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Microsurgical resection of vestibular schwannomas: complication avoidance

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Abstract

Vestibular schwannoma (VS) surgery requires appropriate patient selection, meticulous microsurgical technique and optimal post-operative care. Focused radiation is an effective alternative for the treatment of smaller VSs. For VS surgery to remain a reasonable option, surgery must be performed with a limited number of complications. Complication rates for VS surgery have increased over the last decade. This is likely due to (1) decreased surgical volume and as a result decreased microsurgical experience, (2) larger tumors undergoing surgery while smaller tumors are reserved for radiation, and (3) surgery for previously radiated tumors resulting in more difficult anatomic dissection. Appropriate management of complications is paramount. Herein, we discuss complications related to VS microsurgery and methods of avoidance. Specifically, we discuss the most frequently encountered complications, intraoperative monitoring and finally, methods of addressing these complications. With meticulous microsurgical technique, careful intraoperative monitoring and vigilant perioperative care one will ensure optimal patient outcomes.

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References

  1. Gal TJ, Shinn J, Huang B (2010) Current epidemiology and management trends in acoustic neuroma. Otolaryngol Head Neck Surg 142:677–681

    Article  PubMed  Google Scholar 

  2. MacKeith S, Kerr R, Milford C (2013) Trends in acoustic neuroma management: a 20-year review of the oxford skull base clinic. J Neurol Surg B 74:194–200

    Article  Google Scholar 

  3. Barker FG, Carter BS, Ojemann RG, Jyung RW, Poe DS, McKenna MJ (2003) Surgical excision of acoustic neuroma: patient outcome and provider caseload. Laryngoscope 113:1332–1343

    Article  PubMed  Google Scholar 

  4. Patel S, Nuño M, Mukherjee D, Nosova K, Lad SP, Boakye M, Black KL, Patil CG (2013) Trends in surgical use and associated patient outcomes in the treatment of acoustic neuroma. World Neurosurg 80:142–147

    Article  PubMed  Google Scholar 

  5. Oghalai JS, Buxbaum JL, Pitts LH, Jackler RK (2003) The effect of age on acoustic neuroma surgery outcomes. Otol Neurotol 24:473

    Article  PubMed  Google Scholar 

  6. Samii M, Matthies C (1995) Hearing preservation in acoustic tumour surgery. In: Advances and technical standards in neurosurgery. Springer, Vienna, pp 343–373

    Chapter  Google Scholar 

  7. Strauss C, Romstöck J, Fahlbusch R, Rampp S, Scheller C (2006) Preservation of facial nerve function after postoperative vasoactive treatment in vestibular schwannoma surgery. Neurosurgery 59:577–584

    Article  PubMed  Google Scholar 

  8. Sameshima T, Fukushima T, McElveen JTJ, Friedman AH (2010) Critical assessment of operative approaches for hearing preservation in small acoustic neuroma surgery: retrosigmoid vs middle fossa approach. Neurosurgery 67:640–645

    Article  PubMed  Google Scholar 

  9. Colletti V, Fiorino F (2003) Middle fossa versus retrosigmoid-transmeatal approach in vestibular schwannoma surgery: a prospective study. Otol Neurotol 24:927

    Article  PubMed  Google Scholar 

  10. Brackmann DE, Owens RM, Friedman RA, Hitselberger WE, la Cruz De A, House JW, Nelson RA, Luxford WM, Slattery WHI, Fayad JN (2000) Prognostic factors for hearing preservation in vestibular schwannoma surgery. Otol Neurotol 21:417

    CAS  Google Scholar 

  11. Colletti V, Fiorino F (2005) Is the middle fossa approach the treatment of choice for intracanalicular vestibular schwannoma? Otolaryngol Head Neck Surg 132:459–466

    Article  PubMed  Google Scholar 

  12. Wanibuchi M, Fukushima T, McElveen JT Jr, Friedman AH (2009) Hearing preservation in surgery for large vestibular schwannomas. J Neurosurg 111:845–854

    Article  PubMed  Google Scholar 

  13. Nonaka Y, Fukushima T, Watanabe K, Friedman AH, Sampson JH, McElveen JTJ, Cunningham CDI, Zomorodi AR (2013) Contemporary surgical management of vestibular schwannomas: analysis of complications and lessons learned over the past decade. Neurosurgery 72:ons103–ons115

