Management Of Vestibular Schwannomas Research Articles

Management of vestibular schwannoma: A pilot case series with postoperative ABR monitoring

ObjectiveAuditory brainstem response (ABR) monitoring is regularly used in surgery of vestibular schwannoma to achieve hearing preservation. Despite ABR preservation at the end of surgery, there are cases with postoperative deafness. To date it is unclear whether these are false positive ABR data or cases of secondary hearing loss. In this pilot study, we focused on the early postoperative phase and possible ABR changes in this period. Patient and methodIn a prospective study from March 2008 to April 2009, eleven patients (5 female and 6 male) with vestibular schwannoma and preoperative residual hearing were investigated by repeated postoperative ABR investigation at seven dates during the first week. ABR results, hearing function and tumor extension were categorized according to Hannover classification system. The postoperative developments of the first week after surgery are described. ResultsHearing preservation was achieved in 55% (6 of 11) of the patients. In the early postoperative phase, three patients with an ABR loss at the end of surgery showed some kind of recovery. In one case, a permanent recovery could be reproduced and developed step by step during the early postoperative phase. Three patients showed a postoperative deterioration resulting in a complete ABR loss. In one of these cases, it was probably a technical problem, but in the two other cases it was a real impairment. In 8 of 11 ABR, quality changed considerably during the early postoperative phase. ConclusionThis pilot study identifies considerable change of ABR formation occurring in a considerable proportion of patients early after vestibular schwannoma resection. Obviously, in some patients, the endoperative state of the ABR is not the final state. Some patients show a postoperative improvement and some a deterioration towards a complete loss of all ABR components. Whether secondary hearing loss could be presented by early detection, will be a matter of further studies.

The Glasgow Benefit Inventory: a systematic review of the use and value of an otorhinolaryngological generic patient-recorded outcome measure.

BackgroundThe Glasgow Benefit Inventory (GBI) is a validated, generic patient-recorded outcome measure widely used in otolaryngology to report change in quality of life post-intervention.Objectives of reviewTo date, no systematic review has made (i) a quality assessment of reporting of Glasgow Benefit Inventory outcomes; (ii) a comparison between Glasgow Benefit Inventory outcomes for different interventions and objectives; (iii) an evaluation of subscales in describing the area of benefit; (iv) commented on its value in clinical practice and research.Type of reviewSystematic review.Search strategy‘Glasgow Benefit Inventory’ and ‘GBI’ were used as keywords to search for published, unpublished and ongoing trials in PubMed, EMBASE, CINAHL and Google in addition to an ISI citation search for the original validating Glasgow Benefit Inventory paper between 1996 and January 2015.Evaluation methodPapers were assessed for study type and quality graded by a predesigned scale, by two authors independently. Papers with sufficient quality Glasgow Benefit Inventory data were identified for statistical comparisons. Papers with <50% follow-up were excluded.ResultsA total of 118 eligible papers were identified for inclusion. A national audit paper (n = 4325) showed that the Glasgow Benefit Inventory gave a range of scores across the specialty, being greater for surgical intervention than medical intervention or ‘reassurance’. Fourteen papers compared one form of surgery versus another form of surgery. In all but one study, there was no difference between the Glasgow Benefit Inventory scores (or of any other outcome). The most likely reason was lack of power. Two papers took an epidemiological approach and used the Glasgow Benefit Inventory scores to predict benefit. One was for tonsillectomy where duration of sore throat episodes and days with fever were identified on multivariate analysis to predict benefit albeit the precision was low. However, the traditional factor of number of episodes of sore throat was not predictive. The other was surgery for chronic rhinosinusitis where those with polyps on univariate analysis had greater benefit than those without. Forty-three papers had a response rate of >50% and gave sufficient Glasgow Benefit Inventory total and subscales for meta-analysis. For five of the 11 operation categories (vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery) that were most likely to have a single clear clinical objective, score data had low-to-moderate heterogeneity. The value in the Glasgow Benefit Inventory having both positive and negative scores was shown by an overall negative score for the management of vestibular schwannoma. The other six operations gave considerable heterogeneity with rhinoplasty and septoplasty giving the greatest percentages (98% and 99%) most likely because of the considerable variations in patient selection. The data from these operations should not be used for comparative purposes. Five papers also reported the number of patients that had no or negative benefit, a potentially a more clinically useful outcome to report. Glasgow Benefit Inventory subscores for tonsillectomy were significantly different from ear surgery suggesting different areas of benefitConclusionsThe Glasgow Benefit Inventory has been shown to differentiate the benefit between surgical and medical otolaryngology interventions as well as ‘reassurance’. Reporting benefit as percentages with negative, no and positive benefit would enable better comparisons between different interventions with varying objectives and pathology. This could also allow easier evaluation of factors that predict benefit. Meta-analysis data are now available for comparison purposes for vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery. Fuller report of the Glasgow Benefit Inventory outcomes for non-surgical otolaryngology interventions is encouraged.

