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Hosmann A, Misra BK. Microsurgery for symptomatic extratumoral cyst formation in vestibular schwannoma post-radiosurgery. J Neurosci Rural Pract 2024; 15:153-155. [PMID: 38476417 PMCID: PMC10927063 DOI: 10.25259/jnrp_384_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 07/25/2023] [Indexed: 03/14/2024] Open
Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Basant K Misra
- Department of Neurosurgery and Gamma Knife Surgery, P D Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Hosmann A, Hari S, Misra BK. Cystic recurrence of vestibular schwannoma post-radiosurgery: an institutional experience. Acta Neurochir (Wien) 2023; 165:4149-4156. [PMID: 38008799 DOI: 10.1007/s00701-023-05841-x] [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: 08/02/2023] [Accepted: 10/05/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Stereotactic radiosurgery effectively controls vestibular schwannoma (VS). However, in certain cases, microsurgical resection may be necessary for post-radiosurgery tumour progression. The characteristics and microsurgical challenges of uncommon cystic recurrences post-radiosurgery are rarely addressed. METHOD We retrospectively analysed 24 consecutive patients who underwent microsurgical intervention for recurrent VS post-radiosurgery by the senior author. RESULTS Tumour recurrence post-radiosurgery occurred as solid growth in 19 patients (79%), while 5 patients (21%) developed large brainstem-compressing cysts. The median time interval for tumour recurrence post-radiosurgery was similar between cystic and non-cystic recurrent VS (30 vs. 25 months; p=0.08). Cystic recurrences occurred in primarily cystic VS in 3 patients, and new cysts developed in 2 patients with primarily solid VS. Intra-operatively, tumours were firm in 18 cases (75%) and strongly adhered to surrounding structures in 14 cases (58%). All cystic cases underwent cyst decompression, while complete resection of solid tumour components was avoided due to neurovascular adherence. At a mean follow-up of 42±39 months, 12 patients (50%) showed contrast-enhancing tumour residuals in follow-up imaging, including all cystic recurrent cases. Tumour residuals remained stable without requiring further intervention, except for one patient revealing malignant tumour transformation. House-Brackmann grade I/II was preserved in 15 patients (62%). Three patients (13%) developed new facial palsy, and two patients (8%) improved to House-Brackmann grade II. Cystic recurrences had a significantly higher frequency of tumour residuals compared to solid recurrences (100% vs. 37%; p=0.01) but similar rates of facial palsy (60% vs. 32%; p=0.24) CONCLUSIONS: Cyst development in VS post-radiosurgery is more common in primary cystic lesions but can also occur in rare cases of primary solid VS. Symptomatic cysts require microsurgical decompression. However, complete resection of the solid tumour component is not crucial for long-term tumour control and should be avoided if it risks neurological function in this delicate area.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery & Gamma Knife Surgery, P D Hinduja National Hospital & Medical Research Centre, Veer Savarkar Marg, Mumbai, India
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Subhashree Hari
- Department of Neurosurgery & Gamma Knife Surgery, P D Hinduja National Hospital & Medical Research Centre, Veer Savarkar Marg, Mumbai, India
| | - Basant K Misra
- Department of Neurosurgery & Gamma Knife Surgery, P D Hinduja National Hospital & Medical Research Centre, Veer Savarkar Marg, Mumbai, India.
