Surgery of Large and Giant Residual/Recurrent Vestibular Schwannomas

Abstract

Over the last decades, significant advances in skull base surgery and technology have made possible in many neurosurgical centers around the world the surgical removal of vestibular schwannomas (VSs) with good functional outcomes, concerning preservation of facial nerve and hearing. Better understanding of the natural history and development of radiosurgery increased the options in the management of these lesions. Radical surgical removal is the only treatment modality able to offer cure and remains one of the key treatment for VS. Goals of surgery are complete removal with no mortality and functional preservation of facial nerve, and in selected cases hearing. However, in some occasions, subtotal resection or staged resection is recommended in order to achieve better facial nerve outcomes [18, 25]. The fate of residual tumor rests is not well known, and recurrence rate may be high depending on the extent of resection and clinicopathological factors [5, 8]. Usually, the tumor remnant is small. Large recurrent VSs are rare because after subtotal removal, most patients are followed with regular MRI examinations. Small tumor rests presenting progressive growth are usually treated by repeated surgery or stereotactic radiosurgery with good results [2, 11, 19, 22]. Many series presenting small- and medium-sized recurrent VSs have been reported [2, 19, 22, 23]. Very few studies dealing with large residual/recurrent VSs can be found in the literature [16]. Surgical removal of these large and giant residual/recurrent VSs compressing the brainstem is the only possible treatment. Severe adherence to the cranial nerves, vessels, and brainstem due to scar tissue makes the procedure much more difficult than the first surgery.