckland, Auckland, New Zealand
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Yu Y, Song G, Zhao Y, Liang J, Liu Q. Prediction of Vestibular Schwannoma Surgical Outcome Using Deep Neural Network. World Neurosurg 2023; 176:e60-e67. [PMID: 36966911 DOI: 10.1016/j.wneu.2023.03.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/21/2023] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To compare shallow machine learning models and deep neural network (DNN) model in prediction of vestibular schwannoma (VS) surgical outcome. METHODS One hundred eighty-eight patients with VS were included; all underwent suboccipital retrosigmoid sinus approach, and preoperative magnetic resonance imaging recorded a series of patient characteristics. Degree of tumor resection was collected during surgery, and facial nerve function was evaluated on the eighth day after surgery. Potential predictors of VS surgical outcome were obtained by univariate analysis, including tumor diameter, tumor volume, tumor surface area, brain tissue edema, tumor property, and tumor shape. This study proposes a DNN framework to predict the prognosis of VS surgical outcomes based on potential predictors and compares it with a series of classic machine learning algorithms including logistic regression. RESULTS The results showed that 3 predictors of tumor diameter, tumor volume, and tumor surface area were the most important prognostic factors for VS surgical outcomes, followed by tumor shape, while brain tissue edema and tumor property were the least influential. Different from shallow machine learning models, such as logistic regression with average performance (area under the curve: 0.8263; accuracy: 81.38%), the proposed DNN shows better performance, where area under the curve and accuracy were 0.8723 and 85.64%, respectively. CONCLUSIONS Based on potential risk factors, DNN can be exploited to achieve preoperative automatic assessment of VS surgical outcomes, and its performance is significantly better than other methods. It is therefore highly warranted to continue to investigate their utility as complementary clinical tools in predicting surgical outcomes preoperatively.
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Affiliation(s)
- Yansuo Yu
- Academy of Artificial Intelligence, Beijing Institute of Petrochemical Technology, Beijing, China
| | - Gang Song
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Yixin Zhao
- Academy of Artificial Intelligence, Beijing Institute of Petrochemical Technology, Beijing, China
| | - Jiantao Liang
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.
| | - Qiang Liu
- Academy of Artificial Intelligence, Beijing Institute of Petrochemical Technology, Beijing, China
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Assessing the Efficacy of Anastomosis between Ansa Cervicalis and Facial Nerve for Patients with Concomitant Facial Palsy and Peripheral Neuropathy. J Pers Med 2022; 13:jpm13010076. [PMID: 36675739 PMCID: PMC9863281 DOI: 10.3390/jpm13010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/29/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
Background: For decades, patients with facial asymmetry have experienced social interaction difficulties, leading them to seek treatment in the hope of restoring facial symmetry and quality of life. Researchers evaluated numerous surgical techniques, but achieving results remains a significant hurdle. Specifically, anastomosis between the ansa cervicalis (AC) and facial nerve (FN) can hinder the patient's physical appearance. Objective: Our study goal was to examine the efficiency of anastomosis between AC and FN for facial motor function recovery even in the presence of peripheral neuropathy. Materials and Methods: Four patients diagnosed with facial palsy grade VI on the House & Brackmann Scale (HB) after vestibular schwannoma (VS) resection (Koos grade IV) via the retrosigmoid approach underwent AC and FN anastomosis. Outcomes were related to tumor grade, previous therapy, and the time between postoperative facial palsy and anastomosis. Images and neurophysiological data were evaluated. Results: After vs. resection, all four patients demonstrated HB grade VI facial palsy for an average of 17 months. During the follow-up program, lasting between 6 and 36 months, two patients were evaluated as having HB grade III facial palsy; the other two patients were diagnosed with grade IV HB facial palsy. None of the patients developed tongue atrophy, speech disorder, or masticatordys function. Conclusions: Anastomosis between the AC and FN is a safe and effective treatment for facial paralysis after cerebellopontine tumor resection. Nerve reanimation may be feasible even for patients with peripheral polyneuropathy. This study also offers a new option for patients with a progression-free status.
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Sahana D, Kumar S, Rathore L, Mittal J, Sahu RK, Jain AK, Tawari M. Is Preoperative Facial Palsy a Deterrent to Facial Nerve Preservation after Gross-Total Removal of Giant Vestibular Schwannomas? INDIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1055/s-0042-1757919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Background Although rare in small vestibular schwannomas, preoperative facial nerve paresis is often present in giant schwannomas. Preserving facial nerve function in these cases remains a herculean task. This study evaluates the facial functions after complete tumor removal and whether preoperative facial nerve involvement affects postoperative functional status.
Methods This retrospective study from January 2014 to August 2021 excluded nongiant tumors (< 4 cm), neurofibromatosis type 2 cases, incomplete removals, redo surgeries, deaths, and cases done without nerve monitoring. These were grouped into preoperative facial palsy present (PFP) and no preoperative facial palsy (NFP). Facial nerve functions were assessed on first postoperative day, at the time of discharge, and at last follow-up and dichotomized into two groups: nondisfiguring (House–Brackmann [HB] grades I–III) and disfiguring (HB grades IV–VI). The cohort outcomes of patients with nondisfiguring PFP (HB grades I–III) were also analyzed.
Results There were 88 cases (PFP, n = 57; NFP, n = 31). Facial nerve was preserved anatomically in 62 (70.45%) patients (PFP, n = 38; NFP, n = 24) without any statistical difference (p = 0.29). Statistically significant disfiguring facial outcomes (HB IV, V, VI) were seen in patients with preoperative facial palsy (p = 0.01); however, a comparison of facial functions in patients with only nondisfiguring PFP with those in NFP group did not show the statistical difference (p = 0.12).
Conclusions Facial nerve palsy present before surgery does not seem to be a deterrent to intraoperative preservation of facial nerve during complete removal of giant vestibular schwannomas. Patients with nondisfiguring facial palsies have postoperative facial functions comparable to those without facial palsy.
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Affiliation(s)
- Debabrata Sahana
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Sanjeev Kumar
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Lavlesh Rathore
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Jatinder Mittal
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Rajiv K. Sahu
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Amit K. Jain
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Manish Tawari
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur, Chhattisgarh, India
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North M, Weishaar J, Nuru M, Anderson D, Leonetti JP. Assessing Surgical Approaches for Acoustic Neuroma Resection: Do Patients Perceive a Difference in Quality-of-Life Outcomes? Otol Neurotol 2022; 43:1245-1251. [DOI: 10.1097/mao.0000000000003720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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12
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Liu C, Shen Y, Han D, Zhang D. Analysis of Related Factors Affecting Facial Nerve Function after Acoustic Neuroma Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:5194566. [PMID: 35982999 PMCID: PMC9381189 DOI: 10.1155/2022/5194566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/30/2022]
Abstract
Objective To investigate the factors affecting facial nerve function after acoustic neuroma surgery and to provide theoretical reference for clinicians to preserve facial nerve function better after surgery. Methods A retrospective cohort study was conducted to analyze the correlation between postoperative facial nerve function and surgical approach, age, sex, tumor size and adhesion degree of facial nerve in 152 patients with acoustic neuroma. Results In the choice of surgical approach, there was no significant difference in the anatomy of the complete facial nerve in labyrinth path, retrosigmoid sinus path, and middle cranial fossa path. There was no statistically significant difference between the middle cranial fossa path and the retrosigmoid sinus path in facial nerve function preservation 7 days after surgery. The difference between middle cranial fossa path and labyrinthine path was statistically significant (P < 0.01). There were statistically significant differences between labyrinth path and retrosigmoid sinus path (P < 0.05). Logistic multivariate regression analysis showed that the operative approach and the degree of adhesion between tumor and facial nerve were the risk factors affecting functional preservation of facial nerve 7 days after surgery. Age and the degree of adhesion between tumor and facial nerve were the risk factors for functional preservation of facial nerve 1 year after operation. Conclusion The facial nerve function injury in patients with acoustic neuroma may be related to the choice of surgical approach, the adhesion degree of tumor and facial nerve, and their age. Clinicians need to comprehensively evaluate the risk factors before surgery, so as to achieve individualized treatment to protect the integrity of postoperative facial nerve function of patients.
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Affiliation(s)
- Chunhan Liu
- Vertigo Clinic, The Third People's Hospital of Shenzhen, Shenzhen 518000, China
- Department of Otolaryngology, The Third People's Hospital of Shenzhen, Shenzhen 518000, China
| | - Yage Shen
- Baoding No. 1 Hospital of TCM, Baoding 071000, China
| | - Dongyi Han
- College of Otolaryngology Head and Neck Surgery, Chinese People's Liberation Army General Hospital, Chinese People's Liberation Army Medical School, National Clinical Research Center for Otolaryngologic Diseases, State Key Lab of Hearing Science, Ministry of Education, Beijing 100853, China
| | - Di Zhang
- Department of Otolaryngology, The Third People's Hospital of Shenzhen, Shenzhen 518000, China
- College of Otolaryngology Head and Neck Surgery, Chinese People's Liberation Army General Hospital, Chinese People's Liberation Army Medical School, National Clinical Research Center for Otolaryngologic Diseases, State Key Lab of Hearing Science, Ministry of Education, Beijing 100853, China
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Sun Y, Yang J, Li T, Gao K, Tong X. Nomogram for Predicting Facial Nerve Outcomes After Surgical Resection of Vestibular Schwannoma. Front Neurol 2022; 12:817071. [PMID: 35211077 PMCID: PMC8860821 DOI: 10.3389/fneur.2021.817071] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/28/2021] [Indexed: 11/24/2022] Open
Abstract
Objective The facial nerve (FN) outcomes after vestibular schwannoma surgery seriously affect the social psychology and quality of life of patients. More and more attention has been paid to the protection of FN function. This study aimed to identify significant prognostic factors for FN outcomes after vestibular schwannoma surgery and create a new nomogram for predicting the rates of poor FN outcomes. Methods Data from patients who had undergone operations for vestibular schwannoma between 2015 and 2020 were retrieved retrospectively and patients were divided into good and poor FN outcomes groups according to postoperative nerve function. The nomogram for predicting the risk of poor FN outcomes was constructed from the results of the univariate logistic regression analysis and the multivariate logistic regression analysis of the influencing factors for FN outcomes after surgical resection of vestibular schwannoma. Results A total of 392 participants were enrolled. The univariate logistic regression analysis revealed that age, tumor size, cystic features of tumors, cerebrospinal fluid (CSF) cleft sign, tumor adhesion to the nerve, learning curve, and FN position were statistically significant. The multivariate logistic regression analysis showed that age, tumor size, cystic features of tumors, CSF cleft sign, tumor adhesion to the nerve, learning curve, and FN position were independent factors. The nomogram model was constructed according to these indicators. At the last follow-up examination, a good FN outcome was observed in 342 patients (87.2%) and only 50 patients (12.8%) was presented with poor FN function. Application of the nomogram in the validation cohort still gave good discrimination [area under the curve (AUC), 0.806 (95% CI, 0.752–0.861)] and good calibration. Conclusion This study has presented a reliable and valuable nomogram that can accurately predict the occurrence of poor FN outcomes after surgery in patients. This tool is easy to use and could assist doctors in establishing clinical decision-making for individual patients.
