Management Of Acoustic Neuromas Research Articles

ICU Management of Post-Craniotomy Patients with Schwannoma Vestibular Tumor Removal

Background: Vestibular schwannoma (VS) is a relatively common tumor that arises from the vestibulocochlear nerve (CN VIII) and represents 80% of cerebellopontine angle (CPA) masses. CPA tumors are mostly benign, slow growing with low malignant potential (~1%). VS have rarely been reported, and there is a lack of in-depth discussion on the experience of management of massive acoustic neuromas in ICU. It represents the case in which the patient presented with obstructive hydrocephalus and progressive neurological deficits. The purpose of this case report is to understand the management of post-operative patients with VS with several comorbidities in the ICU.Case: We present a 53 years old woman with a giant VS and obstructive hydrocephalus. An imaging findings revealed a brain tumor in the CPA region and obstructive hydrocephalus. Consequently, she relieved her hydrocephalus with a ventriculoperitoneal shunt (VP shunt). After 1.5 years, her mental condition deteriorated, and her left limb muscle strength gradually decreased. Under a joint consultation with Department of Neurosurgery and Anesthesiology, she underwent tumor removal. Upon discharge, the previously observed neurological deficits, which were reversible had been successfully resolved. The neuroimaging confirmed the complete tumor removal, while the neuropathologic examination revealed a VS.Discussion: If untreated, an acoustic neuroma can grow large enough to cause pressure on the brain stem. The tumor can block the flow of cerebrospinal fluid (CSF) between the brain and the spinal cord, causing a buildup of the fluid in the brain. Because the skull is a closed structure, excess fluid in the brain (hydrocephalus) can press against the brain, causing unsteady movement and lack of coordination (ataxia), headaches and confusion. Patients with brainstem compression had significantly longer mean LOS than patients without. Also, the dissection of the facial nerve from the tumor in order to preserve it can sometimes cause swelling, which can result in weakness or paralysis (complete or partial loss of muscle function). This is usually temporary but can take weeks to months to recover. After the operation, the patient was treated in the ICU, a ventilator was installed,insulin was given to regulate blood sugar and anti-hypertension medication for maintaining blood pressure. During treatment in the ICU, adequate fluids and nutrition are provided. Monitoring is carried out on cardiovascular function, hemodynamics and respiration by monitoring blood pressure, electrocardiogram (ECG), oxygen saturation. The patient was moved to high care unit (HCU) after being treated for 3 days in the ICU.Conclusion: Postoperative therapy is more focused on supportive therapy, including maintaining the airway, regulating blood sugar, blood pressure and providing mechanical ventilation to maintain adequate oxygenation.

Long-Term Quality of Life and Audiometric Outcomes Following Noninvasive Stereotactic Radiosurgery for Acoustic Neuromas

Though microsurgery remains the most common method for management of acoustic neuromas (ANs), stereotactic radiosurgery continues to be a promising alternative. This study assesses long-term quality of life (QOL) outcomes and changes in hearing acuity in patents who have undergone single fraction Gamma Knife stereotactic radiosurgery (GKSRS) for AN.Prospective QOL outcomes were collected and analyzed to include Hearing Handicap Inventory (HHI), Dizziness Handicap Inventory (DHI), Tinnitus Handicap Inventory (THI), and 36-Item Short-Form Survey (SF-36) scores. Likewise, audiometric outcomes including speech discrimination (SD) and pure-tone average (PTA) were assessed. These data points were collected prior to and following GKSRS at regular intervals up to 5 years post-treatment. A mixed effects model for repeated measures was employed to assess QOL data for statistical significance.A total of 235 patients underwent GKSRS for AN at our institution from January 2007 to January 2017. Of these, 130 patients had available QOL and audiometric follow-up data and were included in this study. Median age was 60 y and median follow-up time was 36 mo. Median tumor size was 1.6 cm (0.1 - 3.6 cm), with median tumor volume of 0.552 cm3 (0.028 - 11.31 cm3), while median cochlear mean dose was 2.4 Gy (0 - 9.7 Gy). Baseline mean (median) HHI, DHI, THI, and SF-36 scores were 31.7 (28), 19.3 (12), 18.2 (12), and 70.0 (73.4) respectively. For each of these QOL metrics, mixed effects analysis indicated no statistically significant decline at any time point out to 5 years post-treatment. Indeed, 87% of patients had baseline SD and PTA scores available; 70% had follow-up SD and PTA available. Of these, 59% had baseline serviceable hearing (Gardner-Robertson score of I or II). Serviceable hearing was preserved in 71% of patients at 1 month, 79% at 6 months, 79% at 12 months, 62% at 18 months, 67% at 24 months, and 68% at 36 months.GKSRS provides long-term maintenance of QOL in the treatment of AN. HHI, DHI, THI, and SF-36 scores showed no significant decline up to 5 years post-radiosurgery. Patients with baseline serviceable hearing exhibited adequate hearing preservation.J.S. Lee: None. K.C. Lee: Royalty; Regents of the University of Michigan. Patent/License Fees/Copyright; Regents of the University of Michigan. D. Bojrab: None. P.Y. Chen: Stock; Greater Michigan Gamma Knife (GMGK). J. Jacob: None. I.S. Grills: Greater Michigan Gamma Knife.

