Postoperative headache following treatment of vestibular schwannoma: A literature review

Perceived Health Benefits in Vestibular Schwannoma Patients with Long-Term Postoperative Headache: Insights from Personality Traits and Pain Coping-A Cross-Sectional Study

Postoperative headaches (POHs) following retrosigmoid microsurgery for vestibular schwannoma (VS) can significantly impact patients' perceived health benefits (PHBs). In this cross-sectional observational study, 101 VS patients were investigated. For the assessment of pain, the Rostock Headache Compendium (RoKoKo) and the German pain processing questionnaire (FESV) were used. The perceived health benefits (PHBs) were assessed by the Glasgow Benefit Inventory (GBI) and Big Five personality traits were measured using the Ten-Item Personality Inventory (TIPI-G). We showed that 55% of the participants experienced POHs, leading to a marked reduction in overall PHBs compared to those without POHs. The correlation analysis revealed an association between decreased PHBs and elevated levels of pain-related helplessness, depression, anxiety, and anger. Positive correlations were identified between PHBs and action-planning competence, cognitive restructuring, and the experience of competence. Low emotional stability and openness yielded associations with pain-related psychological impairment. Hearing loss and facial paresis did not exert a significant impact on PHBs. The study highlights the influence of pain-related coping strategies on PHBs in long-term POH patients. Thus, coping mechanisms and personality traits should be assessed even before surgery for post-surgery pain prevention. The limitations of this study include a relatively small sample size, potential biases introduced by the overrepresentation of female patients, and the use of an online survey methodology. In conclusion, this research highlights that the interplay between headaches, PHBs, and psychological factors is also relevant in VS patients undergoing microsurgery. Short-term psychological interventions should therefore be taken into account to improve post-surgery adaptive coping strategies.

Single-fraction stereotactic radiosurgery versus microsurgical resection for the treatment of vestibular schwannoma: a systematic review and meta-analysis

BACKGROUND

Vestibular schwannomas are benign tumours for which various treatments are available. We performed a systematic review of prospective controlled trials comparing the patient-relevant benefits and harms of single-fraction stereotactic radiosurgery (sfSRS) with microsurgical resection (MR) in patients with vestibular schwannoma.

METHODS

We searched for randomized controlled trials (RCTs) and non-randomized prospective controlled trials in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and study registries (last search: 09/2021) and also screened reference lists of relevant systematic reviews. Manufacturers were asked to provide unpublished data. Eligible studies investigated at least one patient-relevant outcome. We assessed the risk of bias (high or low) at the study and outcome level. If feasible, meta-analyses were performed. We graded the results into different categories (hint, indication, or proof of greater benefit or harm).

RESULTS

We identified three non-randomized prospective controlled trials of generally low quality with evaluable data on 339 patients with unilateral vestibular schwannoma. There was an indication of greater benefit of sfSRS compared with MR for facial palsy (OR 0.06, 95% CI 0.02-0.21, p < 0.001, 2 studies), hearing function (no pooled estimate available, 2 studies), and length of hospital stay (no pooled estimate available, 2 studies). We found no clinically relevant differences for mortality, vertigo, headaches, tinnitus, balance function, work disability, adverse events, and health-related quality of life.

CONCLUSIONS

Our systematic review indicates that sfSRS has greater benefits than MR in patients with unilateral vestibular schwannoma. However, it is unclear whether this conclusion still holds after 2 years, as long-term studies are lacking. It is also unclear whether the effects of sfSRS are similar in patients with bilateral vestibular schwannomas. Long-term prospective studies including patients with this condition would therefore be useful.

SYSTEMATIC REVIEW REGISTRATION

The full (German language) protocol and report (Commission No. N20-03) are available on the institute's website: www.iqwig.de/en/projects/n20-03.html.