Surgical management of vestibular schwannomas after failed radiation treatment.

Increasing numbers of patients with vestibular schwannoma (VS) have been treated with focused-beam stereotactic radiation treatment (SRT) including Gamma knife, CyberKnife, X-knife, Novalis, or proton beam therapy. The purpose of this study was to document the incidence of tumor regrowth or symptoms that worsened or first developed following SRT and to discuss surgical strategies for patients who have failed SRT for VS. A consecutive series of 39 patients with SRT failed VS were surgically treated. Clinical symptoms, tumor regrowth at follow-up, intraoperative findings, and surgical outcome were evaluated. There were 15 males and 24 females with a mean age of 51.8 years. Thirty-six patients (92.3%) demonstrated steady tumor growth after SRT. Two (5.1%) patients with slight increase of the mass underwent surgical resection because of development of unbearable facial pain. Symptoms that worsened or newly developed following SRT in this series were deafness (41%), dizziness (35.9%), facial numbness (25.6%), tinnitus (20.5%), facial nerve palsy (7.7%), and facial pain (7.7%). Intraoperative findings demonstrated fibrous changes of the tumor mass, cyst formation, and brownish-yellow or purple discoloration of the tumor capsule. Severe adhesions between the tumor capsule and cranial nerves, vessels, and the brainstem were observed in 69.2%. Additionally, the facial nerve was more fragile and irritable in all cases. Gross total resection (GTR) was achieved in 33.3% of patients, near-total resection (NTR) in 35.9%, and subtotal resection (STR) in 30.8% of patients. New facial nerve palsy was seen in seven patients (19.4%) postoperatively. Our findings suggest that patients with VS who fail SRT with either tumor progression or worsening of clinical symptoms will have an increased rate of adhesions to the neurovascular structures and may have radiation-influenced neuromalacia. Salvage surgery of radiation-failed tumors is more difficult and will have a higher risk of postoperative complications. Radical total resection may not be feasible, and conservative modality of subtotal resection needs to be considered to avoid new neurologic deficits.

Microsurgical management of vestibular schwannoma after failed previous surgery.

OBJECTIVE Microsurgical treatment of recurrent vestibular schwannoma (VS) is difficult and poses specific challenges. The authors report their experience with 53 cases of surgically treated recurrent VS. Outcome of these tumors was compared to that of primarily operated on VS. Special attention was given to the facial nerve functional outcome. METHODS A retrospective analysis was performed of the patients who underwent surgery for recurrent VS at one institution from 2000 to 2013. The preoperative data, intraoperative findings, and outcome in terms of facial nerve function and improvement of the preoperative symptoms were analyzed and compared with those in a control group of 30 randomly selected patients with primarily operated on VS. A multivariate regression analysis was performed to test the factors that could affect the facial nerve outcome in each group. RESULTS Fifty-three consecutive patients underwent surgery for recurrent VS. Seventeen patients were previously operated on and received postoperative radiosurgery (Group A). Thirty-six patients were previously operated on but did not receive postoperative radiosurgery (Group B). The overall postoperative facial nerve function was significantly worse in Groups A and B in comparison with the control group (Group C). Interestingly, there was no significant difference in the facial nerve outcome among the 3 groups in patients who had good preoperative facial nerve function. The tumor size and the preoperative facial nerve function are variables that significantly affect the facial nerve outcome. Most of the patients showed improvement of the preoperative symptoms, such as trigeminal hypesthesia, gait disturbance, and headache. CONCLUSIONS Complete microsurgical tumor removal is the optimal management for patients with recurrent or regrowing VS. The procedure is safe, associated with favorable facial nerve outcome, and may also improve existing neurological symptoms.