Cochlear and Auditory Brainstem Implants in the Management of Acoustic Neuroma and Bilateral Acoustic Neurofibromatosis

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Evolving Role of Non-Total Resection in Management of Acoustic Neuroma in the Gamma Knife Era.

To examine patients with residual tumor after vestibular schwannoma (VS) resection with focus on need for further therapy, including stereotactic radiosurgery (SRS) and revision surgery. Retrospective review at two tertiary otology referral centers. Patients undergoing primary surgery for VS from 2007 to 2017. Degree of resection and need for further treatment. Of 289 patients undergoing surgery, 38 (13.1%) underwent subtotal resections (<95% of tumor resected) and 77 (26.6%) underwent near-total resections (≥95% but <100%). Patients with any residual tumor had larger tumors preoperatively (mean estimated volume 6.3 cm versus 2.1 cm, p < 0.0005) but were otherwise clinically and demographically similar to the population as a whole. Further treatment (surgery or SRS) was needed in 4.6, 14.3, and 50.0% of patients after gross total, near-total, and subtotal resections, respectively (p < 0.0005). Patients undergoing additional therapy had larger residual tumors (median post- to preoperative estimated volume ratio 0.09 versus 0.01, p < 0.0005). Patients undergoing subtotal and near-total resections had poorer facial function at ultimate follow up than those undergoing gross total resections (p = 0.001), likely due to larger tumors and more difficult resections. Literature review revealed higher rates of gross total resection as well as facial palsy in the pre-SRS era. Residual tumor following VS resection is more common today than in the pre-SRS era. Availability of SRS may encourage leaving residual tumor intraoperatively to preserve neural structures. Current surgical strategies decrease surgical morbidity but necessitate further treatment in over 10% of cases.

Management of acoustic neuroma: a retrospective study

Management of acoustic neuroma: a retrospective study

435P - Mature treatment results of 120 cases of acoustic neuroma treated with cyberknife at a single institution