    PubMed  Google Scholar 

  14. John T, McElveen J, House JW, Hitselberger WE, Brackmann DE (1984) Retrolabyrinthine vestibular nerve section: a viable alternative to the middle fossa approach. Otolaryngol Head Neck Surg 92:136–140

    Article  Google Scholar 

  15. Mazzoni A, Biroli F, Foresti C, Signorelli A, Sortino C, Zanoletti E (2011) Hearing preservation surgery in acoustic neuroma. Slow progress and new strategies. Acta Otorhinolaryngol Ital 31:76–84

    CAS  PubMed  PubMed Central  Google Scholar 

  16. Ansari SF, Terry C, Cohen-Gadol AA (2012) Surgery for vestibular schwannomas: a systematic review of complications by approach. Neurosurg Focus 33:E14

    Article  PubMed  Google Scholar 

  17. Yamakami I, Ito S, Higuchi Y (2014) Retrosigmoid removal of small acoustic neuroma: curative tumor removal with preservation of function. J Neurosurg 121:554–563

    Article  PubMed  Google Scholar 

  18. James ML, Husain AM (2005) Brainstem auditory evoked potential monitoring when is change in wave V significant? Neurology 65:1551–1555

    Article  PubMed  Google Scholar 

  19. Upadhyay U, Almefty RO, Dunn IF, Al-Mefty O (2015) Letter to the editor: save the nerve. J Neurosurg 123:821–822

    Article  PubMed  Google Scholar 

  20. Roehm PC, Mallen-St Clair J, Jethanamest D, Golfinos JG, Shapiro W, Waltzman S, Roland JT (2011) Auditory rehabilitation of patients with neurofibromatosis type 2 by using cochlear implants. J Neurosurg 115:827–834

    Article  PubMed  PubMed Central  Google Scholar 

  21. Tufarelli D, Meli A, Alesii A, De Angelis E, Badaracco C, Falcioni M, Sanna M (2006) Quality of life after acoustic neuroma surgery. Otol Neurotol 27:403

    Article  PubMed  Google Scholar 

  22. Wiegand DA, Fickel V (1989) Acoustic neuroma—the patient’s perspective: subjective assessment of symptoms, diagnosis, therapy, and outcome in 541 patients. Laryngoscope 99:179–187

    Article  CAS  PubMed  Google Scholar 

  23. Parving A, Tos M, Thomsen J, Møller H, Buchwald C (1992) Some aspects of life quality after surgery for acoustic neuroma. Arch Otolaryngol Head Neck Surg 118:1061–1064

    Article  CAS  PubMed  Google Scholar 

  24. Betchen SA, Walsh J, Post KD (2009) Self-assessed quality of life after acoustic neuroma surgery. J Neurosurg 99:818–823

    Article  Google Scholar 

  25. Lohne V, Bjørnsborg E, Westerby R, Heiberg E (1987) Effects of facial paralysis after acoustic neuroma surgery in Norway. J Neurosci Nurs 19:123

    Article  CAS  PubMed  Google Scholar 

  26. Arriaga MA, Luxford WM, James S Atkins J, Kwartler JA (1993) Predicting long-term facial nerve outcome after acoustic neuroma surgery. Otolaryngol Head Neck Surg 108:220–224

    Article  CAS  PubMed  Google Scholar 

  27. Brackmann DE, Cullen RD, Fisher LM (2007) Facial nerve function after translabyrinthine vestibular schwannoma surgery. Otolaryngol Head Neck Surg 136:773–777

    Article  PubMed  Google Scholar 

  28. McElveen JT, Belmonte RG, Fukushima T, Bullard DE (2000) A review of facial nerve outcome in 100 consecutive cases of acoustic tumor surgery. Laryngoscope 110:1667–1672

    Article  PubMed  Google Scholar 

  29. Falcioni M, Fois P, Taibah A, Sanna M (2011) Facial nerve function after vestibular schwannoma surgery. J Neurosurg 115:820–826

    Article  PubMed  Google Scholar 

  30. Thakur JD, Khan IS, Shorter CD, Sonig A, Gardner GL, Guthikonda B, Nanda A (2012) Do cystic vestibular schwannomas have worse surgical outcomes? Systematic analysis of the literature. Neurosurg Focus 33:E12

    Article  PubMed  Google Scholar 

  31. Stripf J, Braun K, Gouveris H, Stripf EA, Mann WJ, Amedee RG (2007) Influence of different approaches to the cerebellopontine angle on the function of the intermediate nerve. J Neurosurg 107:927–931

