Evolution in Surgical Treatment of Vestibular Schwannomas

Marcos Tatagiba,Georgios Naros,Taishi Nakamura,Florian H Ebner

doi:10.1007/s40136-021-00366-2

Abstract

Purpose of ReviewManagement of vestibular schwannomas (VSs) is multimodal and include watchful observation, radiation treatment, and surgery. Over the past decades, a shift in treatment strategy toward radiation treatment has gradually displaced surgery from the main treatment option for VS. In recent years, however, surgery has been further refined by developments of microsurgical and endoscopic techniques and advances in intraoperative application of neuroprotective drugs. This article presents outcomes of modern surgical treatment of VS in the era of radiosurgery and reviews recent published advancements relevant to VS management.Recent FindingsFollowing VS surgery, excellent tumor resection rates and cranial nerve outcomes were achieved in a consecutive series of 572 adult patients with mean postoperative follow up of 4 years. Innovations in surgical technique include endoscopic technique as additional tool to microsurgery, exploration of semi-sitting position for large tumors, and intraoperative use of vasoactive agents as neuroprotective strategy.SummaryDespite great developments in radiation treatment of VS, surgery remains the key solution for the majority of the cases in order to achieve cure of the disease, long-term tumor control, and preservation of cranial nerve function at long-term.

Highlights

Vestibular schwannomas (VSs) belong to the most common benign tumors of the skull base, accounting for more than 90% of all non-malignant nerve sheath tumors [1]
While VS has a relatively constant histological appearance with low mitosis rates, radiological presentation may vary considerably (Fig. 1): from large to small, from solid to cystic, from compact with high cellular density to soft and well vascularized, from medial located to invading the petrous bone and filling the entire internal auditory canal (IAC)
The reasons for an early opening of the IAC are as follows: (1) the neurovascular structures in the CPA are still protected by the tumor against bone dust, heat, and irrigation; (2) we gain control of the distal part of the facial and the cochlear nerves; (3) in the final stage of the operation, we can follow the facial nerve at the inferior part of the tumor surface from both sides of the meatus, which facilitates facial preservation while removing the last tumor part

Summary

Introduction

Vestibular schwannomas (VSs) belong to the most common benign tumors of the skull base, accounting for more than 90% of all non-malignant nerve sheath tumors [1]. While VS has a relatively constant histological appearance with low mitosis rates, radiological presentation may vary considerably (Fig. 1): from large to small, from solid to cystic, from compact with high cellular density to soft and well vascularized, from medial located to invading the petrous bone and filling the entire internal auditory canal (IAC). This variability poses a major challenge on decision-making regarding the best treatment. Tumors with previous treatments (surgery or radiation), NF2-associated tumors, and pediatric patients were excluded. We claim that modern VS surgery remains the key solution in a large number of patients enabling long-term tumor control and function preservation

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Conclusion