Nomogram for Postoperative Headache in Adult Patients Undergoing Elective Cardiac Surgery

Background Postoperative headache (POH) is frequent after cardiac surgery; however, few studies on risk factors for POH exist. The aims of the current study were to explore risk factors related to POH after elective cardiac surgery and to establish a predictive system. Methods and Results Adult patients undergoing elective open-heart surgery under cardiopulmonary bypass from 2016 to 2020 in 4 cardiac centers were retrospectively included. Two thirds of the patients were randomly allocated to a training set and one third to a validation set. Predictors for POH were selected by univariate and multivariate analysis. POH developed in 3154 of the 13 440 included patients (23.5%) and the overall mortality rate was 2.3%. Eight independent risk factors for POH after elective cardiac surgery were identified, including female sex, younger age, smoking history, chronic headache history, hypertension, lower left ventricular ejection fraction, longer cardiopulmonary bypass time, and more intraoperative transfusion of red blood cells. A nomogram based on the multivariate model was constructed, with reasonable calibration and discrimination, and was well validated. Decision curve analysis revealed good clinical utility. Finally, 3 risk intervals were divided to better facilitate clinical application. Conclusions A nomogram model for POH after elective cardiac surgery was developed and validated using 8 predictors, which may have potential application value in clinical risk assessment, decision-making, and individualized treatment associated with POH.

Incidence, Risk Factors and Outcomes of Postoperative Headache After Stanford Type a Acute Aortic Dissection Surgery

Background: Postoperative headache (POH) is common in clinical practice, however, no studies about POH after Stanford type A acute aortic dissection surgery (AADS) exist. This study aims to describe the incidence, risk factors and outcomes of POH after AADS, and to construct two prediction models.

Methods: Adults who underwent AADS from 2016 to 2020 in four tertiary hospitals were enrolled. Training and validation sets were randomly assigned according to a 7:3 ratio. Risk factors were identified by univariate and multivariate logistic regression analysis. Nomograms were constructed and validated on the basis of independent predictors.

Results: POH developed in 380 of the 1,476 included patients (25.7%). Poorer outcomes were observed in patients with POH. Eight independent predictors for POH after AADS were identified when both preoperative and intraoperative variables were analyzed, including younger age, female sex, smoking history, chronic headache history, cerebrovascular disease, use of deep hypothermic circulatory arrest, more blood transfusion, and longer cardiopulmonary bypass time. White blood cell and platelet count were also identified as significant predictors when intraoperative variables were excluded from the multivariate analysis. A full nomogram and a preoperative nomogram were constructed based on these independent predictors, both demonstrating good discrimination, calibration, clinical usefulness, and were well validated. Risk stratification was performed and three risk intervals were defined based on the full nomogram and clinical practice.

Conclusions: POH was common after AADS, portending poorer outcomes. Two nomograms predicting POH were developed and validated, which may have clinical utility in risk evaluation, early prevention, and doctor-patient communication.

Role of Craniectomy Versus Craniotomy via the Retrosigmoid Approach in Decreasing the Incidence of Postoperative Headache

Background: Postoperative headache is a major complaint after RS surgery. PH affected the patient’s quality of life. The role of craniotomy in the prevention of such headaches. We aimed to evaluate the role of craniectomy versus craniotomy via the retrosigmoid approach in reducing the incidence of postoperative headaches. Materials and methods: Patients who underwent surgery between January 2012 and December 2018 were retrospectively assessed and were classified into the craniectomy and craniotomy groups. Clinical data, such as those on age, sex, type of surgery, surgical repair technique, development of infection, postoperative cerebrospinal fluid leak, postoperative meningitis, size of the bone flap, and wound infection, were collected. The severity of headache in all patients was clinically assessed using the Catalano grading system. Results: Overall, 95 patients underwent microsurgery via the retrosigmoid approach. Of these, 48 were men and 47 were women. In total, 34 patients underwent craniectomy, and 61 patients underwent craniotomy. On discharge, postoperative headache was observed in 47% (16/34) and 21% (13/61) of patients who underwent craniectomy and craniotomy, respectively ( P =.01). The incidence of headache decreased at follow-up. At 12 months after surgery, 15% of patients in the craniectomy group (5/34) and 2% of patients in the craniotomy group (2/61) experienced headache ( P =.01). Of the 61 patients in the craniotomy group, 2 (2%) had less severe headache at 12 months of follow-up. Conclusion: The severity of headache after surgery and upon discharge significantly decreased in patients who underwent craniotomy than in those who underwent craniectomy.