    Article  PubMed  Google Scholar 

  32. Gurgel RK, Dogru S, Amdur RL, Monfared A (2012) Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?. Neurosurg Focus 33:E16

    Article  PubMed  Google Scholar 

  33. Anderson DE, Leonetti J, Wind JJ, Cribari D, Fahey K (2009) Resection of large vestibular schwannomas: facial nerve preservation in the context of surgical approach and patient-assessed outcome. J Neurosurg 102:643–649

    Article  Google Scholar 

  34. Martin RG, Grant JL, Peace D, Theiss C, Rhoton ALJ (1980) Microsurgical relationships of the anterior inferior cerebellar artery and the facial-vestibulocochlear nerve complex. Neurosurgery 6:483

    Article  CAS  PubMed  Google Scholar 

  35. Rhoton AL (1986) Microsurgical anatomy of the brainstem surface facing an acoustic neuroma. Surg Neurol 25:326–339

    Article  PubMed  Google Scholar 

  36. Song F, Hou Y, Sun G, Chen X, Xu B, Huang JH, Zhang J (2016) In vivo visualization of the facial nerve in patients with acoustic neuroma using diffusion tensor imaging–based fiber tracking. J Neurosurg. doi:10.3171/2015.7.JNS142922

    Google Scholar 

  37. Oh T, Nagasawa DT, Fong BM, Trang A, Gopen Q, Parsa AT, Yang I (2012) Intraoperative neuromonitoring techniques in the surgical management of acoustic neuromas. Neurosurg Focus 33:E6

    Article  PubMed  Google Scholar 

  38. Harner SG, Daube JR, Ebersold MJ, Beatty CW (1987) Improved preservation of facial nerve function with use of electrical monitoring during removal of acoustic neuromas. Mayo Clin Proc 62:92–102

    Article  CAS  PubMed  Google Scholar 

  39. Romstöck J, Strauss C, Fahlbusch R (2009) Continuous electromyography monitoring of motor cranial nerves during cerebellopontine angle surgery. J Neurosurg 93:586–593

    Article  Google Scholar 

  40. Kircher ML, Kartush JM (2012) Pitfalls in intraoperative nerve monitoring during vestibular schwannoma surgery. Neurosurg Focus 33:E5

    Article  PubMed  Google Scholar 

  41. Sampath P, Holliday MJ, Brem H, Niparko JK, Long DM (2009) Facial nerve injury in acoustic neuroma (vestibular schwannoma) surgery: etiology and prevention. J Neurosurg 87:60–66

    Article  Google Scholar 

  42. Romstöck J (2004) Delayed facial nerve paresis following acoustic neuroma resection and postoperative vasoactive treatment. Zentralbl Neurochir 65(3):103-107

    Google Scholar 

  43. Yashar P, Zada G, Harris B, Giannotta SL (2012) Extent of resection and early postoperative outcomes following removal of cystic vestibular schwannomas: surgical experience over a decade and review of the literature. Neurosurg Focus 33:E13

    Article  PubMed  Google Scholar 

  44. Martuza RL (2006) Vestibular schwannoma. J Neurosurg 105:526 (discussion 526)

    Article  PubMed  Google Scholar 

  45. Chen Z, Prasad SC, Di Lella F, Medina M, Piccirillo E, Taibah A, Russo A, Yin S, Sanna M (2014) The behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas. J Neurosurg 120:1278–1287

    Article  PubMed  Google Scholar 

  46. Parhizkar N, Hiltzik DH, Selesnick SH (2005) Facial nerve rerouting in skull base surgery. Otolaryngol Clin N Am 38:685–710–ix

    Article  Google Scholar 

  47. Hoffman RA (1994) Cerebrospinal fluid leak following acoustic neuroma removal. Laryngoscope 104:40–58

    Article  CAS  PubMed  Google Scholar 

  48. Glasscock ME, Kveton JF, Jackson CG, Levine SC, McKennan KX (1986) A systematic approach to the surgical management of acoustic neuroma. Laryngoscope 96:1088–1094

    Article  PubMed  Google Scholar 

  49. Becker SS, Jackler RK, Pitts LH (2003) Cerebrospinal fluid leak after acoustic neuroma surgery: a comparison of the translabyrinthine, middle fossa, and retrosigmoid approaches. Otol Neurotol 24:107–112

    Article  PubMed  Google Scholar 

  50. Brennan JW, Rowed DW, Nedzelski JM, Chen JM (2001) Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment. J Neurosurg 94:217–223