Diagnosis and Management of Hereditary Meningioma and Vestibular Schwannoma.

Bilateral vestibular schwannomata and meningiomata are the tumours most commonly associated with neurofibromatosis type II (NF2). These tumours may also be seen in patients with schwannomatosis and familial meningioma, but these phenotypes are usually easy to distinguish. The main diagnostic challenge when managing these tumours is distinguishing between sporadic disease which carries low risk of subsequent tumours or NF2 with its associated morbidities and reduced life expectancy. This chapter outlines some of the diagnostic and management considerations along with associated evidence.

Evaluation of quality of life issues after different management policies for vestibular schwannomas: what are we measuring?

PURPOSE: To compare the different quality of life measures used to report the outcomes of the different forms of management of vestibular schwannomas. METHODS: Literature search and critical evaluation of outcome measures and comparison between different studies. RESULTS: A total number of 6749 patients were included in 31 studies. Eighteen studies used the SF36 forms, 17 - custom questionnaires, 7 - the GBI and 8 used various other questionnaires. The most commonly reported handicaps included hearing loss, facial nerve paralysis, tinnitus, gait and balance disorders, pain and headache, psychological and cognitive problems, loss of taste and lacrimation and facial hypoesthesia. CONCLUSIONS: When evaluating QOL issues in patients with vestibular schwannoma, the type of intervention as well as the pre-interventional status should be considered. More specific comprehensive systems of evaluation should be devised through the cooperation of multiple centers with different management policies and variable patient populations as well.

Self-reported symptoms and patient experience: A British Acoustic Neuroma Association survey

Objective. To assess patient-reported outcomes and experience of vestibular schwannoma (VS) management. Study design. Survey of members of the British Acoustic Neuroma Association (BANA). Methods. Members of the BANA were invited to complete an online survey. Questions were divided into five areas: Demographic details; symptoms at diagnosis; level of information received; treatment after-effects; and overall experience of diagnosis and/or treatment. Results. Demographics: 598 (58%) BANA members completed the survey. 77.1% of respondents were aged between 41 and 70 years. Symptoms at diagnosis: hearing loss (84%), unilateral tinnitus (40%) and imbalance (51%) were commonest. Isolated tinnitus and imbalance occurred in 2% and 6%, respectively. Information received: 39% stated they were given ‘just the right amount of information about all management options’, and 32% ‘not enough information’. Treatment after-effects: Overall quality of life was classified as ‘a lot better’ (11%), ‘a little better’ (7%), ‘unchanged’ (25%), ‘a little worse’ (38%) and ‘a lot worse’ (19%). 61% respondents continued in the same job. Return to social life, hobbies and sports was impaired in 65%. Overall experience: Experience of treatment was graded as ‘much better than expected’ (20%), ‘a little better’ (15%), ‘about the same’ (27%), ‘a little worse’ (22%) and ‘much worse’ (16%). Conclusion. Quality of life measures are important in assessing VS management outcomes, and will increasingly inform clinical decision-making. Further examination of how patients with VS perceive their disease, cope with illness and use social support networks may also help to inform future practice and the creation of decision analytical models.

Strategy for the surgical treatment of vestibular schwannomas in patients with neurofibromatosis type 2

ObjectiveGuidelines for appropriate management of vestibular schwannomas in NF2 patients are controversial. In this paper we reviewed our experience with patients with NF2 for the results of surgical treatment with particular reference to hearing and facial nerve preservation. MethodsWe included in the study 30 patients (16 women and 14 men) with the diagnosis of NF2 treated in our department between 1998 and 2014 who underwent surgery for vestibular schwannoma removal with a follow-up for at least 1 year. In 3 cases, the vestibular schwannomas were unilateral. Six patients with bilateral vestibular schwannomas underwent unilateral procedure. Therefore, 51 acoustic tumors were studied in 30 patients. ResultsNo operative death we noted. Significant deterioration to the non-functional level occurred in 19 out of 22 cases with well-preserved preoperative hearing. Only three ears maintained their preoperative good hearing. Hearing was preserved in cases of small schwannoma not exceeding 2cm. Among 21 patients who underwent bilateral operations hearing was preserved in 3 out of 7 cases when smaller tumor or better hearing level side was attempted at first surgery. In contrary none of the 14 patients retained hearing when the first operation concerned the worse-hearing ear. Among 14 tumors up to 2cm there was only one case of moderately severe facial nerve dysfunction (House–Brackmann Grade IV) in the long follow-up. ConclusionEarly surgical intervention for vestibular schwannoma in NF2 patient is a viable management strategy to maintain hearing function and preserve facial nerve function.