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Affiliation(s)
- Yang Sun
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Jianhua Yang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Tang Li
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Kaiming Gao
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Xiaoguang Tong
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China.,Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
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Schipmann S, Lohmann S, Al Barim B, Suero Molina E, Schwake M, Toksöz ÖA, Stummer W. Applicability of contemporary quality indicators in vestibular surgery-do they accurately measure tumor inherent postoperative complications of vestibular schwannomas? Acta Neurochir (Wien) 2022; 164:359-372. [PMID: 34859305 PMCID: PMC8854327 DOI: 10.1007/s00701-021-05044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 10/28/2021] [Indexed: 12/01/2022]
Abstract
Background Due to rising costs in health care delivery, reimbursement decisions have progressively been based on quality measures. Such quality indicators have been developed for neurosurgical procedures, collectively. We aimed to evaluate their applicability in patients that underwent surgery for vestibular schwannoma and to identify potential new disease-specific quality indicators. Methods One hundred and three patients operated due to vestibular schwannoma were subject to analysis. The primary outcomes of interest were 30-day and 90-day reoperation, readmission, mortality, nosocomial infection and surgical site infection (SSI) rates, postoperative cerebral spinal fluid (CSF) leak, facial, and hearing function. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes. Results Thirty-day (90-days) outcomes in terms of reoperation were 10.7% (14.6%), readmission 9.7% (13.6%), mortality 1% (1%), nosocomial infection 5.8%, and SSI 1% (1%). A 30- versus 90-day outcome in terms of CSF leak were 6.8% vs. 10.7%, new facial nerve palsy 16.5% vs. 6.1%. Hearing impairment from serviceable to non-serviceable hearing was 6.8% at both 30- and 90-day outcome. The degree of tumor extension has a significant impact on reoperation (p < 0.001), infection (p = 0.015), postoperative hemorrhage (p < 0.001), and postoperative hearing loss (p = 0.026). Conclusions Our data demonstrate the importance of entity-specific quality measurements being applied even after 30 days. We identified the occurrence of a CSF leak within 90 days postoperatively, new persistent facial nerve palsy still present 90 days postoperatively, and persisting postoperative hearing impairment to non-serviceable hearing as potential new quality measurement variables for patients undergoing surgery for vestibular schwannoma.
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Affiliation(s)
- Stephanie Schipmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Sebastian Lohmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Bilal Al Barim
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Özer Altan Toksöz
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Farag AA, Ibrahim AEKSED, Alaghory IM. Clinical Benefits of Facial Nerve Monitoring during Cerebellopontine Angle Surgery. OPEN JOURNAL OF MODERN NEUROSURGERY 2022; 12:9-27. [DOI: 10.4236/ojmn.2022.121002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Delayed Facial Nerve Palsy Following Resection of Vestibular Schwannoma: Clinical and Surgical Characteristics. Otol Neurotol 2021; 43:244-250. [PMID: 34699397 DOI: 10.1097/mao.0000000000003392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Analyze delayed facial nerve palsy (DFNP) following resection of vestibular schwannoma (VS) to describe distinct characteristics and facial nerve (FN) functional course. STUDY DESIGN Prospective cohort with retrospective review. SETTING Academic medical center. PATIENTS Consecutive patients undergoing VS resection 11/2017 to 08/2020. Exclusion criteria: preoperative House-Brackmann (HB) ≥ III, postoperative HB ≥ III without delayed palsy, <30 days follow-up. INTERVENTIONS VS resection with intraoperative electromyographic monitoring. MAIN OUTCOME MEASURES FN outcomes utilizing the HB scale; comparison between patients with DFNP (deterioration greater than one HB grade 24 hours to 30 days postoperatively) vs. those with HBI-II throughout. RESULTS Two hundred eighty-eight patients met criteria: mean age 47.6 years, 36.1% male; 24.0% middle cranial fossa, 28.5% retrosigmoid, 47.6% translabyrinthine. DFNP occurred in 31 (10.8%) patients with average time to onset of 8.1 days. Of these, 22 (71.0%) recovered HBI-II and 3 (9.7%) recovered HBIII. Patients who experienced DFNP, on average, had larger maximum tumor diameter (23.4 vs. 18.7 mm, p = 0.014), lower rate of gross-total resection (54.8% vs. 75.5%, p = 0.014), and lower rate of ≥100 μV FN response to 0.05 mA stimulus intraoperatively (80.6% vs. 94.9%, p = 0.002). Compared to overall incidence of DFNP, translabyrinthine approach demonstrated higher incidence (15.3%, p = 0.017) while retrosigmoid lower (3.7%, p = 0.014). In multivariable logistic regression, patients with FN response ≥100 μV to 0.05 mA stimulus were 72.0% less likely to develop DFNP (p = 0.021). CONCLUSIONS Intraoperative electromyographic facial nerve response, tumor size, surgical approach, and extent of resection may play a role in development of DFNP following resection of VS. Most patients who develop DFNP recover near-normal function.
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Perkins EL, Manzoor NF, Totten DJ, Sherry AD, Cass N, Thompson R, Tawfik K, O'Malley M, Bennett M, Haynes DS. The Influence of Extent of Resection and Tumor Morphology on Facial Nerve Outcomes Following Vestibular Schwannoma Surgery. Otol Neurotol 2021; 42:e1346-e1352. [PMID: 34238899 DOI: 10.1097/mao.0000000000003253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the influence extent of resection and tumor characteristics on facial nerve (FN) outcomes following microsurgical resection of vestibular schwannoma (VS). STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS Three hundred eighty-five patients who underwent VS microsurgical resection. INTERVENTIONS Microsurgical VS resection. MAIN OUTCOME MEASURES House-Brackmann (HB) scores postoperatively. Good FN function was defined as HB grade I and II and poor FN function was defined as HB grade III and VI. Gross total resection (GTR) versus subtotal resection (STR). Propensity-score matching was used in subset analysis to balance tumor volume between the surgical cohorts, followed by multivariable analysis. RESULTS Seventy-one patients (18%) underwent STR and 314 patients (82%) underwent GTR. Two hundred fourteen patients (63%) had good FN function at 2 to 3 weeks postoperatively, and 80% had good FN function at 1 year. In single predictor analysis, STR did not influence FN function at 2 to 3 weeks (p = 0.65). In propensity-score matched subset analysis (N = 178), patients with STR were less likely to have poor FN function at 2 to 3 weeks (p = 0.02) independent of tumor volume (p = 0.004), but there was no correlation between STR and FN function at 1 year (p = 0.09). Ventral extension of tumor relative to the internal auditory canal plane was associated with poor FN outcomes at 2 to 3 weeks (p = 0.0001) and 1-year postop (p = 0.002). CONCLUSIONS When accounting for tumor volume, STR is protective in immediate postoperative FN function compared to GTR. Ventral extension of the tumor is a clinical predictor of long-term FN outcomes.
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Affiliation(s)
- Elizabeth L Perkins
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nauman F Manzoor
- Department of Otolaryngology/Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals ENT Institute, Cleveland, Ohio
| | - Douglas J Totten
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center
| | - Nathan Cass
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reid Thompson
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kareem Tawfik
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew O'Malley
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc Bennett
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David S Haynes
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Kiyofuji S, Neff BA, Carlson ML, Driscoll CLW, Link MJ. Large and small vestibular schwannomas: same, yet different tumors. Acta Neurochir (Wien) 2021; 163:2199-2207. [PMID: 33471207 DOI: 10.1007/s00701-021-04705-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vestibular schwannomas (VS) present at variable size with heterogeneous symptomatology. Modern treatment paradigms for large VS include gross total resection, subtotal resection (STR) in combination with observation, and/or radiation to achieve optimal function preservation, whereas treatment is felt to be both easier and safer for small VS. The objective is to better characterize the presentation and surgical outcomes of large and small VS. METHODS We collected data of patients who had surgically treated VS with a posterior fossa diameter of 4.0 cm or larger (large tumor group, LTG) and smaller than 1.0 cm in cisternal diameter (small tumor group, STG). Statistical significance was defined as p < 0.05. RESULTS LTG included 48 patients (average tumor size: 44.9 mm) and STG 38 (7.9 mm). Patients in STG presented more frequently with tinnitus and sudden hearing loss. Patients in LTG underwent more STR than STG (50.0% vs. 2.6%, p < 0.0001). LTG had more complications (31.3% vs. 13.2%, p = 0.049). Postoperative facial nerve function in STG was significantly better than LTG. STG had better hearing preoperatively (p < 0.0001) and postoperatively than LTG (p = 0.0002). Postoperative headache was more common in STG (13.2% vs. 2.1%, p = 0.045). The rate of recurrence/progression needing treatment was not statistically different between the groups (12.5% in LTG vs. 7.9% in STG, p = 0.49). Those patients who required periprocedural cerebrospinal fluid diversion had higher risk of infection (20.8% vs 4.8%, p = 0.022). CONCLUSION Large and small VS present differently. LTG showed more unsatisfactory outcomes in facial nerve function and postoperative hearing despite maximal efforts undertaken toward function-preservation strategy; however, similar tumor control was achieved.
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Affiliation(s)
- Satoshi Kiyofuji
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 154-0023, Japan.
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
| | - Brian A Neff
- Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Matthew L Carlson
- Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
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Elsayed M, Jia H, Hochet B, Sterkers O, Torres R, Nguyen Y, Bernat I, Lahlou G, Kalamarides M. Intraoperative facial nerve electromyography parameters to optimize postoperative facial nerve outcome in patients with large unilateral vestibular schwannoma. Acta Neurochir (Wien) 2021; 163:2209-2217. [PMID: 33825973 DOI: 10.1007/s00701-021-04814-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Decision-making for large sporadic vestibular schwannomas (VS) resection guided by the intraoperative change in supramaximal facial nerve (FN) amplitude and latency response to optimize post-operative FN outcome. METHODS Prospectively study of 43 patients, from January to December 2018, of large sporadic VS with preoperative normal FN function at our center. Tumors were removed through retrosigmoid (81%) or translabyrinthine (19%) approaches with FN monitoring. Intraoperative pre- and post-VS resection supramaximal (2 mA) amplitude and latency responses at the proximal FN root were recorded. RESULTS Total, near-/subtotal VS resections (TR, NTR, STR) were achieved in 51%, 38%, and 11% of tumors, respectively, guided by no more than 40% decrease in supramaximal amplitude. Pre- and post-resection supramaximal amplitude and latency responses were lower and longer, respectively, in NTR+STR than in TR. At day 8, FN function was grade I-II in 77% of patients and grade III-V in 23%, and after 6 months, it was in grade I-II in 95% and grade III in 5%, and there was no significant difference between TR and NTR+STR. Facial palsy occurred in older patients and in the case of severe FN adhesion. At day 8, pre- and post-resection supramaximal amplitude but not latency responses were different between FN grade III-V and grade I-II. Serviceable hearing was preserved in 28% of large VS. CONCLUSIONS Intraoperative FN monitoring guided VS resection in large VS so that 49% retained some residual tumor. Accordingly, 95% good postoperative FN function and significant hearing preservation were achieved after 6 months.