    Article  CAS  PubMed  Google Scholar 

  51. Mangus BD, Rivas A, Yoo MJ, Alvarez J, Wanna GB, Haynes DS, Bennett ML (2011) Management of cerebrospinal fluid leaks after vestibular schwannoma surgery. Otol Neurotol 32:1525–1529

    Article  PubMed  PubMed Central  Google Scholar 

  52. Falcioni M, Mulder JJ, Taibah A, De Donato G, Sanna M (1999) No cerebrospinal fluid leaks in translabyrinthine vestibular schwannoma removal: reappraisal of 200 consecutive patients. Am J Otol 20:660–666

    CAS  PubMed  Google Scholar 

  53. Copeland WR, Mallory GW, Neff BA, Driscoll CLW, Link MJ (2015) Are there modifiable risk factors to prevent a cerebrospinal fluid leak following vestibular schwannoma surgery? J Neurosurg 122:312–316

    Article  PubMed  Google Scholar 

  54. Stieglitz LH, Wrede KH, Gharabaghi A, Gerganov VM, Samii A, Samii M, Luedemann WO (2009) Factors affecting postoperative cerebrospinal fluid leaks after retrosigmoidal craniotomy for vestibular schwannomas. J Neurosurg 111:874–883

    Article  PubMed  Google Scholar 

  55. Miyakoshi A, Kohno M, Nagata O, Sora S, Sato H (2013) Hydrocephalus associated with vestibular schwannomas: perioperative changes in cerebrospinal fluid. Acta Neurochir (Wien) 155:1271–1276

    Article  Google Scholar 

  56. Kwartler JA, Schulder M, Baredes S, Chandrasekhar SS (1996) Endoscopic closure of the eustachian tube for repair of cerebrospinal fluid leak. Otol Neurotol 17:470

    CAS  Google Scholar 

  57. Selesnick SH, Liu JC, Jen A, Newman J (2004) The incidence of cerebrospinal fluid leak after vestibular schwannoma surgery. Otol Neurotol 25:387

    Article  PubMed  Google Scholar 

  58. Sade B, Mohr G, Dufour JJ (2007) Vascular complications of vestibular schwannoma surgery: a comparison of the suboccipital retrosigmoid and translabyrinthine approaches. J Neurosurg 105:200–204

    Article  Google Scholar 

  59. Keiper GL Jr, Sherman JD, Tomsick TA, Tew JM Jr (2009) Dural sinus thrombosis and pseudotumor cerebri: unexpected complications of suboccipital craniotomy and translabyrinthine craniectomy. J Neurosurg. 91:192–197

    Article  Google Scholar 

  60. Ohata K, Haque M, Morino M, Nagai K, Nishio A, Nishijima Y, Hakuba A (2009) Occlusion of the sigmoid sinus after surgery via the presigmoidal—transpetrosal approach. J Neurosurg 89:575–584

    Article  Google Scholar 

  61. Crocker M, Nesbitt A, Rich P, Bell B (2009) Symptomatic venous sinus thrombosis following bone wax application to emissary veins. Br J Neurosurg 22:798–800

    Article  Google Scholar 

  62. von Gösseln HH, Samii M, Suhr D, Bini W (1991) The lounging position for posterior fossa surgery: anesthesiological considerations regarding air embolism. Childs Nerv Syst 7:368–374

    Article  Google Scholar 

  63. Samii M, Matthies C (1997) Management of 1000 vestibular schwannomas (acoustic neuromas): surgical management and results with an emphasis on complications and how to avoid them. Neurosurgery 40:11

    CAS  PubMed  Google Scholar 

  64. Sanna M, Taibah A, Russo A, Falcioni M, Agarwal M (2004) Perioperative complications in acoustic neuroma (vestibular schwannoma) surgery. Otol Neurotol 25:379

    Article  PubMed  Google Scholar 

  65. Ebersold MJ, Harner SG, Beatty CW, Harper CM Jr, Quast LM (2009) Current results of the retrosigmoid approach to acoustic neurinoma. J Neurosurg 76:901–909

    Article  Google Scholar 

  66. Inamasu J, Shiobara R, Kawase T, Kanzaki J (2002) Haemorrhagic venous infarction following the posterior petrosal approach for acoustic neurinoma surgery: a report of two cases. Eur Arch Otorhinolaryngol 259:162–165