BackgroundStereotactic radiosurgery (SRS) is a noninvasive alternative to microsurgery in the management of acoustic neuromas. Single fraction Gamma Knife SRS of acoustic neuromas results in high rates of local control (85-97 %). CyberKnife (CK) Robotic SRS is an alternative technique delivering the same quality SRS but with the benefits of a frameless treatment system allowing for fractionated treatment. The body of evidence in its use for acoustic neuromas is less robust. We present mature outcomes of a large cohort of patients treated with CK at a single institution. MethodsThis study consisted of 120 acoustic neuroma patients treated with CK from Sept 2010 until March 2016. Patients with complete hearing loss were treated with a single 12Gy fraction (6 Pts). Those with hearing preservation or moderate to large tumors were treated with 18Gy in 3 fractions (114pts). Follow-up T2 axial MRIs (0.50mm slice) were analyzed to evaluate rates of tumor control and incidence of pseudo-progression. To obtain volumetric response data, MRI images were contoured on PACs imaging station using Aquarius Net version 4.4.13 by a single radiation oncologist. ResultsPatients range in age from 15 to 91 (mean 58). The median follow up time was 60 months. Mean tumor size was 2.8cm3 (Range 0.1-30). Progression occurred in 4 patients (local control rate of 97%). Pseudo-progression was seen in 17 cases. For patients with pseudo-progression mean time to the maximum imaged tumor volume post treatment was 5 months (Range of 3 to 12 months) with an average volume increase of 11% (Max 31%). Mean time to subsequent regression to pre-treatment size was 15 months (Range of 10-23) No pseudo-progression led to subsequent local recurrence. There were low rates of late toxicity. One patient who progressed suffered CN VII palsy prior to salvage surgery. All other patients had preserved CNV and CNVII function and there was no case of brain stem necrosis. ConclusionsCyberknife offered high rates of durable local control (97 %) for acoustic neuromas with low rates of toxicity. Pseudo-progression was seen in 14% of patients and was not a predictor for treatment failure. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureS. Malone: Honoraria (self): Janssen; Honoraria (self): Astellas; Travel / Accommodation / Expenses: TerSera; Honoraria (self): AstraZeneca; Honoraria (self): AMGEN; Travel / Accommodation / Expenses: Sanofi; Honoraria (self): Abbvie; Honoraria (self): Bayer. All other authors have declared no conflicts of interest.

Retrosigmoid Transmeatal Approach for Resection of Acoustic Neuroma: Operative Video and Technical Nuances of Subperineural Dissection for Facial Nerve Preservation.

The retrosigmoid (suboccipital) approach is the workhorse for most acoustic neuromas in the cerebellopontine angle. In this operative video atlas manuscript, the authors demonstrate the nuances of the subperineural dissection technique for microsurgical resection of an acoustic neuroma via the retrosigmoid transmeatal approach. The plane is developed by separating the perineurium of the vestibular nerve away from the tumor capsule. This perineurium provides a protective layer between the tumor capsule and the facial nerve which serves as a buffer to avoid direct dissection and potential trauma to the facial nerve. Using this technique during extracapsular tumor dissection helps to maximize the extent of tumor removal while preserving facial nerve function. A gross total resection of the tumor was achieved, and the patient exhibited normal facial nerve function ( Fig. 1 ). In summary, the retrosigmoid transmeatal approach with the use of subperineural dissection are important strategies in the armamentarium for surgical management of acoustic neuromas with the goal of maximizing tumor removal and preserving facial nerve function ( Fig. 2 ). The link to the video can be found at: https://youtu.be/L3lPtSvJt60 .

Translabyrinthine Approach for Resection of Large Cystic Acoustic Neuroma: Operative Video and Technical Nuances of Subperineural Dissection for Facial Nerve Preservation.

The translabyrinthine approach is advantageous for the resection of large acoustic neuromas compressing the brainstem when hearing loss is nonserviceable. This approach provides wide access through the presigmoid corridor without prolonged cerebellar retraction. Early identification of the facial nerve at the fundus is also achieved. In this operative video atlas manuscript, the authors demonstrate a step-by-step technique for microsurgical resection of a large cystic acoustic neuroma via a translabyrinthine approach. The nuances of microsurgical and skull base technique are illustrated including performing extracapsular dissection of the tumor while maintaining a subperineural plane of dissection to preserve the facial nerve. This strategy maximizes the extent of removal while preserving facial nerve function. A microscopic remnant of tumor was left adherent to the perineurium. A near-total resection of the tumor was achieved and the facial nerve stimulated briskly at low thresholds. Other than preexisting hearing loss, the patient was neurologically intact with normal facial nerve function postoperatively. In summary, the translabyrinthine approach and the use of subperineural dissection are important strategies in the armamentarium for surgical management of large acoustic neuromas while preserving facial nerve function. The link to the video can be found at: https://youtu.be/zld2cSP8fb8 .

