Near Total Versus Gross Total Resection of Large Vestibular Schwannomas: Facial Nerve Outcome.

BACKGROUND: Large vestibular schwannomas (VSs) with brainstem compression are generally reserved for surgical resection. Surgical aggressiveness must be balanced with morbidity from cranial nerve injury. The purpose of the present investigation is to evaluate the clinical presentation, management modality, and patient outcomes following near total resection (NTR) vs gross total resection (GTR) of large VSs. OBJECTIVE: To assess facial nerve outcome differences between GTR and NTR patient cohorts. METHODS: Between January 2010 and March 2018, a retrospective chart review was completed to capture patients continuously who had VSs with Hannover grades T4a and T4b. NTR was decided upon intraoperatively. Primary data points were collected, including preoperative symptoms, tumor size, extent of resection, and postoperative neurological outcome. RESULTS: A total of 37 patients underwent surgery for treatment of large and giant (grade 4a and 4b) VSs. Facial nerve integrity was preserved in 36 patients (97%) at the completion of surgery. A total of 27 patients underwent complete resection, and 10 had near total (>95%) resection. Among patients with GTR, 78% (21/27) had House-Brackmann (HB) grade I-II facial nerve function at follow-up, whereas 100% (10/10) of the group with NTR had HB grade I-II facial nerve function. Risk of meningitis, cerebrospinal fluid leak, and sinus thromboses were not statistically different between the 2 groups. There was no stroke, brainstem injury, or death. The mean follow-up was 36 mo. CONCLUSION: NTR seems to offer a benefit in terms of facial nerve functional outcome compared to GTR in surgical management of large VSs without significant risk of recurrence.

Cerebrospinal fluid macrophage migration inhibitory factor: a potential predictor of cerebral vasospasm and clinical outcome after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: In patients with aneurysmal subarachnoid hemorrhage (aSAH), poor outcomes have been shown to be correlated with subsequent cerebral vasospasm (CV) and delayed cerebral ischemia (DCI). The identification of novel biomarkers may aid in the prediction of which patients are vulnerable to developing vasospasm, cerebral ischemia, and neurological deterioration. METHODS: In this prospective clinical study at North Shore University Hospital, patients with aSAH or normal pressure hydrocephalus (NPH) with external ventricular drains were enrolled. The concentration of macrophage migration inhibitory factor (MIF) in CSF was assessed for correlation with CV or DCI, the primary outcome measures. RESULTS: Twenty-five patients were enrolled in the aSAH group and 9 were enrolled in the NPH group. There was a significant increase in aggregate CSF MIF concentration in patients with aSAH versus those with NPH (24.4 ± 19.2 vs 2.3 ± 1.1 ng/ml, p < 0.0002). Incidence of the day of peak MIF concentration significantly correlated with the onset of clinical vasospasm (rho = 0.778, p < 0.0010). MIF concentrations were significantly elevated in patients with versus those without evidence of DCI (18.7 ± 4.93 vs 8.86 ± 1.28 ng/ml, respectively, p < 0.0025). There was a significant difference in MIF concentrations between patients with infection versus those without infection (16.43 ± 4.21 vs 8.5 ± 1.22 ng/ml, respectively, p < 0.0119). CONCLUSIONS: Preliminary evidence from this study suggests that CSF concentrations of MIF are correlated with CV and DCI. These results, however, could be confounded in the presence of clinical infection. A study with a larger patient sample size is necessary to corroborate these findings.