Predictors and nomogram models for postoperative headache in patients undergoing heart valve surgery

Background

Headache is a frequent complication after cardiac surgery. However, studies on the risk factors of postoperative headache (POH) are rare. The purpose of this study was to identify independent risk factors for POH in patients undergoing heart valve surgery (HVS) and to develop and validate risk prediction models.

Methods

Consecutive patients undergoing open HVS from 2016 to 2019 were enrolled in this study. Patients were randomly assigned to training and validation sets at a 2:1 ratio. Univariate and multivariate analysis were applied to identify independent predictors for POH in the training set. A nomogram predicting POH was developed based on these factors, and was validated in the independent validation set.

Results

POH developed in 1,061 of the 3,853 patients (27.5%). The overall mortality was 2.9%, and it was significantly higher in patients with POH (4.3% versus 2.4%, P<0.001). In the training set, six independent predictors were identified by multivariate analysis, including female, smoking history, hypertension, headache history, left ventricular ejection fraction, and cardiopulmonary bypass time. The model demonstrated good discrimination in both the training (c-index: 0.811) and validation sets (c-index: 0.814), and calibration was assessed by visual inspection. A second nomogram was also constructed including only preoperative predictors, with good discrimination (c-index: 0.792) and calibration. The decision and clinical impact curves of the models showed good clinical utility.

Conclusions

We developed and validated two risk prediction models for POH in patients undergoing HVS. The models may have clinical utility in individualized risk assessment and preventive interventions.

Defining current practice patterns of vestibular schwannoma management in Italy: results of a nationwide survey

Objective

Despite the increasing incidence rate of vestibular schwannomas (VS), controversies in their management are still present.

Methods

A 35-item multiple-choice survey investigating the current practice patterns of VS care was sent to the members of the Italian Society of Otolaryngology, Head and Neck Surgery (SIO) and of the Italian Society of Neurosurgery (SINCH).

Results

Among 66 respondents, 37 (56.0%) claimed to be actively involved in VS management. Most interviewees (35.1%) declared > 20 years of experience and 59.5% claimed to work in an academic practice. The number of cases evaluated in each centre per year varied widely, with 54.0% evaluating > 25 cases/year and only 13.6% > 100 cases/year. Multidisciplinary care for VS evaluation was confirmed by 50.0% of respondents, and multidisciplinary surgical care by 62.2%. Observation and surgery were the most common management options proposed. Further details regarding VS care are presented.

Conclusions

The present study provides the first overview on the current practice patterns of VS care in Italy. Although integrated in most centres, a multidisciplinary model of care needs to be encouraged. Wide heterogeneity in experience and practices is mostly influenced by the surgeon’s different specialties and by the lack of shared guidelines.

Large and small vestibular schwannomas: same, yet different tumors

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.

Postoperative headache after surgical treatment of cerebellopontine angle tumors: a systematic review

Purpose

Postoperative headache (POH) is a complication that occurs after surgical resection of cerebellopontine angle (CPA) tumors. The two most common surgical approaches are the translabyrinthine (TL), and retrosigmoid (RS) approach. The objective of this systematic review was to investigate whether POH occurs more frequently after RS compared to TL approaches.

Methods

A systematic search was conducted in Cochrane, Pubmed and Embase. Studies were included if POH after CPA tumor removal was reported and both surgical approaches were compared. The methodological quality of the studies was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool.

Results

In total, 3,942 unique articles were screened by title and abstract. After the initial screening process 63 articles were screened for relevance to the inquiry, of which seven studies were included. Three studies found no significant difference between both surgical approaches (p = 0.871, p = 0.120, p = 0.592). Three other studies found a lower rate of POH in the TL group compared to the RS group (p = 0.019, p < 0.001, p < 0.001). Another study showed a significantly lower POH rate in the TL group after one and six months (p = 0.006), but not after 1 year (p = 0.6).

Conclusion

The results of this systematic review show some evidence of a lower rate of POH in favor of the TL approach versus the RS approach for CPA tumor resection. Prospective research studies are needed to further investigate this finding.