Electrophysiological Monitoring of Fifth and Seventh Cranial Nerves in Cerebellopontine Angle Lesions

Introduction: Neural preservation is particularly imperative in the surgical management of acoustic neuromas. Intraoperative neuromonitoring is essential in structural and functional preservation of these cranial nerves during the operations. Intraoperative stimulus threshold and response amplitude measurements from trigeminal and facial nerves can predict the functional outcome postoperatively. Materials and Methods: A prospective study was conducted on 30 patients over a period of one year from March 2011 to April 2012 in the Govind Ballabh Pant Hospital, New Delhi, India. Results: There were 27 (90%) cases of vestibular schwannomas, one of meningioma (3.33%), and two of epidermoids (total cases n = 30). Among these, 11 (36.66%) were male and 19 (63.33%) were female patients, and 37% of patients in our study were in the age group of 20 to 30 years. Among the vestibular schwannomas, 16 were right sided and 11 were left sided. Hearing loss was the main presenting symptom (56%) followed by tinnitus (27%), facial pain (10%), and gait instability (7%) in our study. Conclusion: Intraoperative neurophysiological monitoring showed strong support in the value of identification of facial and trigeminal nerves, prevention of injury, and value of prognosis. Stimulus thresholds, response amplitude, and proximal-to-distal amplitude ratio can assist the surgeon during tumor dissection.

Conservative Management of Small Acoustic Neuromas: Compliance Rates and Outcomes Over 5 Years at a Single Institution

Conservative Management of Small Acoustic Neuromas: Compliance Rates and Outcomes Over 5 Years at a Single Institution

Transcanal Transpromontorial Acoustic Neuroma Surgery: Results and Facial Nerve Outcomes.

Recently, the transcanal approach for the removal of acoustic neuromas has been introduced. Facial nerve (FN) preservation is one of the main challenges of this kind of surgery. To describe our experience in the surgical treatment of acoustic neuromas, focusing on the functional results of FN preservation after a transcanal approach. A retrospective chart review was carried out on clinical data and videos from operations on 49 patients who underwent surgery with a totally transcanal exclusive endoscopic approach for Koos stage I-II lesions, or an enlarged transcanal transpromontorial approach for Koos stage II-III tumors, between March 2012 and February 2017. Patients and tumor characteristics, clinical manifestations, radiologic features, audiological results, FN outcomes (according to the House-Brackmann [HB] grading system) and complications were evaluated. Tumors were classified according to the Koos grading system. The age of the patients (34 females and 15 males) ranged from 27 to 77 years (mean age: 54.9 yr). Preoperative diagnosis was "vestibular schwannoma" in all patients. At the last follow-up (range 1-60 mo, mean 13.9 mo), 42 of 49 showed grade I HB FN function, 5 of 49 grade II HB, and 2 of 49 grade III HB. Overall, in 95.9%, FN function was preserved (grade I-II HB) with stable results at follow-up; in 4.1% of cases, FN function was reduced, but not worse than grade III. The transcanal approach represents a feasible, minimally invasive, and conservative technique for the management of acoustic neuromas of the internal auditory canal.

Operative Mortality Rates of Acoustic Neuroma Surgery: A National Cancer Database Analysis.

Optimal acoustic neuroma (AN) management involves choosing between three treatment modalities: microsurgical excision, radiation, or observation with serial imaging. The reported in-hospital mortality rate of surgery for AN in the United States is 0.5%. However, there has yet to be a nationwide examination of the AN surgery mortality rate encompassing the period beyond initial hospital discharge. The National Cancer Data Base (NCDB) from 2004 to 2013 identified AN patients receiving surgery. Multivariate logistic regression assessed 30-day operative mortality, adjusting for several variables including patient age, race, sex, income, geographic region, primary payer for care, tumor size, and medical comorbidities. Ten thousand one hundred thirty six patients received surgery as solitary treatment for AN. Mortality at 30 days postoperatively occurred in 49 patients (0.5%); only a Charlson/Deyo score of 2 (odds ratio [OR] = 6.6;95% confidence interval [CI] = 2.6-16.6; p = 0.002) was predictive of increased mortality. No other patient demographic including African-American race, minimum age of 65 or government insurance was predictive of 30-day operative mortality. The 30-day mortality rate following surgery for AN is 1 of 200 (0.5%), equivalent to the established in-hospital operative mortality rate, and 2.5 times higher than the cumulative assessment from single-center studies. No patient demographic other than increasing medical comorbidities reached significance in predicting 30-day operative mortality. The nearly identical rates of 30-day and in-hospital mortality from separate nationwide analyses indicate that nearly all of the operative mortality occurs before initial postoperative discharge from the hospital. This mortality rate provides a framework for comparing the true risks and benefits of surgery versus radiation or observation for AN.