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Affiliation(s)
- Mohamed Elsayed
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Faculty of Medicine, ORL Department, Alexandria University, Alexandria, Egypt
| | - Huan Jia
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France.
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
- Department of Otolaryngology Head & Neck Surgery, Shanghai 9th People's Hospital, Shanghai Jiat Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China.
| | - Baptiste Hochet
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Olivier Sterkers
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Renato Torres
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Facultad de Medicina, Centro de Investigación y Desarrollo Científico, Universidad Nacional de San Agustín, Arequipa, Peru
| | - Yann Nguyen
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Isabelle Bernat
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Ghizlene Lahlou
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
- Department of Clinical Neurophysiology, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Michel Kalamarides
- Department of Otology, Auditory Implants and Skull Base Surgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France.
- Department of Neurosurgery, Sorbonne Université-APHP6, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
- Service de Neurochirurgie, Hôpital Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75013, Paris, France.
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Kawashima M, Hasegawa H, Shin M, Shinya Y, Katano A, Saito N. Outcomes of stereotactic radiosurgery in young adults with vestibular schwannomas. J Neurooncol 2021; 154:93-100. [PMID: 34241770 DOI: 10.1007/s11060-021-03803-w] [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] [Received: 05/15/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Vestibular schwannomas (VSs) are comparatively rare in younger patients, and stereotactic radiosurgery (SRS) outcome data are limited. We aimed to evaluate long-term SRS outcomes concerning sporadic VSs in patients aged ≤ 40 years. METHODS Of 383 patients with VS who had undergone SRS at our institution between 1990 and 2017, we retrospectively compared younger and older patients' tumor control and radiation-induced complication rates using case-control propensity score (PS) matching. RESULTS The mean follow-up was 83 and 92 months in older and younger patients, respectively. Compared with older patients, younger patients were more likely to have a history of resection (20% vs. 39%, p = 0.006) and be treated with higher marginal doses (median, 12 Gy vs. 14 Gy; p = 0.014). Cumulative 5- and 10-year tumor control rates were higher in older patients (97.7% and 93.9%, respectively) than in younger patients (90.2% and 85.4%, respectively, p = 0.024). After PS matching, younger patients' cumulative tumor control rates (93.6%, 85.4%, and 85.4% at 5, 10, and 15 years, respectively) were similar to those of older patients (p = 0.411). No significant between-cohort differences in hearing preservation rates or other cranial nerve complications were observed. Two younger patients had malignant tumors several years post-SRS, with one patient having confirmed histological transformation. CONCLUSIONS SRS is equally effective for younger and older patients. Complications other than hearing deterioration are uncommon. However, malignant transformation is possible, and long-term post-SRS surveillance MRI is important. These data are useful for decision-making involving young adults with VSs.
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Affiliation(s)
- Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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21
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Gürün E, Akdulum İ, Kılıç P, Tokgöz N, Uçar M. Evaluation of schwannoma using the 3D-SPACE sequence: comparison with the 3D-CISS sequence in 3T-MRI. Turk J Med Sci 2021; 51:1123-1135. [PMID: 33387986 PMCID: PMC8283456 DOI: 10.3906/sag-2010-30] [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: 10/03/2020] [Accepted: 01/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background/aim The purpose of this study is to compare the diagnostic accuracy and interobserver reliability of the T2-weighted 3D-SPACE (three-dimensional sampling perfection with application-optimized contrasts by using different flip angle evolutions) sequence in comparison with T2-weighted 3D-CISS (three-dimensional constructive interference in steady state) sequences for diagnosis of schwannomas. Materials and methods Forty patients with cerebellopontine angle (CPA), internal acoustic canal (IAC), and cochlear schwannoma who had undergone magnetic resonance imaging (MRI) using the 3D-CISS and 3D-SPACE sequences were identified. The sequences were retrospectively evaluated by two radiologists for the qualitative analyses, which were subsequently compared using the Mann–Whitney U test. Following this, kappa values were used for interobserver agreement. P < 0.05 was considered to be of statistical significance. Results The interobserver agreement was found to be excellent between the two observers for the interpretation of all qualitative analyses for both sequences (kappa value > 0.8). The 3D-SPACE sequences demonstrated significantly better qualitative scores and fewer artifacts compared with the 3D-CISS sequences (p < 0.05). Conclusion Our results demonstrate that 3D-SPACE is superior to 3D-CISS in the imaging process of the schwannoma in terms of image quality, description of the relationship between the lesion and cranial nerve, signal differentiation between lesion and cistern, and signal differentiation between the lesion and adjacent brain.
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Affiliation(s)
- Enes Gürün
- Department of Radiology, İskilip Atıf Hoca State Hospital, Çorum, Turkey
| | - İsmail Akdulum
- Department of Radiology, Gazi University Hospital, Ankara, Turkey
| | - Pınar Kılıç
- Department of Radiology, Pursaklar State Hospital, Ankara, Turkey
| | - Nil Tokgöz
- Department of Radiology, Gazi University Hospital, Ankara, Turkey
| | - Murat Uçar
- Department of Radiology, Gazi University Hospital, Ankara, Turkey
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Hostettler IC, Jayashankar N, Bikis C, Wanderer S, Nevzati E, Karuppiah R, Waran V, Kalbermatten D, Mariani L, Marbacher S, Guzman R, Madduri S, Roethlisberger M. Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery-A Systematic Review and Future Perspectives. Front Bioeng Biotechnol 2021; 9:659413. [PMID: 34239858 PMCID: PMC8259738 DOI: 10.3389/fbioe.2021.659413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury. Methods: A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base. Results: One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent (n = 4) or non-rodent model (n = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones. Conclusion: The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.
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Affiliation(s)
- Isabel C Hostettler
- Department of Neurosurgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Narayan Jayashankar
- Department of Oto-Rhino-Laryngology, Nanavati Super Speciality Hospital, Mumbai, India
| | - Christos Bikis
- Department of Biomedical Engineering, Biomaterials Science Center, University of Basel, Allschwil, Switzerland.,Integrierte Psychiatrie Winterthur - Zürcher Unterland, Winterthur, Switzerland
| | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Edin Nevzati
- Department of Neurosurgery, Kantonsspital Luzern, Lucerne, Switzerland
| | - Ravindran Karuppiah
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia
| | - Vicknes Waran
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia
| | - Daniel Kalbermatten
- Department of Plastic Surgery, University Hospital Geneva, Geneva, Switzerland.,Department of Surgery, Biomaterials and Neuro Tissue Bioengineering, University of Geneva, Geneva, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland.,Department of Biomedicine, Brain Ischemia and Regeneration, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
| | - Srinivas Madduri
- Department of Surgery, Biomaterials and Neuro Tissue Bioengineering, University of Geneva, Geneva, Switzerland.,Department of Biomedicine, Brain Ischemia and Regeneration, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia.,Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
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23
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Funk EK, Greene JJ. Advances in Facial Reanimation: Management of the Facial Nerve in the Setting of Vestibular Schwannoma. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00343-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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24
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Song G, Bai X, Wu X, Zhang X, Cheng Y, Wei P, Bao Y, Liang J. Facial Nerve Length Influence on Vestibular Schwannoma Microsurgery Outcomes. World Neurosurg 2021; 150:e400-e407. [PMID: 33737256 DOI: 10.1016/j.wneu.2021.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Facial nerve (FN) function preservation is the primary goal during vestibular schwannoma (VS) resection. Many factors are linked to postoperative FN outcomes. In the present study, we evaluated the association between FN length and VS surgical outcomes. METHODS We included 70 consecutive patients who had undergone VS microsurgery between October 2019 and November 2020. The clinical data were prospectively obtained from the patients. The relative FN (rFN) length was obtained by subtracting the contralateral FN length from the ipsilateral FN length as measured using DSI Studio software (available at: http://dsi-studio.labsolver.org/). RESULTS The postoperative FN function was House-Brackmann grade I in 47 of the 70 patients (67.1%), grade II in 10 (14.3%), and grade III in 13 (18.6%). Gross total resection (GTR) was performed in 61 patients (87.1%). A residual tumor was retained to preserve FN function in 9 of the 70 patients (12.9%), and rFN length was measured (mean diameter, 20.8 mm; range, 2.5-51.5]). On multivariate analysis, the rFN length was significantly associated with the extent of tumor resection. The receiver operating characteristic curve indicated that the cutoff value for rFN length to predict for intraoperative near total resection versus GTR was 36.6 mm, with a specificity and sensitivity of 93.4% and 88.9%, respectively. CONCLUSIONS The rFN length is important for predicting surgical outcomes. An rFN length >36.6 mm might indicate difficulty in achieving GTR with preservation of FN function. Therefore, the rFN length could become an objective indicator for neurosurgeons to predict the difficulty of GTR to preserve FN function.
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Affiliation(s)
- Gang Song
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Xiaolong Wu
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Zhang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Ye Cheng
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Penghu Wei
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Yuhai Bao
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Jiantao Liang
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute, XuanWu Hospital, Capital Medical University, Beijing, China.
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25
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Park HH, Park SH, Oh HC, Jung HH, Chang JH, Lee KS, Chang WS, Hong CK. The behavior of residual tumors following incomplete surgical resection for vestibular schwannomas. Sci Rep 2021; 11:4665. [PMID: 33633337 PMCID: PMC7907355 DOI: 10.1038/s41598-021-84319-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/15/2021] [Indexed: 11/09/2022] Open
Abstract
The management of vestibular schwannoma (VS) with residual tumor following incomplete resection remains controversial and little is known regarding postoperative tumor volume changes. The behavior of residual tumors was analyzed for 111 patients who underwent surgery for newly diagnosed VS between September 2006 and July 2017. The postoperative tumor volume changes were assessed during a mean follow-up of 69 months (range 36–147 months). Fifty-three patients underwent imaging surveillance following incomplete resection. There was no residual tumor growth in 44 patients (83%). A significant regression of residual tumor volume was noted in the no growth group at postoperative 1 year (p = 0.028), 2 years (p = 0.012), but not from 3 years onwards. Significant predictors of regrowth were immediate postoperative tumor volume ≥ 0.7 cm3 (HR 10.5, p = 0.020) and residual tumor location other than the internal auditory canal (IAC) (HR 6.2, p = 0.026). The mean time to regrowth was 33 months (range 5–127 months). The 2-, 5-, and 10-year regrowth-free survival rates were 90.6%, 86.8%, and 83%, respectively. In conclusion, significant residual tumor regression could occur within 2 years for a VS with an immediate postoperative tumor volume less than 0.7 cm3 or residual tumor in IAC.
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Affiliation(s)
- Hun Ho Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - So Hee Park
- Department of Neurosurgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Gamma Knife CenterSeverance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Brain Tumor Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Brain Research Institute, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Hyeong-Cheol Oh
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Hyun-Ho Jung
- Department of Neurosurgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Gamma Knife CenterSeverance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Brain Tumor Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Brain Research Institute, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Gamma Knife CenterSeverance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Brain Tumor Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Brain Research Institute, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Kyu-Sung Lee
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Gamma Knife CenterSeverance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Brain Tumor Center, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.,Brain Research Institute, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea.