    Article  PubMed  Google Scholar 

  67. Bejjani GK, Sekhar LN, Yost A-M, Bank WO, Wright DC (1999) Vasospasm after cranial base tumor resection: pathogenesis, diagnosis, and therapy. Surg Neurol 52:577–584

    Article  CAS  PubMed  Google Scholar 

  68. Leroux PD, Haglund MM, Mayberg MR, Winn HR (1991) Symptomatic cerebral vasospasm following tumor resection: report of two cases. Surg Neurol 36:25–31

    Article  CAS  PubMed  Google Scholar 

  69. Qi J, Jia W, Zhang L, Zhang J, Wu Z (2015) Risk factors for postoperative cerebral vasospasm after surgical resection of acoustic neuroma. World Neurosurg 84:1686–1690

    Article  PubMed  Google Scholar 

  70. Schankin CJ, Gall C, Straube A (2009) Headache syndromes after acoustic neuroma surgery and their implications for quality of life. Cephalalgia 29:760–771

    Article  CAS  PubMed  Google Scholar 

  71. Farace E, Marshall LF (2003) Quality of life in acoustics. J Neurosurg 99:807–808 (discussion 808–809)

    Article  PubMed  Google Scholar 

  72. Martin HC, Sethi J, Lang D, Neil-Dwyer G, Lutman ME, Yardley L (2009) Patient-assessed outcomes after excision of acoustic neuroma: postoperative symptoms and quality of life. J Neurosurg 94:211–216

    Article  Google Scholar 

  73. Schaller B, Baumann A (2003) Headache after removal of vestibular schwannoma via the retrosigmoid approach: a long-term follow-up-study. Otolaryngol Head Neck Surg 128:387–395

    Article  PubMed  Google Scholar 

  74. Schessel DA, Nedzelski JM, Rowed D, Feghali JG (1992) Pain after surgery for acoustic neuroma. Otolaryngol Head Neck Surg 107:424–429

    Article  CAS  PubMed  Google Scholar 

  75. Catalano PJ, Jacobowitz O, Post KD (1996) Prevention of headache after retrosigmoid removal of acoustic tumors. Am J Otol 17:904–908

    CAS  PubMed  Google Scholar 

  76. Weber JD, Samy RN, Nahata A, Zuccarello M, Pensak ML, Golub JS (2015) Reduction of bone dust with ultrasonic bone aspiration implications for retrosigmoid vestibular schwannoma removal. Otolaryngol Head Neck Surg 152:1102–1107

    Article  PubMed  Google Scholar 

  77. Fetterman BL, Lanman TH, House JW (1997) Relief of headache by cranioplasty after skull base surgery. Skull Base Surg 7:1–4

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  78. Malis LI (1989) Titanium mesh and acrylic cranioplasty. Neurosurgery 25:351–355

    Article  CAS  PubMed  Google Scholar 

  79. Ducic I, Felder JM III, Endara M (2012) Postoperative headache following acoustic neuroma resection: occipital nerve injuries are associated with a treatable occipital neuralgia. Headache J Head Face Pain 52:1136–1145

    Article  Google Scholar 

  80. Higgins JNP, Pickard JD (2013) Intractable headache after excision of an acoustic neuroma treated by stent revascularisation of the sigmoid sinus. Br J Neurosurg 27:819–821

    Article  CAS  PubMed  Google Scholar 

  81. Nonaka Y, Fukushima T, Watanabe K, Friedman AH, Cunningham CD III, Zomorodi AR (2016) Surgical management of vestibular schwannomas after failed radiation treatment. Neurosurg Rev 39:303–312

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, Duke University Medical Center, 1000 Trent Drive 4520 Hosp South, Box 3807, Durham, NC, 27710, USA

    Shervin Rahimpour, Allan H. Friedman, Takanori Fukushima & Ali R. Zomorodi

  2. Carolina Neuroscience Institute, 4030 Wake Forest Rd suite 115, Raleigh, NC, 27612, USA

    Takanori Fukushima

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  1. Shervin Rahimpour
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  2. Allan H. Friedman
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  3. Takanori Fukushima
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  4. Ali R. Zomorodi
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Correspondence to Shervin Rahimpour.

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Rahimpour, S., Friedman, A.H., Fukushima, T. et al. Microsurgical resection of vestibular schwannomas: complication avoidance. J Neurooncol 130, 367–375 (2016). https://doi.org/10.1007/s11060-016-2260-4

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