[Surgical treatment of acoustic neuromas (vestibular schwannomas)]

[Vestibular rehabilitation for peripheral vestibular hypofunction: an interdisciplinary consensus]

The literature review presents approaches to the management of patients with vestibular disorders. The principles of organization of vestibular rehabilitation in peripheral vestibular hypofunction, indications for appointment, factors influencing its implementation, technique, methods of evaluating effectiveness are considered in detail. Attention is drawn to the fact that the selection of exercises and the duration of vestibular rehabilitation is carried out individually and depends on many factors, including the nature of vestibular deficiency and the specific characteristics of the patient. The possibilities of using additional pharmacological therapy with histamine preparations, which can accelerate the onset of vestibular compensation, are shown. It is noted that vestibular rehabilitation is a safe and effective method of treating peripheral vestibular hypofunction and should be recommended to patients of all ages with vestibular disorders leading to limited social and physical activity.

[New classification and approaches to the treatment of schwannomatosis]

Schwannomatoses is a new classification unit for all the hereditary diseases caused by chromosome 22 damage followed by multiple benign neoplasms of the peripheral and central nervous system. Schwannomatosis occurs as a result of damage to different genes: NF2, SMARCB1, LZRT1, loss of heterozygosity of the long arm of chromosome 22. Nevertheless, clinical manifestations are similar. Molecular diagnostics not only confirms the diagnosis, but also predicts the course of disease. Thus, the most severe clinical manifestations are observed in patients with violation of semantic sequences and reading frame shift in exons 2-13 of the NF2 gene. A more favorable course with less number of tumors is observed in patients with somatic mosaicism. Stereotactic irradiation and surgery are the main treatment options for schwannomatosis. However, there is evidence of effective targeted therapy with bevacizumab (inhibitor of vascular endothelial growth factor). Bevacizumab is used in patients with bilateral vestibular schwannomas and high risk of hearing loss, as well as for intramedullary tumor growth control.

[«Burr hole» microsurgery for vestibular schwannoma]

OBJECTIVE

To evaluate the efficacy and safety of minimally invasive «burr hole» microsurgery for vestibular schwannoma.

MATERIAL AND METHODS

A retrospective analysis of postoperative outcomes in 50 consecutive patients with vestibular schwannoma was performed. All patients underwent burr hole microsurgery between 2016 and 2020.

RESULTS

All patients satisfactorily tolerated surgical treatment. Total resection was carried out in 21 (42%) cases, almost total resection - in 21 (42%) patients (>95% of baseline volume). Subtotal resection was performed in 8 (16%) cases. Mean surgery time was 132 min (range 60-340). Postoperative deterioration of facial nerve function occurred in 20 (40%) patients. Severe dysfunction (House-Brackmann grade V-VI) was observed only in three patients. Other 17 patients had moderate dysfunction of the facial nerve (House-Brackmann grade III-IV). Useful hearing was preserved in 6 (50%) out of 12 patients with preoperative useful hearing.

CONCLUSION

Minimally invasive burr hole microsurgery is an effective method for vestibular schwannoma. Moreover, the proposed technique reduces surgery time due to simpler craniotomy and wound closure.

[Trigeminal radiculopathy in vestibular schwannomas]

OBJECTIVE

To evaluate the correlation of trigeminal radiculopathy with anatomical relationships of trigeminal nerve root, brainstem, tumors and vessels in patients with vestibular schwannomas.

MATERIAL AND METHODS

A retrospective analysis included 153 patients (106 females and 47 males aged 22-82 years) with vestibular schwannomas who underwent surgery via retromastoid approach. Preoperative trigeminal radiculopathy (facial pain and sensory disturbances) was examined after microsurgical resection. Brainstem compression was analyzed by comparison of transverse size of contralateral to vestibular schwannoma half of brainstem and ipsilateral side.