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26
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Starnoni D, Giammattei L, Cossu G, Link MJ, Roche PH, Chacko AG, Ohata K, Samii M, Suri A, Bruneau M, Cornelius JF, Cavallo L, Meling TR, Froelich S, Tatagiba M, Sufianov A, Paraskevopoulos D, Zazpe I, Berhouma M, Jouanneau E, Verheul JB, Tuleasca C, George M, Levivier M, Messerer M, Daniel RT. Surgical management for large vestibular schwannomas: a systematic review, meta-analysis, and consensus statement on behalf of the EANS skull base section. Acta Neurochir (Wien) 2020; 162:2595-2617. [PMID: 32728903 PMCID: PMC7550309 DOI: 10.1007/s00701-020-04491-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/10/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The optimal management of large vestibular schwannomas continues to be debated. We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of this problem from a European perspective. MATERIAL AND METHODS A systematic review of MEDLINE database, in compliance with the PRISMA guidelines, was performed. A subgroup analysis screening all surgical series published within the last 20 years (January 2000 to March 2020) was performed. Weighted summary rates for tumor resection, oncological control, and facial nerve preservation were determined using meta-analysis models. This data along with contemporary practice patterns were discussed within the task force to generate consensual recommendations regarding preoperative evaluations, optimal surgical strategy, and follow-up management. RESULTS Tumor classification grades should be systematically used in the perioperative management of patients, with large vestibular schwannomas (VS) defined as > 30 mm in the largest extrameatal diameter. Grading scales for pre- and postoperative hearing (AAO-HNS or GR) and facial nerve function (HB) are to be used for reporting functional outcome. There is a lack of consensus to support the superiority of any surgical strategy with respect to extent of resection and use of adjuvant radiosurgery. Intraoperative neuromonitoring needs to be routinely used to preserve neural function. Recommendations for postoperative clinico-radiological evaluations have been elucidated based on the surgical strategy employed. CONCLUSION The main goal of management of large vestibular schwannomas should focus on maintaining/improving quality of life (QoL), making every attempt at facial/cochlear nerve functional preservation while ensuring optimal oncological control, thereby allowing to meet patient expectations. Despite the fact that this analysis yielded only a few Class B evidences and mostly expert opinions, it will guide practitioners to manage these patients and form the basis for future clinical trials.
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Affiliation(s)
- Daniele Starnoni
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | | | - Giulia Cossu
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Michael J Link
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Pierre-Hugues Roche
- Department of Neurosurgery, CHU North Hospital, Aix-Marseille University, Marseille, France
| | - Ari G Chacko
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Majid Samii
- Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Michael Bruneau
- Department of Neurosurgery, Erasme Hospital, Brussels, Belgium
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Luigi Cavallo
- Department of Neurosurgery, University Hospital of Naples Federico II, Naples, NA, Italy
| | - Torstein R Meling
- Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
| | | | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Albert Sufianov
- Federal Centre of Neurosurgery, Tyumen, Russian Federation; Department of Neurosurgery, The State Education Institution of Higher Professional Training, The First Sechenov Moscow State Medical University under Ministry of Health, Tyumen, Russian Federation
| | - Dimitrios Paraskevopoulos
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK
| | - Idoya Zazpe
- Servicio de Neurocirugía, Complejo Hospitalario de Navarra, Pamplona, Spain
- Servicio de Cirugía Torácica, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Moncef Berhouma
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Lyon, France
| | - Emmanuel Jouanneau
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Lyon, France
| | - Jeroen B Verheul
- Department of Neurosurgery and Gamma knife Centre, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Constantin Tuleasca
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5) Ecole Polytechnique Fédérale de Lausanne (EPFL) Lausanne, Lausanne, Switzerland
| | - Mercy George
- ENT Service, Centre Hospitalier Universitaire Vaudois (CHUV); Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Marc Levivier
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
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27
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Ren Y, MacDonald BV, Tawfik KO, Schwartz MS, Friedman RA. Clinical Predictors of Facial Nerve Outcomes After Surgical Resection of Vestibular Schwannoma. Otolaryngol Head Neck Surg 2020; 164:1085-1093. [PMID: 33048002 DOI: 10.1177/0194599820961389] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To identify clinical predictors of facial nerve (FN) outcomes after microsurgical resection of vestibular schwannoma (VS). STUDY DESIGN Prospective cohort study. SETTING Academic medical center. METHODS Consecutive patients undergoing VS resection from November 2017 to October 2019 were included. FN function was evaluated with the House-Brackmann (HB) scale and stratified into good (HB I-II) and poor (HB III-VI) function. Analyses included descriptive statistics, correlation, and logistic regression. RESULTS Of 256 patients who met criteria (mean age, 47.7 years; 62.5% female), 227 (88.7%) achieved good FN function postoperatively and 238 (93.0%) at latest follow-up (mean, 154.8 days). Operative approaches consisted of translabyrinthine (50.8%), retrosigmoid (25.0%), and middle fossa craniotomies (24.2%). Extent of resection was decided intraoperatively, and gross or near total resection was accomplished in 237 (92.6%) cases. Postoperative HB grade correlated with latest HB grade (0.615, P < .001). Factors associated with good postoperative FN function included small tumor size (≤15 mm; odds ratio [OR], 2.425; P = .042), gross or near total resection (OR, 3.170; P = .041), and ≥100-µV intraoperative FN electromyographic response to a 0.05-mA stimulus (OR, 22.242; P < .001). Factors associated with good FN function at latest follow-up included gross total resection (OR, 7.764; P = .003) and ≥100-µV FN electromyographic response (OR, 8.518; P < .001), accounting for surgical approach and tumor size. CONCLUSION Microsurgical resection of VS can be accomplished with excellent FN outcomes. Gross total resection and ≥100-µV intraoperative FN electromyographic response predicted excellent FN outcomes. Immediate postoperative FN function is a prognosticator of long-term FN function.
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Affiliation(s)
- Yin Ren
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California at San Diego, La Jolla, California, USA
| | - Bridget V MacDonald
- School of Medicine, University of California at San Diego, La Jolla, California, USA
| | - Kareem O Tawfik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California at San Diego, La Jolla, California, USA.,Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marc S Schwartz
- Department of Neurosurgery, University of California at San Diego, La Jolla, California, USA
| | - Rick A Friedman
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California at San Diego, La Jolla, California, USA
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28
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Sobieski C, Killeen DE, Barnett SL, Mickey BE, Hunter JB, Isaacson B, Kutz JW. Facial Nerve Outcomes After Vestibular Schwannoma Microsurgical Resection in Neurofibromatosis Type 2. Otolaryngol Head Neck Surg 2020; 164:850-858. [PMID: 32957864 DOI: 10.1177/0194599820954144] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study is to investigate facial nerve outcomes after microsurgical resection in neurofibromatosis type 2 (NF2) compared to sporadic tumors. STUDY DESIGN Single institutional retrospective chart review. SETTING Tertiary referral center. METHODS All adult patients with NF2 vestibular schwannoma (VS) or sporadic VS who underwent microsurgical resection from 2008 to 2019 with preoperative magnetic resonance imaging (MRI) and 1 year of postsurgical follow-up were included. The primary outcome measure was postoperative House-Brackmann (HB) facial nerve score measured at first postoperative visit and after at least 10 months. RESULTS In total, 161 sporadic VSs and 14 NF2 VSs met inclusion criteria. Both median tumor diameter (NF2, 33.5 mm vs sporadic, 24 mm, P = .0011) and median tumor volume (NF2, 12.4 cm3 vs sporadic, 2.9 cm3, P = .0005) were significantly greater in patients with NF2. The median follow-up was 24.9 months (range, 12-130.1). Median facial nerve function after 1 year for patients with NF2 was HB 3 (range, 1-6) compared to HB 1 (range, 1-6) for sporadic VS (P = .001). With multivariate logistic regression, NF2 tumors (odds ratio [OR] = 13.9, P = .001) and tumor volume ≥3 cm3 (OR = 3.6, P = .025) were significantly associated with HB ≥3 when controlling for age, sex, extent of tumor resection, translabyrinthine approach, and prior radiation. CONCLUSION Tumor volume >3 cm3 and NF2 tumors are associated with poorer facial nerve outcomes 1 year following microsurgical resection.
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Affiliation(s)
- Catherine Sobieski
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel E Killeen
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel L Barnett
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bruce E Mickey
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jacob B Hunter
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Brandon Isaacson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Joe Walter Kutz
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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29
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Rueß D, Pöhlmann L, Grau S, Hamisch C, Hoevels M, Treuer H, Baues C, Kocher M, Ruge M. Outcome and toxicity analysis of single dose stereotactic radiosurgery in vestibular schwannoma based on the Koos grading system. Sci Rep 2020; 10:9309. [PMID: 32518238 PMCID: PMC7283483 DOI: 10.1038/s41598-020-66213-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/18/2020] [Indexed: 11/09/2022] Open
Abstract
Stereotactic radiosurgery (SRS) has evolved as widely accepted treatment option for small-sized (Koos I up to II) vestibular schwannoma (VS). For larger tumors (prevalent Koos VI), microsurgery or combined treatment strategies are mostly recommended. However, in patients not suited for microsurgery, SRS might also be an alternative to balance tumor control, hearing preservation and adverse effects. The purpose of this analysis was to evaluate the efficacy and toxicity of SRS for VS with regard to different Koos grades. All patients with untreated VS who received SRS at our center were included. Outcome analysis included tumor control, preservation of serviceable hearing based on median pure tone averages (PTA), and procedure-related adverse events rated by the Common Terminology Criteria for Adverse Events (CTCAE; v4.03) classification. In total, 258 patients (median age 58 years, range 21-84) were identified with a mean follow-up of 52 months (range 3-228 months). Mean tumor volume was 1.8 ml (range 0.1-18.5). The mean marginal dose was 12.3 Gy ± 0.6 (range 11-13.5). The cohort was divided into two groups: A (Koos grades I and II, n = 186) and B (Koos grades III and IV, n = 72). The actuarial tumor control rate was 98% after 2 years and 90% after 5 and 10 years. Koos grading did not show a significant impact on tumor control (p = 0.632) or hearing preservation (p = 0.231). After SRS, 18 patients (7%) had new transient or permanent symptoms classified by the CTCAE. The actuarial rate of CTCAE-free survival was not related to Koos grading (p = 0.093). Based on this selected population of Koos grade III and IV VS without or with only mild symptoms from brainstem compression, SRS can be recommended as the primary therapy with the advantage of low morbidity and satisfactory tumor control. The overall hearing preservation rate and toxicity of SRS was influenced by age and cannot be predicted by tumor volume or Koos grading alone.