Impact of insurance status and race on receipt of treatment for acoustic neuroma: A national cancer database analysis

Acoustic neuroma (AN) management involves surgery, radiation, or observation. Previous studies have demonstrated that patient race and insurance status impact in-hospital morbidity/mortality following surgery; however the nationwide impact of these demographics on the receipt of each treatment modality has not been examined. The National Cancer Data Base (NCDB) from 2004 to 2013 identified AN patients. Multivariate analysis adjusted for several variables within each treatment modality, including patient age, race, sex, income, primary payer for care, tumor size, and medical comorbidities. Patients who were African-American (OR=0.7; 95%CI=0.5–0.9; p=0.01), elderly (minimum age 65) (OR=0.4; 95%CI=0.4–0.6; p<0.0001), on Medicare (OR=0.6; 95% CI=0.4–0.7; p=0.0005), or treated at a community hospital (OR=0.4; 95%CI=0.2–0.7; p=0.007) were less likely to receive surgery. Patients on Medicaid (OR=1.2; 95%CI=0.8–1.8; p=0.04) or treated at an integrated network (OR=1.2; 95%CI=0.9–1.6; p=0.0004) were more likely to receive surgery. Patients who were elderly (OR=2.2; 95%CI=1.7–2.9; p<0.0001) or treated in a comprehensive cancer center (OR=1.5; 95%CI=1.3–1.9; p=0.02) were more likely and Medicaid patients (OR=0.8; 95%CI=0.5–1.2; p=0.04) were less likely to receive radiation. Patients who were elderly (OR=2.2; 95%CI=1.7–2.7; p<0.0001), African-American (OR=1.5; 95%CI=1.1–2.0; p=0.01), on Medicare (OR=1.8; 95%CI=1.4–2.3; p=0.0003), or treated in a community hospital (OR=3.0; 95%CI=1.6–5.6; p=0.0007) were more likely to receive observation. Patients on Medicaid (OR=0.8; 95%CI=0.5–1.2; p=0.04) or treated in an integrated network (OR=0.8; 95%CI=0.6–1.0; p=0.0001) were less likely to receive observation. African-American race, elderly age, and community hospital treatment triaged towards observation/away from surgery; age also triaged towards radiation. Conversely, integrated networks triaged towards surgery/away from observation; comprehensive cancer centers triaged towards radiation. Medicaid insurance triaged towards surgery/away from radiation/observation; this may be detrimental since lack of private insurance is a known risk factor for increased in-hospital postoperative morbidity.

Summary and consensus in 7th International Conference on acoustic neuroma: An update for the management of sporadic acoustic neuromas.

Sporadic vestibular schwannoma (acoustic neuroma) is a benign tumor arising from cochleovestibular nerve. Nowadays, various specialties and medical centers are treating this disease, and the multidisciplinary collaboration is the trend. In an effort to promote a uniform standard for reporting clinical results, even for treatment indications, the mainly controversies were posed and discussed during the 7th International Conference on acoustic neuroma, and the agreement was summarized by the Committee of this conference. The main symptoms grading and tumor stage should note its name of classification for making them comparable. The goal of the modern managements for vestibular schwannoma is to improve the quality of life with lower mortality, lower morbidity and better neurological function preservation. The experience of surgical team and their preference might be a major factor for the outcome. Because of lacking of long-term follow-up large data after radiotherapy, and with the development of microsurgery, radiotherapy is now less recommended except for recurrent cases or elderly patients.