The Changing Landscape of Vestibular Schwannoma Management in the United States--A Shift Toward Conservatism.

To characterize the evolving management of vestibular schwannoma (VS) in the United States. Retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) database. SEER database. All patients with a diagnosis of VS were analyzed. Data were described and compared using trend analyses and univariate and multivariable logistic regression. A total of 8330 patients (average age 54.7 years, 51.9% female) were analyzed. The mean incidence was approximately 1.1 per 100,000 per year and did not vary significantly across time; however, from 2004 to 2011, there was a statistically significant decrease in tumor size category at time of diagnosis (P < .01). Overall, 3982 patients (48%) received primary microsurgery, 1978 (24%) radiation therapy alone, and 2370 (29%) observation. Within the microsurgical cohort, 732 (18%) underwent subtotal resection, and of those, 98 (13.4%) received postoperative radiation therapy. Multivariable regression revealed that surgical treatment was more common in younger patients and larger tumor size categories (P < .05). Management trend analysis revealed that microsurgery was used less frequently over time (P < .0001), observation was used more frequently (P < .0001), and the pattern of radiation therapy remained unchanged. Linear regression was used to create an equation that was applied to predict future management practices. These data predict that by 2026, half of all cases of VS will be managed initially with observation. While the incidence of VS has remained steady, tumor size at time of diagnosis has decreased over time. Within the United States there has been a clear, recent evolution in management toward observation.

The long-term outcomes of wait-and-scan and the role of radiotherapy in the management of vestibular schwannomas.

To analyze the growth characteristics in patients assigned to wait and scan in vestibular schwannomas (VSs) during long-term follow-up. The wait-and-scan policy and radiotherapy (RT) are conservative management strategies for VSs. A better insight into the natural history of the tumor and growth patterns is quintessential in planning optimal management. The charts of 576 patients with unilateral sporadic VSs who were assigned to wait and scan at our center from 1986 to 2013 were reviewed. A systematic review of radiosurgical literature was done and compared with results of wait and scan. The overall mean follow-up was 36.9 ± 30.2 months. One hundred fifty-four patients with a 5-year follow-up were analyzed separately for patterns of tumor growth. Varied combinations of growth patterns were observed. Eighty-four (54.5%) tumors showed no growth throughout 5 years, 12 (7.8%) showed slow growth throughout 5 years, 2 (1.3%) tumors showed fast growth throughout 5 years. A total of 134 tumors (87%) showed favorable growth patterns for wait and scan. When the results of wait and scan were compared with those of RT, it pointed to the possibility that at least a portion of control of tumor by RT could be attributed to the natural course of the tumor. The wait-and-scan modality is ideal for management of VSs in the elderly population and also in younger patients with intrameatal tumors. Considering the fact that a large percentage of tumors do not require any form of treatment, the role of RT in VSs needs to be reinvestigated.

Benign brain tumors and tumors associated with phakomatoses.

This article reviews the clinical features, diagnostic criteria, molecular genetics, and management of sporadic meningiomas and vestibular schwannomas and tumors associated with the major neurocutaneous disorders. Recent advances in cancer genomics are now allowing sequencing of the genome of these tumors to identify oncogenic drivers and possible therapeutic targets. Sporadic meningiomas and schwannomas, and tumors occurring as part of a neurocutaneous syndrome, have been the subjects of strong biological and therapeutic interest in the past few years; new and exciting therapies are either under investigation or will be in the upcoming years. This article takes an in-depth look at sporadic meningiomas and schwannomas, followed by a review of the phakomatoses and their associated tumors.

Conservative management of vestibular schwannoma: Predictors of growth and hearing.