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Affiliation(s)
- Daniel Rueß
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany.
| | - Lea Pöhlmann
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Stefan Grau
- Department of General Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Christina Hamisch
- Department of General Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Mauritius Hoevels
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Harald Treuer
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Baues
- Institute of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - Martin Kocher
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Maximillian Ruge
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
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30
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Abstract
Vestibular schwannoma (VS) is a Schwann cell-derived tumour arising from the vestibulocochlear nerve. Although benign, it represents a threat to intracranial structures due to mass effect and carries a small risk of malignant transformation. VS therefore represents an important healthcare burden. We review the literature regarding pathogenesis, risk factors, and diagnosis of VS. The current and future potential management strategies are also discussed. A narrative review of all relevant papers known to the authors was conducted. The majority of VS remain clinically stable and do not require interventional procedures. Nevertheless, various surgical techniques exist for removing VS, the most common of which are translabyrinthine and retrosigmoid approaches. Due to surgical risks such as hearing loss, facial nerve dysfunction, post-operative headache, and cerebrospinal fluid leakage, a "watch and rescan" approach is adopted for most patients. Radiotherapy is a useful alternative and has been shown to have a similar response for growth restriction. Due to the heterogeneous nature of VS, there is a lack of consensus regarding management of tumours that are too large for conservative management but too small to indicate surgery. Emerging biologic therapies, such as Bevacizumab, Everolimus, and Lapatinib, as well as anti-inflammatories like aspirin are promising potential treatments; however, long-term evidence of their efficacy is required. The knowledge base regarding VS continues to improve. With increased understanding of the pathogenesis of these tumors, we believe future work should focus on pharmacologic intervention. Biologic therapies aimed toward improved patient outcomes are particularly promising.
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Kunert P, Podgórska A, Dziedzic TA, Marchel A. Utility of preoperative electrophysiological testing of the facial nerve in patients with vestibular schwannoma. PLoS One 2019; 14:e0226607. [PMID: 31869358 PMCID: PMC6927592 DOI: 10.1371/journal.pone.0226607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/29/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose The aim of this study was to analyze the utility of various preoperative electrophysiological tests of the facial nerve CNVII in predicting CNVII function after vestibular schwannoma surgery. Methods This retrospective study included 176 patients who had preoperative facial nerve electroneurography and electrically evoked blink reflex testing. We defined the following variables: axonal degeneration of CNVII (AD-CNVII), trigeminal nerve damage (D-CNV), disturbances in the short-latency pathway of the blink reflex (D-BR), and any changes in electrophysiological test results (A-EMG). Results AD-CNVII, D-CNV, D-BR, and A-EMG were noted in 24%, 10%, 64%, and 71% of the patients, respectively. Negative D-CNV correlated with good CNVII function in early (p = 0.005) and long-term follow-up (p = 0.003) but was not an independent prognostic factor for postoperative facial muscles function. D-CNV appeared to be closely related to tumor size. D-BR was related to tumor size and had no predictive value. AD-CNVII (amplitude reduction of 50% or more compared to the healthy side) was an independent factor associated with increased risk of facial muscles weakness (p = 0.015 and p = 0.031 for early and late outcomes, respectively). Conclusions Further studies are needed to establish which tests and cut-off values are the most useful for predicting post-surgical facial nerve function.
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Affiliation(s)
- Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
- * E-mail:
| | - Anna Podgórska
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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MARCOS-ALONSO S, VILLAOSLADA-FUENTES R, MUÑOZ-HERRERA Á, BATUECAS-CALETRÍO Á, SANTA-CRUZ-RUÍZ S, MARTÍNEZ-CARRANZA RA. Cirugía del schwannoma vestibular. Factores predisponentes y predictores de parálisis facial. REVISTA ORL 2019. [DOI: 10.14201/orl.20152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Rajput MSA, Ahmad AN, Arain AA, Adeel M, Akram S, Awan MS, Bari ME. Preservation of Hearing and Facial Nerve Function with the Microsurgical Excision of Large Vestibular Schwannomas: Experience with the Retrosigmoid Approach. Cureus 2018; 10:e3684. [PMID: 30761236 PMCID: PMC6367112 DOI: 10.7759/cureus.3684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Vestibular schwannomas (VS) are the most common benign neoplasms of a cerebellopontine angle (CPA), which arise from the Schwann cells of the vestibulocochlear nerve. Eighty percent of CPA tumors are VS followed by meningioma as the second common mass lesion in this critical potential space. Treatment options range from watchful waiting with serial imaging studies to radiosurgery or a microsurgical excision or a combination of surgery and radiation therapy. The primary objective of the study was to assess hearing and facial nerve status before and after the surgery via the retrosigmoid approach. Methods The database of Aga Khan University Hospital was searched for diagnoses of vestibular schwannomas between 2000 and 2007. A total of 35 patients were identified; among them, 27 were selected for the study who met the inclusion criteria. The variables of the study were age, gender, presenting symptoms, size of the tumor, surgical approach, hearing levels, and facial nerve function. Hearing loss was categorized according to the Gardener-Robertson hearing classification and the House-Brackmann Scale was used for facial nerve assessment. Results Out of the 27 patients, 18 were male and nine were female. The mean age was 43 years. The most common presenting complaint was hearing loss and tinnitus, seen in 21 patients. Headache was present in six patients, ataxia in five, and vertigo in three. Facial nerve weakness was noticed in six patients. Two patients had Grade-III paralysis, three had Grade-IV paralysis, and one had Grade-V paralysis. The audiogram confirmed the presence of sensorineural hearing loss (SNHL) in all patients. Twelve patients out of 27 had Class II hearing with the threshold between 31 and 50 decibels and a Speech Discrimination Score (SDS) of 50% to 69%. Ten patients had non-serviceable hearing and the remaining five had poor hearing. The audiogram was repeated after surgery for those 12 patients who had Class II hearing and showed that seven out of 12 patients maintained a hearing threshold within the range of Class II at the one-year follow-up (hearing preservation 58%). The facial nerve preservation rate was 56% considering House-Brackmann Grade III or less as acceptable facial nerve function. Conclusion The optimal treatment for small vestibular schwannomas is a matter of controversy; however, the choice of treatment for large vestibular schwannomas in patients without significant comorbidity is generally microsurgical excision. The surgical excision of a large VS with the retrosigmoid approach is found to be safe consistently. The hearing and facial nerve preservation in our study were found comparable with the literature.
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Affiliation(s)
| | - Ahmad Nawaz Ahmad
- Otolaryngology, Liaquat National Hospital and Medical College, Karachi, PAK
| | | | - Mohammad Adeel
- Otolaryngology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Saeed Akram
- Internal Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, SAU
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Suero Molina E, van Eck ATCJ, Sauerland C, Schipmann S, Horstmann G, Stummer W, Brokinkel B. Local Tumor Control and Clinical Symptoms After Gamma Knife Radiosurgery for Residual and Recurrent Vestibular Schwannomas. World Neurosurg 2018; 122:e1240-e1246. [PMID: 30447443 DOI: 10.1016/j.wneu.2018.11.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of Gamma Knife radiosurgery (GKRS) for recurrent or residual vestibular schwannoma (VS) after microsurgery (MS) has been investigated in several retrospective studies. The purpose of this study was to identify potential risk factors for both neurologic deterioration and tumor progression after GKRS for previously operated VSs in a prospective setting. METHODS Patients who underwent GKRS for previously operated and histopathologically confirmed VS between 1998 and 2015 were prospectively followed-up. Risk factors for therapy side effects and predictors for tumor control were investigated in uni- and multivariate analyses. RESULTS A total of 160 individuals with a median age of 55 years were included. Median tumor volume prior to GKRS was 1.40 cm3 (range, 0.06-35.80 cm3). After a median follow-up of 36 months, hearing and facial nerve function were serviceable (modified Gardner-Robertson and House-Brackmann grades I and II) in 7 (5%) and 82 (55%) patients, respectively. Deterioration to a nonserviceable facial nerve function after GKRS was found in 3% (3/89) and tended to increase with rising tumor volume (odds ratio, 1.65 per cm3; 95% confidence interval, 1.00-2.71; P = 0.051). Median tumor volume prior to GKRS was higher in patients with radiologic (P = 0.020) or clinical tumor progression (P < 0.001). Critical tumor volume prior to GKRS to predict clinical and radiologic tumor progression was 1.30 cm3 (P < 0.001) and 3.30 cm3 (P = 0.019), respectively. However, in multivariate analyses, none of the analyzed variables were found to independently predict tumor progression. CONCLUSIONS Intended submaximal resection followed by GKRS is a viable treatment for VS. Because tumor remnant size after MS is an important predictor for recurrence after adjuvant GKRS, both brainstem and cerebellar decompression and maximal safely achievable resection should remain major goals of microsurgery.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | | | - Cristina Sauerland
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | | | | | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
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Cohen-Inbar O, Sviri GE. Adaptive Hybrid Surgery: Paradigm Shift for Patient-centered Neurosurgery. Rambam Maimonides Med J 2018; 9:RMMJ.10346. [PMID: 30089092 PMCID: PMC6115482 DOI: 10.5041/rmmj.10346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The surgical management of cerebral and skull base lesions has evolved greatly in the last few decades. Still, a complete resection of lesions abutting critical neurovascular structures carries significant morbidity. Stereotactic radiosurgery (SRS) has emerged as an increasingly accepted treatment option. Minimally invasive, SRS results in excellent tumor control and low complication rates in patients with moderate-size tumors. The management of large cerebral and skull base tumors remains a formidable challenge. In such large tumors, radical surgical extirpation offers a significantly higher risk of neurological deficit, and SRS alone cannot be used because of the elevated incidence of radiation-induced complications known to be associated with large-volume tumors. With increasing treatment volumes, SRS-associated tumor control rates decrease and complication rates increase. Planned subtotal resection (STR) with adjuvant SRS (adaptive hybrid surgery [AHS]) has gained increasing interest in recent years as a multimodal approach. In AHS, a planned STR (aimed at decreasing surgical morbidity) followed by SRS to a preplanned residual tumor aids in harnessing advantages offered by both approaches. Although intuitive and reasonable, this paradigm shift from maximal resection at all cost has not been adopted widely. Combining open microsurgery with SRS requires a good understanding of both surgical and SRS modalities and their respective safety-efficacy features. We present a review and discussion on AHS as a modern, multidisciplinary treatment approach. Available data and views are discussed for vestibular schwannoma (VS) as a sample tumor. Other indications for AHS are mentioned in brief.