Nonoperative management of acoustic neuroma in geriatric patients: a National Cancer Database analysis

Background and purpose The in-hospital mortality rate of surgery for acoustic neuroma (AN) is 0.5% and increases exponentially with age. There have been no studies examining the nationwide distribution of nonoperative management (radiation or observation) in the geriatric (≥ age 65) AN population.

SURG-14. OPERATIVE MORTALITY RATES OF ACOUSTIC NEUROMA SURGERY: A NATIONWIDE CANCER DATABASE ANALYSIS

Optimal management of acoustic neuroma (AN) involves choosing between three treatment modalities: microsurgical excision, radiation (fractionated stereotactic radiotherapy or stereotactic radiosurgery), or observation with serial imaging. The in-hospital mortality rate of surgery for AN in the United States is 0.5% (McClelland et al., 2011). However, there has yet to be a nationwide examination of the AN surgery mortality rate encompassing the period beyond initial hospital discharge. The National Cancer Data Base (NCDB) from 2004-2013 identified AN patients receiving surgery. Multivariate logistic regression assessed the mortality of surgery at 30 days postoperatively, adjusting for several variables including patient age, race, sex, income, geographic region, primary payer for care, tumor size, and medical comorbidities. A total of 10,136 patients received surgery as solitary treatment for AN. Mortality at 30 days postoperatively occurred in 49 patients (0.5%). Mortality at 60 and 90 days postoperatively occurred in 67 (0.7%) and 81 (0.8%) patients, respectively. At 30 days postoperatively, only a Charlson/Deyo score of 2 (OR=6.6;95%CI=2.6-16.6;p=0.002) was predictive of increased mortality. No other patient demographic, including African-American race (OR=1.9;95%CI=0.7-5.1;p=0.23), minimum age of 65 (OR=2.2;95%CI=0.8-5.6;p=0.11) or government insurance (OR=6.2;95%CI=2.0-18.9;p=0.06) was predictive of 30-day operative mortality. The 30-day mortality rate following surgery for AN is 1/200 (0.5%), which is equivalent to the established in-hospital operative mortality rate, and is 2.5 times higher than the cumulative assessment from single-center studies (Sughrue et al., 2011). No patient demographic other than increasing medical comorbidities reached significance in predicting 30-day operative mortality. The nearly identical rates of 30-day and in-hospital mortality from separate nationwide analyses indicate that nearly all of the operative mortality occurs prior to initial postoperative discharge from the hospital. This mortality rate provides a framework for comparing the true risks and benefits of surgery versus radiation or observation for AN.

P19.02 Clinical and radiological long term outcome of acoustic neuromas (Koos grade I - IV) after stereotactic radiosurgery

AbstractIntroduction:In the management of acoustic neuroma (AN) stereotactic radiosurgery (SRS) has evolved as widely accepted treatment option for small-sized tumors (Koos I and II). For larger AN (Koos III and IV) microsurgery is treatment of choice. However, for patients not suitable for microsurgery SRS might also be an alternative that balances tumor control, hearing preservation and adverse effects. The purpose of this analysis was to evaluate the efficacy and toxicity of SRS for different Koos grades including AN Koos III and IV.Methods:In this single center retrospective analysis (1991 - 2015) we included all patients with previously untreated AN who underwent single session LINAC or Cyberknife® based SRS with a minimum follow-up of 3 months. Patient data were analyzed and correlated (Pearson`s coefficient) with the different Koos grades in terms of radiological tumor control, preservation of serviceable hearing, course of median pure tone averages (PTA) and adverse events rated by Common Terminology Criteria for Adverse Events (CTCAE; v4.03).Results:301 patients (f:m = 151:150, median age 59 years ±13.6, range 17–84) were identified with a mean follow-up of 50.9 months (range 3–265). Mean tumor volume was 1.85 ml ±2.4 (range 0.1–23.7, the mean marginal dose was 12.4 Gy ± 0.8 (range 11–20) and the prescription isodose was 69.3 % ± 12.5 (range 32.9–86.2). With regard to the Koos classification 52 patients were considered as grade I, 162 as grade II, 42 and 45 as grade III and IV, respectively.At last follow-up after SRS 94% of the patients showed radiological tumor control. There was no significant correlation (p < 0.113) between Koos grades I/II vs III/IV and radiological tumor control.Median PTA of Koos I/II tumors increased about 49% (37,2 dB prior to SRS up to 55,6 dB at last follow-up). In case of Koos III/IV tumors the increase of median PTA was similar (47%; 46,2 dB up to 68,2 dB).The rate of transient facial nerve dysfunction CTCAE grade 1 or 2 in Koos I/II tumors was 2.3% and 4.6% in Koos III/IV. Permanent facial nerve dysfunction CTCAE grade 1 was observed in one patient with Koos grade I and III, respectively. Transient trigeminal nerve impairment CTCAE grade 1/2 occurred with 3.7% in Koos I/II and with 6.9% in Koos III/IV. Four patients (4.6%) with Koos III/IV tumors had permanent trigeminal nerve impairment CTCAE grade 1/2.Conclusion:SRS for AN shows reliable long term tumor control and a high rate of hearing preservation and without considerable permanent side effects. Therefore, SRS can be proposed as safe and effective treatment option for AN, even with higher Koos grades.