To describe the clinical outcomes of patients undergoing serial observation for vestibular schwannoma (VS) and identify factors that may predict tumor growth or hearing loss. Retrospective review. A retrospective review was conducted of patients seen at a tertiary care medical center between 2002 and 2013 with an International Classification of Diseases-9 diagnosis code of 225.1. Patients electing observation as initial management, with at least two documented imaging results, were included. Exclusion criteria comprised bilateral VS, diagnosis of neurofibromatosis type 2, and neoplasms other than VS. Decline in serviceable hearing, tumor growth, and changes in management strategy were recorded. Survival analysis to assess median time to outcomes and multiple logistic regression analyses were performed. A total of 94 patients met inclusion criteria. While undergoing observation, 22.3% of patients underwent a change in management strategy to microsurgical excision or stereotactic radiotherapy. For patients with initial serviceable hearing, 24.3% observed a decline to a nonserviceable level. No significant clinical factors were identified to predict changes in hearing. Survival analysis revealed that an estimated 69.1% of patients electing observation as initial management continued to do so at 5 years. Imbalance or disequilibrium at presentation was found to be associated with an increased adjusted odds ratio (OR) (OR 2.96; 95% confidence interval, 1.03-8.50; P = 0.04) for tumor growth. Serial observation of VS is a viable treatment strategy for selected patients, with two-thirds of patients electing to continue this management option after 5 years. Disequilibrium as a presenting symptom may be associated with subsequent tumor growth. 4.

Neurosurgical decision making: personal and professional preferences.

Physicians are often solicited by patients or colleagues for clinical recommendations they would make for themselves if faced by a clinical situation. The act of making a recommendation can alter the clinical course being taken. The authors sought to understand this dynamic across different neurosurgical scenarios by examining how neurosurgeons value the procedures that they offer. The authors conducted an online survey using the Congress of Neurological Surgeons listserv in May 2013. Respondents were randomized to answer either as the surgeon or as the patient. Questions encompassed an array of distinct neurosurgical scenarios. Data on practice parameters and experience levels were also collected. Of the 534 survey responses, 279 responded as the "neurosurgeon" and 255 as the "patient." For both vestibular schwannoma and arteriovenous malformation management, more respondents chose resection for their patient but radiosurgery for themselves (p = 0.002 and p = 0.001, respectively). Aneurysm coiling was chosen more often than clipping, but those whose practice was ≥ 30% open cerebrovascular neurosurgery were less likely to choose coiling. Overall, neurosurgeons who focus predominantly on tumors were more aggressive in managing the glioma, vestibular schwannoma, arteriovenous malformation, and trauma. Neurosurgeons more than 10 years out of residency were less likely to recommend surgery for management of spinal pain, aneurysm, arteriovenous malformation, and trauma scenarios. In the majority of cases, altering the role of the surgeon did not change the decision to pursue treatment. In certain clinical scenarios, however, neurosurgeons chose treatment options for themselves that were different from what they would have chosen for (or recommended to) their patients. For the management of vestibular schwannomas, arteriovenous malformations, intracranial aneurysms, and hypertensive hemorrhages, responses favored less invasive interventions when the surgeon was the patient. These findings are likely a result of cognitive biases, previous training, experience, areas of expertise, and personal values.

Modern Gamma Knife radiosurgery of vestibular schwannomas: treatment concept, volumetric tumor response, and functional results.

The objective of the present study was longitudinal evaluation of the volumetric tumor response and functional results after Gamma Knife radiosurgery of vestibular schwannomas, performed according to the modern standards of treatment. From October 2003 to September 2007, 133 consecutive patients with vestibular schwannomas were treated according to the concept of robotic Gamma Knife microradiosurgery, which is based on precise irradiation of the lesion, sparing adjacent structures, and delivery of the high radiation energy to the target. Multiple small-sized isocenters located within the border of the neoplasm were applied. The mean marginal dose was 11.5 Gy (range, 11-12 Gy). In total, 126 cases with a minimum posttreatment follow-up of 2 years (range, 2-7 years; median, 4 years) were analyzed. Temporary enlargement was noted in 25% of tumors at 6 months after radiosurgery. At 3 years of follow-up, tumor shrinkage, stabilization, and increase in volume were marked in 73%, 23%, and 4% of cases, respectively. All progressing lesions spontaneously stabilized later on and did not require additional management. In 3% of patients, transitory impairment of the facial nerve function was marked; however, neither its permanent dysfunction nor trigeminal neuropathy attributed to radiosurgery was noted. Impairment of hearing compared to its pretreatment level was revealed in 4%, 12%, 13%, and 16% of patients at 6 months, 1 year, 2 years, and 3 years after radiosurgery, respectively, and this trend was statistically significant (P = 0.0042). Overall, 77% of patients with serviceable hearing before treatment preserved it 3 years thereafter. In conclusion, modern Gamma Knife radiosurgery provides effective and safe management of vestibular schwannomas. Nevertheless, possible temporary tumor enlargement, delay of its growth arrest, transient dysfunction of the cranial nerves, and gradual deterioration of hearing after irradiation should be always taken into consideration.