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Affiliation(s)
- Or Cohen-Inbar
- Department of Neurological Surgery, Rambam Maimonides Health Care Campus, Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Department of Neurological Surgery and Gamma-Knife Center, University of Virginia Health Care Campus, Charlottesville, VA, USA
- To whom correspondence should be addressed. E-mail:
| | - Gil E Sviri
- Department of Neurological Surgery, Rambam Maimonides Health Care Campus, Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
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Lefranc M, Da Roz LM, Balossier A, Thomassin JM, Roche PH, Regis J. Place of Gamma Knife Stereotactic Radiosurgery in Grade 4 Vestibular Schwannoma Based on Case Series of 86 Patients with Long-Term Follow-Up. World Neurosurg 2018; 114:e1192-e1198. [DOI: 10.1016/j.wneu.2018.03.175] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/23/2018] [Accepted: 03/24/2018] [Indexed: 10/17/2022]
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Sheppard JP, Lagman C, Prashant GN, Alkhalid Y, Nguyen T, Duong C, Udawatta M, Gaonkar B, Tenn SE, Bloch O, Yang I. Planned Subtotal Resection of Vestibular Schwannoma Differs from the Ideal Radiosurgical Target Defined by Adaptive Hybrid Surgery. World Neurosurg 2018. [PMID: 29530701 DOI: 10.1016/j.wneu.2018.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To retrospectively compare ideal radiosurgical target volumes defined by a manual method (surgeon) to those determined by Adaptive Hybrid Surgery (AHS) operative planning software in 7 patients with vestibular schwannoma (VS). METHODS Four attending surgeons (3 neurosurgeons and 1 ear, nose, and throat surgeon) manually contoured planned residual tumors volumes for 7 consecutive patients with VS. Next, the AHS software determined the ideal radiosurgical target volumes based on a specified radiotherapy plan. Our primary measure was the difference between the average planned residual tumor volumes and the ideal radiosurgical target volumes defined by AHS (dRVAHS-planned). RESULTS We included 7 consecutive patients with VS in this study. The planned residual tumor volumes were smaller than the ideal radiosurgical target volumes defined by AHS (1.6 vs. 4.5 cm3, P = 0.004). On average, the actual post-operative residual tumor volumes were smaller than the ideal radiosurgical target volumes defined by AHS (2.2 cm3 vs. 4.5 cm3; P = 0.02). The average difference between the ideal radiosurgical target volume defined by AHS and the planned residual tumor volume (dRVAHS-planned) was 2.9 ± 1.7 cm3, and we observed a trend toward larger dRVAHS-planned in patients who lost serviceable facial nerve function compared with patients who maintained serviceable facial nerve function (4.7 cm3 vs. 1.9 cm3; P = 0.06). CONCLUSIONS Planned subtotal resection of VS diverges from the ideal radiosurgical target defined by AHS, but whether that influences clinical outcomes is unclear.
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Affiliation(s)
- John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Yasmine Alkhalid
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Courtney Duong
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Methma Udawatta
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Bilwaj Gaonkar
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Stephen E Tenn
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Orin Bloch
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA; Department of Radiation Oncology, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA; Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center at the University of California, Los Angeles (UCLA), Los Angeles, California, USA; Department of Neurosurgery, Harbor-UCLA Medical Center of the University of California, Los Angeles (UCLA), Torrance, California, USA; Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center of the University of California, Los Angeles (UCLA), Torrance, California, USA.
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Ho HH, Li YH, Lee JC, Wang CW, Yu YL, Hueng DY, Ma HI, Hsu HH, Juan CJ. Vestibular schwannomas: Accuracy of tumor volume estimated by ice cream cone formula using thin-sliced MR images. PLoS One 2018; 13:e0192411. [PMID: 29438424 PMCID: PMC5810994 DOI: 10.1371/journal.pone.0192411] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 01/08/2018] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We estimated the volume of vestibular schwannomas by an ice cream cone formula using thin-sliced magnetic resonance images (MRI) and compared the estimation accuracy among different estimating formulas and between different models. METHODS The study was approved by a local institutional review board. A total of 100 patients with vestibular schwannomas examined by MRI between January 2011 and November 2015 were enrolled retrospectively. Informed consent was waived. Volumes of vestibular schwannomas were estimated by cuboidal, ellipsoidal, and spherical formulas based on a one-component model, and cuboidal, ellipsoidal, Linskey's, and ice cream cone formulas based on a two-component model. The estimated volumes were compared to the volumes measured by planimetry. Intraobserver reproducibility and interobserver agreement was tested. Estimation error, including absolute percentage error (APE) and percentage error (PE), was calculated. Statistical analysis included intraclass correlation coefficient (ICC), linear regression analysis, one-way analysis of variance, and paired t-tests with P < 0.05 considered statistically significant. RESULTS Overall tumor size was 4.80 ± 6.8 mL (mean ±standard deviation). All ICCs were no less than 0.992, suggestive of high intraobserver reproducibility and high interobserver agreement. Cuboidal formulas significantly overestimated the tumor volume by a factor of 1.9 to 2.4 (P ≤ 0.001). The one-component ellipsoidal and spherical formulas overestimated the tumor volume with an APE of 20.3% and 29.2%, respectively. The two-component ice cream cone method, and ellipsoidal and Linskey's formulas significantly reduced the APE to 11.0%, 10.1%, and 12.5%, respectively (all P < 0.001). CONCLUSION The ice cream cone method and other two-component formulas including the ellipsoidal and Linskey's formulas allow for estimation of vestibular schwannoma volume more accurately than all one-component formulas.
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Affiliation(s)
- Hsing-Hao Ho
- Department of Radiology, Tri-Service General Hospital, Taipei, Taiwan
- Department of Radiology, National Defense Medical Center, Taipei, Taiwan
| | - Ya-Hui Li
- Department of Radiology, Tri-Service General Hospital, Taipei, Taiwan
- Department of Radiology, National Defense Medical Center, Taipei, Taiwan
| | - Jih-Chin Lee
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, Taipei, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Wei Wang
- Department of Radiology, Tri-Service General Hospital, Taipei, Taiwan
- Department of Radiology, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Lin Yu
- Department of Neurological Surgery, Tri-Service General Hospital, Taipei, Taiwan
- Department of Neurological Surgery, National Defense Medical Center, Taipei, Taiwan
| | - Dueng-Yuan Hueng
- Department of Neurological Surgery, Tri-Service General Hospital, Taipei, Taiwan
- Department of Neurological Surgery, National Defense Medical Center, Taipei, Taiwan
- Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-I Ma
- Department of Neurological Surgery, Tri-Service General Hospital, Taipei, Taiwan
- Department of Neurological Surgery, National Defense Medical Center, Taipei, Taiwan
- * E-mail: (CJJ); (H-IM)
| | - Hsian-He Hsu
- Department of Radiology, Tri-Service General Hospital, Taipei, Taiwan
- Department of Radiology, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Jung Juan
- Department of Radiology, Tri-Service General Hospital, Taipei, Taiwan
- Department of Radiology, National Defense Medical Center, Taipei, Taiwan
- * E-mail: (CJJ); (H-IM)
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Yoon YJ, Suh MJ, Lee HY, Lee HJ, Choi EH, Moon IS, Song K. Anti-tumor effects of cold atmospheric pressure plasma on vestibular schwannoma demonstrate its feasibility as an intra-operative adjuvant treatment. Free Radic Biol Med 2018; 115:43-56. [PMID: 29138018 DOI: 10.1016/j.freeradbiomed.2017.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/07/2017] [Accepted: 11/10/2017] [Indexed: 12/12/2022]
Abstract
Vestibular schwannoma (VS), although a benign intracranial tumor, causes morbidities by brainstem compression. Since chemotherapy is not very effective in most Nf2-negative schwannomas, surgical removal or radiation therapy is required. However, depending on the size and site of the tumor, these approaches may cause loss of auditory or vestibular functions, and severely decrease the post-surgical wellbeing. Here, we examined the feasibility of cold atmospheric pressure plasma (CAP) as an intra-operative adjuvant treatment for VS after surgery. Cell death was efficiently induced in both human HEI-193 and mouse SC4 VS cell lines upon exposure to CAP for seven minutes. Interestingly, both apoptosis and necroptosis were simultaneously induced by CAP treatment, and cell death was not completely inhibited by pan-caspase and receptor-interacting serine/threonine-protein kinase 1 (RIK1) inhibitors. Upon CAP exposure, cell death phenotype was similarly observed in patient-derived primary VS cells and tumor mass. In addition, CAP exposure after the surgical removal of primary tumor efficiently inhibited tumor recurrence in SC4-grafted mouse models. Collectively, these results strongly suggest that CAP should be developed as an efficient adjuvant treatment for VS after surgery to eliminate the possible remnant tumor cells, and to minimize the surgical area in the brain for post-surgical wellbeing.
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Affiliation(s)
- Yeo Jun Yoon
- Department of Biochemistry, College of Life Science & Biotechnology, Yonsei University, Seoul 03722, Korea
| | - Michelle J Suh
- Department of Otorhinolaryngology, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Hyun Young Lee
- Department of Electrical Engineering, Pusan National University, Pusan 46269, Korea
| | - Hae June Lee
- Department of Electrical Engineering, Pusan National University, Pusan 46269, Korea
| | - Eun Ha Choi
- Plasma Bioscience Research Center and Department of Electrical and Biological Physics, Kwangwoon University, Seoul 01897, Korea
| | - In Seok Moon
- Department of Otorhinolaryngology, College of Medicine, Yonsei University, Seoul 03722, Korea.
| | - Kiwon Song
- Department of Biochemistry, College of Life Science & Biotechnology, Yonsei University, Seoul 03722, Korea.
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Halliday J, Rutherford SA, McCabe MG, Evans DG. An update on the diagnosis and treatment of vestibular schwannoma. Expert Rev Neurother 2017; 18:29-39. [DOI: 10.1080/14737175.2018.1399795] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Jane Halliday
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, Manchester, UK
| | - Scott A. Rutherford
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, Manchester, UK
| | - Martin G. McCabe
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Dafydd G. Evans
- Manchester Centre for Genomic Medicine, MAHSC, Division of Evolution and Genomic Science, University of Manchester, Manchester, UK
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Mooney MA, Hendricks B, Sarris CE, Spetzler RF, Almefty KK, Porter RW. Long-Term Facial Nerve Outcomes after Microsurgical Resection of Vestibular Schwannomas in Patients with Preoperative Facial Nerve Palsy. J Neurol Surg B Skull Base 2017; 79:309-313. [PMID: 29765830 DOI: 10.1055/s-0037-1607320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022] Open
Abstract
Objectives This study aimed at evaluating facial nerve outcomes in vestibular schwannoma patients presenting with preoperative facial nerve palsy. Design A retrospective review. Setting Single-institution cohort. Participants Overall, 368 consecutive patients underwent vestibular schwannoma resection. Patients with prior microsurgery or radiosurgery were excluded. Main Outcome Measures Incidence, House-Brackmann grade. Results Of 368 patients, 9 had confirmed preoperative facial nerve dysfunction not caused by prior treatment, for an estimated incidence of 2.4%. Seven of these nine patients had Koos grade 4 tumors. Mean tumor diameter was 3.0 cm (range: 2.1-4.4 cm), and seven of nine tumors were subtotally resected. All nine patients were followed up clinically for ≥ 6 months. Of the six patients with a preoperative House-Brackmann grade of II, two improved to grade I, three were stable, and one patient worsened to grade III. Of the three patients with grade III or worse, all remained stable at last follow-up. Conclusions Preoperative facial nerve palsy is rare in patients with vestibular schwannoma; it tends to occur in patients with relatively large lesions. Detailed long-term outcomes of facial nerve function after microsurgical resection for these patients have not been reported previously. We followed nine patients and found that eight (89%) of the nine patients had either stable or improved facial nerve outcomes after treatment. Management strategies varied for these patients, including rates of subtotal versus gross-total resection and the use of stereotactic radiosurgery in patients with residual tumor. These results can be used to help counsel patients preoperatively on expected outcomes of facial nerve function after treatment.