Strategy of the diagnosis and treatment for hydrocephalus associated with acoustic neuroma

To describe and analyze the strategy of the diagnosis and treatment for acoustic neuroma associated with hydrocephalus. A retrospective review was performed in 29 patients with hydrocephalus associated with acoustic neuroma form Apr. 2004 to Apr. 2015. The patients' clinical information, the types of the hydrocephalus, the treatment and the prognosis of the hydrocephalus were recorded. There were 20 patients with obstructive hydrocephalus and 9 patients with communicating hydrocephalus preoperatively. Among the 29 cases, 3 patients had ventriculoperitoneal shunts, 5 patients had external ventricular drains, the remaining 21 patients had no further managements for hydrocephalus; after removing the acoustic neuroma, the hydrocephalus improved in 10 cases, the ventricle unchanged in 10 cases among the obstructive hydrocephalus group, the ventricle unchanged in all 9 cases among the communicating hydrocephalus group. Nineteen cases were diagnosed with communicating hydrocephalus and 10 cases with obstructive hydrocephalus postoperatively. Among the patients of acoustic neuroma associated with hydrocephalus, communicating hydrocephalus is more common than obstructive hydrocephalus. The optimal management of acoustic neuroma associated with hydrocephalus is complete removal of the tumor, with treatment only for patients with persistent hydrocephalus.

Interdisciplinary management of acoustic neuromas

Interdisciplinary management of acoustic neuromas

Fat graft-assisted internal auditory canal closure after retrosigmoid transmeatal resection of acoustic neuroma: Technique for prevention of cerebrospinal fluid leakage

The retrosigmoid transmeatal approach remains an important strategy in the surgical management of acoustic neuromas. Gross total resection of acoustic neuromas requires removal of tumor within the cerebellopontine angle as well as tumor involving the internal auditory canal (IAC). Drilling into the petrous bone of the IAC can expose petrous air cells, which can potentially result in a fistulous tract to the nasopharynx manifesting as cerebrospinal fluid (CSF) rhinorrhea. We describe our method of IAC closure using autologous fat graft and assessed the rates of postoperative CSF leakage. We performed a retrospective study of 24 consecutive patients who underwent retrosigmoid transmeatal resection of acoustic neuroma who underwent our method of fat graft-assisted IAC closure. We assessed rates of postoperative CSF leak (incisional leak, rhinorrhea, or otorrhea), pseudomeningocele formation, and occurrence of meningitis. Twenty-four patients (10 males, 14 females) with a mean age of 47years (range 18–84) underwent fat graft-assisted IAC closure. No lumbar drains were used postoperatively. There were no instances of postoperative CSF leak (incisional leak, rhinorrhea, or otorrhea), pseudomeningocele formation, or occurrence of meningitis. There were no graft site complications. Our results demonstrate that autologous fat grafts provide a safe and effective method of IAC defect closure to prevent postoperative CSF leakage after acoustic tumor removal via a retrosigmoid transmeatal approach. The surgical technique and operative nuances are described.