Combined approach for the management of large vestibular schwannomas: Planned subtotal resection followed by gamma knife surgery in a series of 20 consecutive cases

Introduction The management of large lesions of the skull base, such as vestibular schwannomas (VS) is challenging. Microsurgery remains the main treatment option. Combined approaches (planned subtotal resection followed by gamma knife surgery (GKS) for residual tumor long-term control) are being increasingly considered to reduce the risk of neurological deficits following complete resection. The current study aims to prospectively evaluate the safety-efficacy of combined approach in patients with large VS. Materials and methods We present our experience with planned subtotal resection followed by gamma knife surgery (GKS) in a consecutive a series of 20 patients with large vestibular schwannomas, treated between 2009 and 2014 in Lausanne University Hospital, Switzerland. Clinical and radiological data and audiograms were prospectively collected for all patients, before and after surgery, before and after GKS, at regular intervals, in dedicated case-report forms. Additionally, for GKS, dose-planning parameters were registered. Results Twenty patients (6 males and 14 females) with large VS had been treated by this approach. The mean age at the time of surgery was 51.6 years (range 34.4–73.4). The mean presurgical diameter was 36.7 (range 26.1–45). The mean presurgical tumor volume was 15.9 cm3 (range 5 34.9). Three patients (15%) needed a second surgical intervention because of high volume of the tumor remnant considered too large for a safe GKS. The mean follow-up after surgery was 27.2 months (range 6–61.3). The timing of GKS was decided on the basis of the residual tumor shape and size following surgery. The mean duration between surgery and GKS was 7.6 months (range 4 13.9, median 6 months). The mean tumor volume at the time of GKS was 4.1 cm3 (range 0.5–12.8). The mean prescription isodose volume was 6.3 cm3 (range 0.8–15.5). The mean number of isocenters was 20.4 (range 11–31) and the mean marginal prescription dose was 11.7 Gy (range 11–12). We did not have any major complications in our series. Postoperative status showed normal facial nerve function (House-Brackmann grade I) in all patients. Six patients with useful pre-operative hearing (GR class 1) underwent surgery with the aim to preserve cochlear nerve function; of these patients, 5 (83.3%) of them remained in GR class 1 and one (16.7%) lost hearing (GR class 5). Two patients having GR class 3 at baseline remained in the same GR class, but the tonal audiometry improved in one of them during follow-up. Eleven patients (57.8%) were in GR class 5 preoperatively; one patient improved hearing after surgery, passing to GR class 3 postoperatively. Following GKS, there were no new neurological deficits, with facial and hearing function remaining identical to that after surgery. Conclusion Our data suggest that planned subtotal resection followed by GKS has an excellent clinical outcome with respect to retaining facial and cochlear nerve function. This represents a paradigm shift of the treatment goals from a complete tumor excision perspective to that of a surgery designed to preserve neural functions. As long-term results emerge, this approach of a combined treatment (microsurgery and GKS) will most probably become the standard of care in the management of large vestibular schwanomma.

Experience of multidisciplinary team meetings in vestibular schwannoma: a preliminary report.

To assess the contribution of multidisciplinary team meetings (MTM) on vestibular schwannoma management as well as to (1) compare professional compliance to national guidelines and (2) study the percentage of loss to follow-up in cases of conservative management by radiologic observation. A retrospective descriptive study of MTMs held between January 2011 and May 2013 in a tertiary referral center. Patients were classified in three groups according to the MTM decision (observation, surgery or radiotherapy). A total of 363 cases were discussed during the study period (29 months). One hundred and ninety-four decisions (53.4%) were for conservative management with radiologic observation, 130 (35.8%) for surgery, and 39 (10.7%) for radiation therapy. The sex ratio was 0.94, and the patients had a median age of 59 years (range 18-86 years). Most of the vestibular schwannomas (74.2%) were small (stages I and II). Global concordance between the MTM decision and International Radiosurgery Association guidelines was 88.7%. Twenty-three percent of the 104 files that were discussed in MTMs between January 2011 and July 2012, for which conservative management was decided, were lost to follow-up by 18 months. Management of vestibular schwannoma remains controversial, but it usually depends on the evolutive status. MTMs improve practice and facilitate the creation and maintenance of local registries. Future studies in MTMs are warranted to evaluate the benefit and evaluated if MTM could optimize long-term follow-up, limiting loss to follow-up in the observation of vestibular schwannomas that may be evolutive.

