Vestibular schwannoma surgery

The goal of microsurgical removal of a vestibular schwannoma is to completely remove the tumor, to provide long-term durable cure. In many cases, less than gross total resection (GTR) is performed to preserve neurological, and especially facial nerve function.

In selected cases, hearing preservation.

In modern neurosurgery Madjid Samii is considered to be one of the leading experts in vestibular schwannoma surgery.

Vestibular schwannoma microsurgery via the suboccipital approach with the help of intraoperative brainstem auditory evoked potentials is a common treatment option 2).

The procedure is performed under general anesthesia with cranial nerve monitoring.

Following suboccipital craniotomy craniectomy, durotomy, CSF release from the foramen magnum, and identification of cranial nerve position, the tumor is debulked internally. The internal auditory canal is drilled and dissection of the tumor progresses. Following resection, the IAC is waxed and a fat graft placed. A Water-tight pericranial graft is sewn in and a titanium mesh cranioplastyplaced. The muscle and skin are closed in layers. The video can be found here: 3).

Recent advances in electrophysiological technology have considerably contributed to improvement in functional outcome of vestibular schwannoma surgery in terms of hearing preservation and facial nerve paresis. Perioperative intravenous nimodipine and hydroxyethyl starch may be valuable additions to surgery 4).

The endoscope may be useful, especially in surgical techniques where there is poor control of the internal auditory canal (IAC). An endoscopic support technique is strongly recommended to avoid residual disease, particularly in retrosigmoid and retrolabyrinthine approaches. Moreover, the recent introduction of the transcanal transpromontorial approach allows the endoscope to be used during all the procedures in patients affected by a vestibular schwannoma limited to the IAC or to support surgical procedures during an enlarged microscopic approach 5).

You YP, Zhang JX, Lu AL, Liu N. Vestibular schwannoma surgical treatment. CNS Neurosci Ther. 2013 May;19(5):289-93. doi: 10.1111/cns.12080. Epub 2013 Mar 6. PMID: 23462373; PMCID: PMC6493559.
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Sheth SA, Tirino JL, Martuza RL. Vestibular schwannoma: suboccipital approach. Neurosurg Focus. 2014 Jan;36(1 Suppl):1. doi: 10.3171/2014.V1.FOCUS13318. PubMed PMID: 24380512.
Youssef AS, Downes AE. Intraoperative neurophysiological monitoring in vestibular schwannoma surgery: advances and clinical implications. Neurosurg Focus. 2009 Oct;27(4):E9. doi: 10.3171/2009.8.FOCUS09144. Review. PubMed PMID: 19795957.
Marchioni D, Gazzini L, Boaria F, Pinna G, Masotto B, Rubini A. Is endoscopic inspection necessary to detect residual disease in acoustic neuroma surgery? Eur Arch Otorhinolaryngol. 2019 Apr 26. doi: 10.1007/s00405-019-05442-4. [Epub ahead of print] PubMed PMID: 31028535.
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