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Affiliation(s)
- Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Benjamin Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Kaith K Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Randall W Porter
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
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Tveiten ØV, Carlson ML, Goplen F, Myrseth E, Driscoll CLW, Mahesparan R, Link MJ, Lund-Johansen M. Patient- versus physician-reported facial disability in vestibular schwannoma: an international cross-sectional study. J Neurosurg 2017; 127:1015-1024. [DOI: 10.3171/2016.8.jns16707] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVEPatient-reported outcomes are increasingly used in studies of vestibular schwannoma (VS); however, few studies have examined self-evaluated facial nerve function and its relation to physician-reported outcomes. The primary objective of this study was to compare patient self-evaluations of facial disability with physician-evaluated facial nerve status and with self-evaluations of a healthy control group. The second objective was to provide insight into the controversial subject of the optimal initial management of small- and medium-sized VSs; consequently, the authors compared patient-reported facial nerve disability following treatment via observation (OBS), Gamma Knife surgery (GKS), or microsurgery (MS). Lastly, the authors sought to identify risk factors for facial nerve dysfunction following treatment for small- and medium-sized VSs.METHODSAll patients with a VS 3 cm or smaller that was singly treated with OBS, GKS, or MS at either of 2 independent treatment centers between 1998 and 2008 were retrospectively identified. Longitudinal facial nerve measures and clinical data, including facial nerve evaluation according to the House-Brackmann (HB) grading system, were extracted from existing VS databases. Supplementing the objective data were Facial Disability Index (FDI) scores, which were obtained via survey of patients a mean of 7.7 years after initial treatment.RESULTSThe response rate among the 682 eligible patients was 79%; thus, data from a total of 539 patients were analyzed. One hundred forty-eight patients had been managed by OBS, 247 with GKS, and 144 with MS. Patients who underwent microsurgery had larger tumors and were younger than those who underwent OBS or GKS. Overall, facial nerve outcomes were satisfactory following treatment, with more than 90% of patients having HB Grade I function at the last clinical follow-up. Treatment was the major risk factor for facial nerve dysfunction. Almost one-fifth of the patients treated with MS had an objective decline in facial nerve function, whereas only 2% in the GKS group and 0% in the OBS cohort had a decline. The physical subscale of the FDI in the VS patients was highly associated with HB grade; however, the social/well-being subscale of the FDI was not. Thus, any social disability caused by facial palsy was not detectable by use of this questionnaire.CONCLUSIONSThe majority of patients with small- and medium-sized VSs attain excellent long-term facial nerve function and low facial nerve disability regardless of treatment modality. Tumor size and microsurgical treatment are risk factors for facial nerve dysfunction and self-reported disability. The FDI questionnaire is sensitive to the physical but not the social impairment associated with facial dysfunction.
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Affiliation(s)
- Øystein Vesterli Tveiten
- Departments of 1Neurosurgery and
- 3Department of Clinical Medicine, University of Bergen, Norway; and
| | - Matthew L. Carlson
- 5Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
- Departments of 4Neurologic Surgery and
| | | | | | - Colin L. W. Driscoll
- Departments of 4Neurologic Surgery and
- 5Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | | | - Michael J. Link
- Departments of 4Neurologic Surgery and
- 5Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Morten Lund-Johansen
- Departments of 1Neurosurgery and
- 3Department of Clinical Medicine, University of Bergen, Norway; and
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Spena G, Sorrentino T, Altieri R, Zinis LRD, Stefini R, Panciani PP, Fontanella M. Early-Career Surgical Practice for Cerebellopontine Angle Tumors in the Era of Radiosurgery. J Neurol Surg B Skull Base 2017; 79:269-281. [PMID: 29765825 DOI: 10.1055/s-0037-1606826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 08/12/2017] [Indexed: 10/18/2022] Open
Abstract
We analyzed the outcomes of patients with large cerebellopontine angle (CPA) tumors treated by a skull-base team in which two surgeons (one neurosurgeon and one otological surgeon) were in the beginning of their careers (<40 years old). Data of patients operated on between April 2012 and March 2016 were reviewed. All factors related to surgical training were considered. Thirty-one patients had vestibular schwannomas, while 26 had meningiomas. Mean tumor diameter was 30.6 mm (range, 23-49 mm) for schwannomas and 35 mm (range, 22-51 mm) for meningiomas. Satisfactory postoperative facial nerve function (House-Brackmann's grade I or II) was achieved in 20 (64.5%) schwannoma patients and 21 (80.7%) meningioma patients. Gross total and near-total resections (residual tumor < 5 mm) were achieved in 21 (67.7%) and 9 (29%) schwannoma patients, respectively. Gross total resection (Simpson's grade II) was achieved in 18 (69.2%) meningioma patients. In both groups, the retrosigmoid approach was the most common approach. Regarding surgical training of the two younger surgeons, during the residency period, they attended high-volume centers for CPA tumors. Application of microsurgical techniques was systematically applied from the beginning of their personal series in every intracranial pathology case. During the first 2 years of the series, they were supervised by more experienced surgeons and followed a stepwise sharing of increasingly difficult surgical phases; by comparing results of this period with the last 2 years of the series, where they acquired a complete autonomy, no relevant difference was detected. Our results suggest that young surgeons may achieve good results even at the beginning of their careers, if specific conditions related to training and mentorship are met.
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Affiliation(s)
- Giannantonio Spena
- Clinic of Neurosurgery, Spedali Civili and University of Brescia, Brescia, Italy
| | - Tommaso Sorrentino
- Clinic of ENT Surgery, Spedali Civili and University of Brescia, Brescia, Italy
| | - Roberto Altieri
- Clinic of Neurosurgery, Ospedale Molinette, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | | | - Roberto Stefini
- Clinic of Neurosurgery, Spedali Civili and University of Brescia, Brescia, Italy
| | - Pier Paolo Panciani
- Clinic of Neurosurgery, Spedali Civili and University of Brescia, Brescia, Italy
| | - Marco Fontanella
- Clinic of Neurosurgery, Spedali Civili and University of Brescia, Brescia, Italy
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Wong RH, Copeland WR, Jacob JT, Sivakanthan S, Van Gompel JJ, van Loveren H, Link MJ, Agazzi S. Anterior Extension of Tumor is as Important as Tumor Size to Facial Nerve Outcome and Extent of Resection for Vestibular Schwannomas. J Neurol Surg B Skull Base 2017; 78:473-480. [PMID: 29134166 DOI: 10.1055/s-0037-1604331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 06/08/2017] [Indexed: 10/19/2022] Open
Abstract
Objectives We examined vestibular schwannoma tumor dimension and direction of growth to determine whether these correlate with facial nerve outcome as well as extent of resection (EOR). Design Retrospective review of prospectively maintained databases. Participants 206 patients were a part of this study. Main Outcome Measures Tumor dimensions were measured using preoperative magnetic resonance imaging, and a series of ratios were then calculated to further characterize tumor dimension. Regression analyses were performed to investigate correlation with facial nerve outcome and EOR. Results Patients with tumor extending >1.5 cm anterior to the internal auditory canal (IAC) (AB measurement) were three times more likely to have postoperative House-Brackman grades of 3 or worse. We also found that an EB/BF ratio (representing elongated growth parallel to the IAC axis) ≥1.1 was associated with half the risk of poor facial nerve outcome. Tumors with anterior-posterior diameter (AC measurement) >1.9 cm were five times less likely to undergo gross total resection (GTR). Furthermore, an increased degree of tumor extension into the IAC (DE measurement >2.4 cm) or an increased amount of brainstem compression (EB measurement >1.1 cm) were each associated with a nearly 3-fold decrease in the likelihood of GTR. Conclusion Our study demonstrates that anterior extent of the tumor is as important as tumor size to facial nerve outcome and degree of resection for vestibular schwannomas.
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Affiliation(s)
- Ricky H Wong
- Department of Neurologic Surgery, NorthShore University Health System, Pritzker School of Medicine, Evanston, Illinois, United States
| | - William R Copeland
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Jeffrey T Jacob
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Sananthan Sivakanthan
- Department of Neurologic Surgery, University of New Mexico, Albuquerque, New Mexico, United States
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Harry van Loveren
- Department of Neurologic Surgery, University of South Florida, Tampa, Florida, United States
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Siviero Agazzi
- Department of Neurologic Surgery, University of South Florida, Tampa, Florida, United States
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Grahnke K, Garst JR, Martin B, Leonetti JP, Anderson DE. Prognostic Indices for Predicting Facial Nerve Outcome following the Resection of Large Acoustic Neuromas. J Neurol Surg B Skull Base 2017; 78:454-460. [PMID: 29134163 DOI: 10.1055/s-0037-1604077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022] Open
Abstract
This study analyzes the simple ratio of anterior-to-posterior extension of large (>2.5 cm) acoustic neuromas relative to the internal auditory canal (ICA; anterior-posterior [A/P] index) as a tool for predicting risk of facial nerve (FN) injury. In total, 105 patients who underwent microsurgical resection for large acoustic neuromas were analyzed retrospectively. House-Brackmann (HB) scores were assessed immediately postoperatively, at 1 month, and at 1 year. Lateral-medial, inferior-superior, A/P, and maximum diameters were measured from preoperative magnetic resonance images. These measurements and the A/P index were analyzed using univariable and multivariable statistical models to assess relationship to FN outcomes. The retrosigmoid, translabyrinthine, and combined approaches were used, and the extent of resection was evaluated. For every 1 standard deviation increase in the A/P index, a patient was 3.87 times more likely have a higher postoperative HB score ( p < 0.0001). Accordingly, for every 1-mm increase anterior to the IAC, a patient was 16% more likely have a higher postoperative HB score ( p < 0.001). After controlling for tumor size, a patient was still 3.82 times more likely have a higher postoperative HB score for every 1 standard deviation increase in the A/P index ( p < 0.0001). While larger tumor size trended toward worse postoperative HB scores, it was not statistically significant. Our prognostic index may be useful to assess the risk of FN injury preoperatively for large acoustic neuromas, while also providing information about the tumor-nerve relationship.
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Affiliation(s)
- Kurt Grahnke
- Department of Neurological Surgery and Otolaryngology, Head and Neck Surgery, Loyola University Chicago, Maywood, Illinois, United States
| | - Jonathan R Garst
- Department of Neurological Surgery and Otolaryngology, Head and Neck Surgery, Loyola University Chicago, Maywood, Illinois, United States
| | - Brendan Martin
- Department of Neurological Surgery and Otolaryngology, Head and Neck Surgery, Loyola University Chicago, Maywood, Illinois, United States
| | - John P Leonetti
- Department of Neurological Surgery and Otolaryngology, Head and Neck Surgery, Loyola University Chicago, Maywood, Illinois, United States
| | - Douglas E Anderson
- Department of Neurological Surgery and Otolaryngology, Head and Neck Surgery, Loyola University Chicago, Maywood, Illinois, United States
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46
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Lin EP, Crane BT. The Management and Imaging of Vestibular Schwannomas. AJNR Am J Neuroradiol 2017; 38:2034-2043. [PMID: 28546250 DOI: 10.3174/ajnr.a5213] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Vestibular schwannomas are the most common cerebellopontine angle tumor. During the past century, the management goals of vestibular schwannomas have shifted from total resection to functional preservation. Current treatment options include surgical resection, stereotactic radiosurgery, and observation. Imaging has become a crucial part of the initial screening, evaluation, and follow-up assessment of vestibular schwannomas. Recognizing and understanding the management objectives, various treatment modalities, expected posttreatment findings, and complications allows the radiologist to play an essential role in a multidisciplinary team by providing key findings relevant to treatment planning and outcome assessment. The authors provide a comprehensive discussion of the surgical management, role of radiation therapy and observation, imaging differential, and pre- and posttreatment imaging findings of vestibular schwannomas.