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Roman A, Tufegdzic B, Pinto V, Lamperti M, Elhammady M, Roser F. After the Knife: A Detailed Roadmap for Vestibular Schwannoma Resection in the Semi-Sitting Position - How I do it. World Neurosurg 2023; 175:e1341-e1347. [PMID: 37169076 DOI: 10.1016/j.wneu.2023.05.013] [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: 03/30/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Vestibular schwannoma surgery remains a neurosurgical challenge, with known risks, dependent on a number of factors, from patient selection to surgical experience of the team. The semi-sitting position has gained popularity as an alternative to the traditional supine position for vestibular schwannoma resection due to potential advantages such as improved surgical exposure due to clearer surgical field and anatomical orientation. However, there is a lack of standardized protocols for performing the procedure in the semi-sitting position, leading to variations in surgical techniques and outcomes. METHODS In this study, we aimed to establish a standardized approach for vestibular schwannoma resection using the semi-sitting position. Initiating after final position for semi-sitting, the authors have divided the surgical steps into five major parts for improved understanding and replication. Surgical techniques were analyzed through one hundred steps to identify commonalities, determining the optimal procedural steps for the semi-sitting position using surgical video for visual conceptualization. RESULTS The analysis described one hundred steps for vestibular schwannoma resection in the semi-sitting position, with visual demonstration of the various parts of the procedure through surgical videos. Specific recommendations for each step were outlined, including appropriate approach, monitoring strategies, and tumor and posterior fossa structures manipulation. Five major parts of the procedure were identified, leading to a reproducible standardization of the surgical procedure of vestibular schwannoma resection in the semi-sitting position. CONCLUSIONS This study provides a comprehensive standardized protocol for the semi-sitting procedure in vestibular schwannoma resection. By establishing a consistent approach, surgeons can minimize variations in surgical techniques and improve patient outcomes. The identified steps and recommendations can serve as a valuable resource for surgical teams involved in vestibular schwannoma resection and facilitate the dissemination and reproducibility of best practices.
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Affiliation(s)
- Alex Roman
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.
| | - Boris Tufegdzic
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Vania Pinto
- Neurophysiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | | | - Florian Roser
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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Tosi U, Maayan O, An A, Lavieri MET, Guadix SW, DeRosa AP, Christos PJ, Pannullo S, Stieg PE, Brandmaier A, Knisely JPS, Ramakrishna R. Stereotactic radiosurgery for vestibular schwannomas in neurofibromatosis type 2 patients: a systematic review and meta-analysis. J Neurooncol 2022; 156:431-441. [PMID: 35040021 DOI: 10.1007/s11060-021-03910-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/22/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Neurofibromatosis type 2 (NF2) is characterized by often bilateral vestibular schwannomas (VS) that result in progressive hearing loss and compression of nearby brainstem structures causing cranial nerve palsies. Treatment of these tumors remains challenging, as both surgical removal and expectant management can result in symptom progression. Stereotactic radiosurgery (SRS) has been investigated for the management of NF2-associated VS; however, the role, promises, and pitfalls of this treatment modality remain unclear. METHODS Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Reviews were searched for studies assessing SRS outcome in NF2-associated VS only. Primary endpoints included tumor control, serviceable hearing, presence of tinnitus, and cranial nerve V and VII symptoms. RESULTS A total of 16 studies (589 patients harboring 750 tumors) were analyzed. Clinical tumor control was achieved in 88% of cases (95% CI 80-95%); salvage surgery was needed in 8% (95% CI 4-13%) of cases. Treatment resulted in a worsening of pre-treatment serviceable hearing (OR = 0.26, p < 0.01), increased facial nerve (OR = 1.62, p < 0.01) and trigeminal nerve (OR = 1.42, p = 0.07) impairment. The incidence of vestibular symptoms and hydrocephalus were not consistently reported and thus could not be assessed. CONCLUSIONS The treatment of NF2-associated VS continues to pose a challenge, as current SRS regimens result in impaired hearing and worse cranial nerve comorbidities, despite achieving high tumor control. It remains unclear if these findings have to be regarded as treatment complications or, rather, continued disease progression.
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Affiliation(s)
- Umberto Tosi
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Omri Maayan
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Anjile An
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Miguel E Tusa Lavieri
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Sergio W Guadix
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Antonio P DeRosa
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, USA
| | - Paul J Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Susan Pannullo
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Andrew Brandmaier
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | | | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA.
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Tripathi M, Batish A, Mohindra S, Joshi A. Management of Radio Surgical Failures: New Insights and Future Prospects. Neurol India 2021; 69:511-512. [PMID: 33904492 DOI: 10.4103/0028-3886.314562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Batish
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Mohindra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Joshi
- Department of Neurosurgery, Tanda Medical College, Tanda, Himanchal Pradesh, India
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