RESULTS

Tumor-induced brainstem and trigeminal nerve compression was found in 115 cases. Sixty-four of these patients had trigeminal radiculopathy symptoms. Degree of brainstem compression was significantly higher in trigeminal radiculopathy group. Facial hypoesthesia was found in 61patients, trigeminal neuralgia - in 5 cases, neuropathic pain - in 3 patients. Thirty-seven patients without brainstem compression had no trigeminal nerve involvement. One patient had trigeminal neuralgia following compression by superior cerebellar artery. Total resection with brainstem and trigeminal nerve decompression were performed in all cases. Isolated or combined compression of trigeminal nerve root was noted in 9 patients with trigeminal neuralgia and neuropathic pain, in 2 with facial numbness and in 2 patients without trigeminal symptoms. In case of trigeminal neuralgia following compression by superior cerebellar artery, vascular decompression was performed only in patients with facial pain and numbness. Facial pain completely resolved in all patients. Complete or partial sensory restoration was noted in 25 cases. No facial sensory disorders were noted in 26 cases, transient sensory deterioration - in 10 patients.

CONCLUSION

Trigeminal radiculopathy is caused by severe brainstem compression following vestibular schwannomas and usually results sensory disturbances and rarely facial pain. The impact of tumor on trigeminal nerve root and brainstem trigeminal pathways can be accompanied by vascular compression by superior cerebellar artery. Regression of trigeminal radiculopathy symptoms after resection of vestibular schwannoma is caused by decompression of trigeminal nerve root and brainstem. In case of concomitant neurovascular syndrome, vascular decompression is indicated.

An investigation of life quality of patients after two different acoustic neuroma resections

Background: Patients may suffer postoperative facial nerve injury, hearing loss, or other postoperative complications after the operation, which seriously affect their postoperative life quality. Aims/objectives: To investigate the differences in QOL (quality of life) of patients with acoustic neuroma resection by the translabyrinthine or retrosigmoid approach. Material and methods: Patients with acoustic neuroma resection in our department were enrolled in this experimental study, among which fifty patients underwent the translabyrinthine approach resection, the other 50 patients underwent the retrosigmoid approach resection. Different scores by the SF-36 scale between these two groups of patients one month after discharge were then analyzed. Results: Scores of patients undergoing the retrosigmoid approach were higher in the three dimensions of Social Functioning, Role-emotional and Mental Health than those of patients undergoing the translabyrinthine approach with statistical significance. However, scores of patients undergoing the translabyrinthine approach were higher in the two dimensions of Body Pain and Vitality than those of the patients undergoing the retrosigmoid approach. Conclusions and significance: The results indicated that individual nursing interventions for different patients are necessary to improve the QOL of patients after hospitalization. Moreover, the operated patients with translabyrinthine approach were more advantage than patients with retrosigmoid approach.

[Surgical approach to resection of vestibular schwannomas following stereotactic radiological treatment. Surgical outcomes and morphological changes in tumors after radiotherapy]

INTRODUCTION

Radiation therapy of small vestibular schwannomas is quite often used as an effective alternative to surgical treatment. At the same time, 2-10% of patients are detected with radioresistant tumors progressing to varying degrees, which is associated with continued tumor growth. In these cases, a decision on surgical resection or re-irradiation of the tumor is made depending on the neurological symptoms, patient's somatic status, and neuroimaging data. Surgical outcomes and intraoperative findings in pre-irradiated patients have been poorly represented in the literature, for which reason we decided to conduct this study. The paper presents a series of patients with vestibular schwannomas who underwent surgical removal of the tumor after radiotherapy.

MATERIAL AND METHODS

A total of 39 patients with vestibular schwannomas after radiotherapy underwent surgery at the Burdenko Neurosurgical Institute in 2007-2017. Of these, 22 patients had a tumor removed after a previously performed combined surgical and radiotherapy treatment (group I), and 17 patients underwent tumor resection after previous radiological treatment (group II). The surgical outcomes were studied depending on various factors, and an analysis of the morphological changes in vestibular schwannomas after radiological treatment was carried out.

RESULTS

In group I, the tumor was resected totally in 18% of patients, almost totally in 5% of patients, subtotally in 68% of patients, and partially in 9% of patients. In group II, the tumor was resected totally in 6% of patients, almost totally in 12% of patients, subtotally in 76% of patients, and partially in 6% of patients. We found that post-radiation changes in patients undergoing surgery led to an increase in the response of neurovascular structures to surgical intervention, development of pronounced fibrosis around tumors, and changes in the structure of tumors that became more solid. As a result, surgical morbidity increased, and the patient's quality of life after surgery deteriorated.