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Affiliation(s)
- E P Lin
- From the Departments of Imaging Sciences (E.P.L.)
| | - B T Crane
- Otolaryngology (B.T.C), University of Rochester Medical Center, Rochester, New York
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Bernardeschi D, Pyatigorskaya N, Vanier A, Bielle F, Smail M, Lamas G, Sterkers O, Kalamarides M. Role of electrophysiology in guiding near-total resection for preservation of facial nerve function in the surgical treatment of large vestibular schwannomas. J Neurosurg 2017; 128:903-910. [PMID: 28409723 DOI: 10.3171/2016.11.jns161737] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In large vestibular schwannoma (VS) surgery, the facial nerve (FN) is at high risk of injury. Near-total resection has been advocated in the case of difficult facial nerve dissection, but the amount of residual tumor that should be left and when dissection should be stopped remain controversial factors. The objective of this study was to report FN outcome and radiological results in patients undergoing near-total VS resection guided by electromyographic supramaximal stimulation of the FN at the brainstem. METHODS This study was a retrospective analysis of a prospectively maintained database. Inclusion criteria were surgical treatment of a large VS during 2014, normal preoperative FN function, and an incomplete resection due to the strong adherence of the tumor to the FN and the loss of around 50% of the response of supramaximal stimulation of the proximal FN at 2 mA. Facial nerve function and the amount and evolution of the residual tumor were evaluated by clinical examination and by MRI at a mean of 5 days postoperatively and at 1 year postoperatively. RESULTS Twenty-five patients met the inclusion criteria and were included in the study. Good FN function (Grade I or II) was observed in 16 (64%) and 21 (84%) of the 25 patients at Day 8 and at 1 year postoperatively, respectively. At the 1-year follow-up evaluation (n = 23), 15 patients (65%) did not show growth of the residual tumor, 6 patients (26%) had regression of the residual tumor, and only 2 patients (9%) presented with tumor progression. CONCLUSIONS Near-total resection guided by electrophysiology represents a safe option in cases of difficult dissection of the facial nerve from the tumor. This seems to offer a good compromise between the goals of preserving facial nerve function and achieving maximum safe resection.
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Affiliation(s)
- Daniele Bernardeschi
- Departments of1Otology, Auditory Implants, and Skull Base Surgery.,2Sorbonne Universités, UPMC Université Paris VI; and.,3Inserm UMR-S1159, Réhabilitation Chirurgicale Mini-Invasive et Robotisée de L'Audition, Paris,France
| | | | | | - Franck Bielle
- 2Sorbonne Universités, UPMC Université Paris VI; and.,7Neuropathology, AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix
| | - Mustapha Smail
- Departments of1Otology, Auditory Implants, and Skull Base Surgery
| | - Georges Lamas
- Departments of1Otology, Auditory Implants, and Skull Base Surgery.,2Sorbonne Universités, UPMC Université Paris VI; and.,3Inserm UMR-S1159, Réhabilitation Chirurgicale Mini-Invasive et Robotisée de L'Audition, Paris,France
| | - Olivier Sterkers
- Departments of1Otology, Auditory Implants, and Skull Base Surgery.,2Sorbonne Universités, UPMC Université Paris VI; and.,3Inserm UMR-S1159, Réhabilitation Chirurgicale Mini-Invasive et Robotisée de L'Audition, Paris,France
| | - Michel Kalamarides
- 2Sorbonne Universités, UPMC Université Paris VI; and.,6Neurosurgery, and
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48
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Zhang S, Liu W, Hui X, You C. Surgical Treatment of Giant Vestibular Schwannomas: Facial Nerve Outcome and Tumor Control. World Neurosurg 2016; 94:137-144. [PMID: 27392890 DOI: 10.1016/j.wneu.2016.06.119] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/25/2016] [Accepted: 06/27/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Surgical treatment of giant vestibular schwannomas (GVS) is challenging. The philosophy of incomplete tumor resection may balance the preservation of facial nerve function and long-term tumor control. OBJECTIVE We aimed to evaluate the outcome of facial nerve function and tumor control in treating GVS via our institutional surgical strategy. METHODS From September 2009 to August 2014, 218 patients who underwent surgical treatment of GVS were enrolled in our study. The clinical features, extent of resections, facial nerve outcome, and the tumor regrowth free rate of these patients were retrospectively analyzed. The treatment strategy of this disease was discussed. RESULTS All patients had anatomic preservation of the facial nerve. Gross total resection (GTR) was achieved in 58 patients (28.6%), near-total resection (NTR) in 103 (50.7%), and subtotal resection (STR) in 42 (20.7%). Two patients died because of postoperative complications. After a mean follow-up of 39.7 ± 18.3 months, a favorable facial nerve outcome was achieved in 58.6%, 79.6%, and 83.3% of patients who underwent GTR, NTR, and STR, respectively. During follow-up, 20 patients had tumor regrowth and were treated by stereotactic radiosurgery (SRS), and tumor regrowth free rates were 96.6%, 92.2%, and 76.2% in GTR, NTR, and STR, respectively. The extent of resection was the independent risk factor for poor facial nerve function (P = 0.006). CONCLUSIONS A surgical philosophy of prioritizing facial nerve preservation over total tumor resection was recommended in treatment of GVS. Favorable facial nerve outcome and tumor control were achieved after NTR of the tumors.
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Affiliation(s)
- Si Zhang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wenke Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xuhui Hui
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Taddei G, Marrelli A, Trovarelli D, Ricci A, Galzio RJ. Facial functional outcome in monitored versus not-monitored patients in vestibular schwannomas surgery. Asian J Neurosurg 2016; 11:402-406. [PMID: 27695545 PMCID: PMC4974966 DOI: 10.4103/1793-5482.144208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: Even though advances in surgical techniques have improved facial nerve outcomes, functional preservation is still an issue because injury to the facial nerve has significant physical and psychological consequences for the patient. We retrospectively review our data in VS surgery to compare the facial outcome in intraoperative facial monitored versus not-monitored patients. Materials and Methods: 51 consecutive patients with unilateral vestibular schwannoma in the period from 2005 to 2010 were treated in our Institution. In according to the type of neurophysiological tool used during surgical procedures, two patients groups were identified: Group 1 (facial stimulator only) and Group 2 (stimulator and facial monitoring). Statistical comparison of the two groups was made with the t- test, and facial function results were evaluated with the Fisher's exact test. Results: In the Group 1, of the 22 patients with anatomically preserved facial nerves, 3 (13.6%) showed excellent facial nerve function, 14 (63.6%) showed intermediate function, and 5 (22.7%) showed poor function. In the Group 2, all the 27 patients got anatomically preserved facial nerves, and 18 (66.7%) showed excellent facial nerve function, 9 (33.3%) showed intermediate function, and no one showed poor function. Conclusions: We found that retrosigmoid approach associated with continuous EMG facial monitoring combined with the use of bipolar stimulation is a safe and effective treatment for vestibular schwannomas.
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Affiliation(s)
- Graziano Taddei
- Department of Neurosurgery, S. Salvatore Hospital, L'Aquila, Italy
| | - Alfonso Marrelli
- Department of Neurophysiopathology, S. Salvatore Hospital, L'Aquila, Italy
| | | | - Alessandro Ricci
- Department of Neurosurgery, S. Salvatore Hospital, L'Aquila, Italy
| | - Renato J Galzio
- Department of University of L'Aquila, L'Aquila, Italy; Department of University of L'Aquila, L'Aquila, Italy
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Kunert P, Dziedzic T, Podgórska A, Nowak A, Czernicki T, Marchel A. Surgery for sporadic vestibular schwannoma. Part IV. Predictive factors influencing facial nerve function after surgery. Neurol Neurochir Pol 2015; 50:36-44. [PMID: 26851688 DOI: 10.1016/j.pjnns.2015.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 11/09/2015] [Accepted: 11/13/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To analyze the impact of various clinical, radiological and perioperative factors that could influence the facial nerve intraoperative disruption risk (CNVII-IDR) and its long-term function (CNVII-LTF) after vestibular schwannoma (VS) surgery. MATERIAL AND METHODS The study included 212 patients operated on for sporadic VS with no history of previous treatment for VS or CNVII palsy. The mean size of the tumor was 30 mm. Gross (210) or near-total (2) resections were carried out using the retrosigmoid (210) or translabyrinthine (2) approach. Correlation studies and multivariate regression analysis (RA) were performed. RESULTS In correlation studies, the CNVII-IDR was increased by: headaches and cerebellar ataxia if one of them was the first symptom of the tumor (33% and 29%, respectively, p=0.008); preoperative hydrocephalus (40% vs. 9%, p=0.01), tumor size >3 cm (18% vs. 5%, p<0.01), tumor volume >10 cm(3) (19% vs. 4%, p<0.01), right-sided location 15% vs. 6%, p=0.047), lateral "park-bench" position (19% vs. 5% for supine position, p<0.01) and the procedure order (16% for the first 106 procedures vs. 6% for the last 106 procedures, p<0.05). In RA the tumor volume (p=0.012), side of the tumor (p=0.028) and patient's position during surgery (p=0.016) independently affected the CNVII-IDR. The following factors correlated significantly with satisfactory CNVII-LTF (HB grades I-III): tumor stage <T4 (p=0.000), tumor size ≤3 cm (p=0.000), tumor volume ≤10 cm(3) (p=0.001), and left-sided location (p=0.048). Additional factors correlated significantly with very good CNVII-LTF (HB grades I-II): anterior CNVII displacement (p=0.044), nimodipine use (p=0.016), the absence of postoperative complications (p=0.019), CNVII responsive on final intraoperative EMG stimulation (p=0.000) and supine position during surgery (p=0.018). However, an independent impact on very good CNVII-LTF proved to be the tumor size (p=0.0000), side (p=0.0175), and nimodipine use (p=0.0349). CONCLUSIONS In our series, the factors related to size and side of the tumor confirmed an independent impact on CNVII-IDR and CNVIILTF. The significance of patient positioning may reflect the impact of learning curve as only the first 91 patients were operated on using the lateral "park-bench" position. An independent impact on CNVII-LTF was exerted by the perioperative use of nimodipine.
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Affiliation(s)
- Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland.
| | - Anna Podgórska
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Arkadiusz Nowak
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Czernicki
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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