Current practices in vestibular schwannoma management: A survey of American and Canadian neurosurgeons

ObjectivesComprehensive therapy for vestibular schwannomas has changed dramatically over the past fifty years. Previously, neurosurgeons were most likely to treat these tumors via an independent surgical approach. Currently, many neurosurgeons treat vestibular schwannomas employing an interdisciplinary team approach with neuro-otologists and radiation oncologists. This survey aims to determine the current treatment paradigm for vestibular schwannomas among American and Canadian neurosurgeons, with particular attention to the utilization of a team approach to the surgical resection of these lesions. MethodsA seventeen part survey questionnaire was sent by electronic mail to residency trained members of the American Association of Neurological Surgeons currently practicing in Canada or the United States. Questions were divided into groups regarding physician background, overall practice history, recent practice history, opinions on treatment paradigms, and experience with an interdisciplinary team approach. ResultsSeven hundred and six responses were received. The vast majority of neurosurgeons surgically resect vestibular schwannomas as part of an interdisciplinary team (85.7%). Regional variations were observed in the use of an interdisciplinary team: 52.3% of responding neurosurgeons who surgically treat vestibular schwannomas without neuro-otologists currently practice in the South (no other region represented more than 15.4% of this group, p=0.02). Surgeons who have treated >50 vestibular schwannomas show a trend towards more frequent utilization of an interdisciplinary approach than less experienced surgeons, but this did not reach statistical significance. ConclusionsThe majority of neurosurgeons in the United States and Canada surgically resect vestibular schwannomas via an interdisciplinary approach with the participation of a neuro-otologist. Neurosurgeons in the South appear more likely to surgically treat these tumors alone than neurosurgeons in other regions of the U.S. and Canada.

Current Concepts in Management of Vestibular Schwannomas in Neurofibromatosis Type 2

Neurofibromatosis type 2 (NF2) is an autosomal dominant condition resulting in multiple benign intracranial and spinal tumours including bilateral vestibular schwannomas. The management of vestibular schwannomas in NF2 is particularly challenging, given the young presentation of many patients, the natural history of the disease that often leads to complete loss of hearing in both ears and the burden of other tumours. Specialists from multidisciplinary NF2 teams describe current concepts in the management of vestibular schwannomas in NF2.

Combined Approach for the Management of Large Vestibular Schwannomas: Planned Subtotal Resection Followed by Gamma Knife Surgery in a Series of 16 Consecutive Cases

Combined Approach for the Management of Large Vestibular Schwannomas: Planned Subtotal Resection Followed by Gamma Knife Surgery in a Series of 16 Consecutive Cases

The Factors Associated With Tumor Stability Observed With Conservative Management of Intracanalicular Vestibular Schwannoma

Periodic observation with imaging is an acceptable option for patients with small vestibular schwannomas (VSs). The objective of this study was to evaluate the outcome of conservative management of intracanalicular VSs (ICVSs). We reviewed 31 patients who were followed up for more than 1 year among patients diagnosed as having VS limited to the internal auditory canal. The median follow-up period was 31 months (range, 12-84 mo). We analyzed the patients' clinical features, clinical courses, and audiologic changes. The most frequent initial presenting symptom in patients with ICVS was hearing loss, and one-half of the patients (8 of 16) had a history of sudden hearing loss. Seven patients (22.5%) showed tumor growth during the follow-up period. When we considered the initial tumor size in ICVS, the patients larger in size than the median showed a significantly higher rate of tumor growth. In terms of the initial hearing levels of ICVS according to the Consensus Meeting Guidelines, five patients were classified as Class A (normal hearing) and six patients were classified as Class B. Only one patient among patients with useful hearing (Classes A and B) showed tumor growth. The follow-up hearing levels of all Class A patients were preserved; however, all Class B patients deteriorated to Class C. Patients with ICVS showed favorable results with conservative management. Among them, patients with small tumors and normal hearing showed a good prognosis.