Sigmoid Sinus Patency following Vestibular Schwannoma Resection via Retrosigmoid versus Translabyrinthine Approach

Introduction The treatment options for acoustic neuromas are observation with serial imaging, stereotactic radiation, or surgical resection. The most common surgical approaches are the translabyrinthine (TL), the retrosigmoid (RS), and the middle cranial fossa. During the TL approach the sigmoid sinus is decompressed with bipolar cautery to allow greater medial exposure. It is unknown if this causes any long-term narrowing or thrombus of the sigmoid sinus.

Methods We performed a retrospective review of patients who underwent acoustic neuroma resection to determine if patients undergoing a TL approach for acoustic neuroma resection develop radiographic evidence of sigmoid sinus stenosis or thrombosis compared with patients undergoing a RS approach.

Results A total of 128 patients were included in this study, 56 patients underwent a TL approach and 72 patients underwent a RS approach. We compared the preoperative and postoperative diameter of the ipsilateral and contralateral sigmoid sinus at proximal, midpoint, and distal locations on magnetic resonance imaging examinations. There was no significant difference between the preoperative and postoperative diameter of the ipsilateral or contralateral sigmoid sinus based on surgical approach.

Conclusion Decompression of the sigmoid sinus during the TL approach does not have a significant postoperative effect on the dural venous sinus patency.

Surgery of the lateral skull base: a 50-year endeavour

Disregarding the widely used division of skull base into anterior and lateral, since the skull base should be conceived as a single anatomic structure, it was to our convenience to group all those approaches that run from the antero-lateral, pure lateral and postero-lateral side of the skull base as “Surgery of the lateral skull base”. “50 years of endeavour” points to the great effort which has been made over the last decades, when more and more difficult surgeries were performed by reducing morbidity. The principle of lateral skull base surgery, “remove skull base bone to approach the base itself and the adjacent sites of the endo-esocranium”, was then combined with function preservation and with tailoring surgery to the pathology. The concept that histology dictates the extent of resection, balancing the intrinsic morbidity of each approach was the object of the first section of the present report. The main surgical approaches were described in the second section and were conceived not as a step-by-step description of technique, but as the highlighthening of the surgical principles. The third section was centered on open issues related to the tumor and its treatment. The topic of vestibular schwannoma was investigated with the current debate on observation, hearing preservation surgery, hearing rehabilitation, radiotherapy and the recent efforts to detect biological markers able to predict tumor growth. Jugular foramen paragangliomas were treated in the frame of radical or partial surgery, radiotherapy, partial “tailored” surgery and observation. Surgery on meningioma was debated from the point of view of the neurosurgeon and of the otologist. Endolymphatic sac tumors and malignant tumors of the external auditory canal were also treated, as well as chordomas, chondrosarcomas and petrous bone cholesteatomas. Finally, the fourth section focused on free-choice topics which were assigned to aknowledged experts. The aim of this work was attempting to report the state of the art of the lateral skull base surgery after 50 years of hard work and, above all, to raise questions on those issues which still need an answer, as to allow progress in knowledge through sharing of various experiences. At the end of the reading, if more doubts remain rather than certainties, the aim of this work will probably be achieved.

Long-term quality of life in patients with vestibular schwannoma managed with microsurgery

OBJECTIVE

Little is known about the long term (greater than 10 years) quality of life in patients with vestibular schwannoma. This study aimed to evaluate long-term outcomes in patients with vestibular schwannoma.

METHOD

A retrospective cohort study was performed across 2 academic institutions, with patients followed at least 10 years after vestibular schwannoma surgery (2000 to 2007). Telephone interviews were used to assess quality of life using the Glasgow Benefit Inventory and short form 12 item (version 2) health survey.

RESULTS

A total of 99 out of 110 patients were included. Increasing age and symptom burden were associated with poorer quality of life (p = 0.01 and 0.02, respectively). The presence of imbalance, headache and facial nerve dysfunction were all associated with poorer quality of life scores (p = 0.01, 0.04 and 0.02, respectively).

CONCLUSION

Identifying and managing post-operative symptoms may improve quality of life in vestibular schwannoma patients and can guide clinical decision making.

Peri-Incisional Botulinum Toxin Therapy for Treatment of Intractable Head Pain After Lateral Skull Base Surgery: A Case Series

OBJECTIVE

The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery.

BACKGROUND

Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes.

METHODS

In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months.

RESULTS

All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value.

CONCLUSIONS

Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings.