Retrosigmoid versus middle fossa approach for hearing and facial nerve preservation in vestibular schwannoma surgery: A systematic review and comparative meta-analysis.

BACKGROUND: Vestibular schwannomas (VS) are benign tumors arising from vestibular nerve's Schwann cells. Surgical resection via retrosigmoid (RS) or middle fossa (MF) is standard, but the optimal approach remains debated. This meta-analysis evaluated RS and MF approaches for VS management, emphasizing hearing preservation and Cranial nerve seven (CN VII) outcomes stratified by tumor size. METHODS: Systematic searches across PubMed, Cochrane, Web of Science, and Embase identified relevant studies. Hearing and CN VII outcomes were gauged using the American Academy of Otolaryngology-Head and Neck Surgery, Gardner Robertson, and House-Brackmann scores. RESULTS: Among 7228 patients, 56 % underwent RS and 44 % MF. For intracanalicular tumors, MF recorded 38 % hearing loss, compared to RS's 54 %. In small tumors (<1.5 cm), MF showed 41 % hearing loss, contrasting RS's lower 15 %. Medium-sized tumors (1.5 cm-2.9 cm) revealed 68 % hearing loss in MF and 55 % in RS. Large tumors (>3cm) were only reported in RS with a hearing loss rate of 62 %. CONCLUSION: Conclusively, while MF may be preferable for intracanalicular tumors, RS demonstrated superior hearing preservation for small to medium-sized tumors. This research underlines the significance of stratified outcomes by tumor size, guiding surgical decisions and enhancing patient outcomes.

Tratamiento multimodal en los schwanomas vestibulares grandes / Multimodal Treatment for Large Vestibular Schwannomas

Introducción: Los schwanomas vestibulares son lesiones clasificadas como grado I por la Organización Mundial de la Salud. Las opciones conductuales incluyen la observación, la radiocirugía o la resección microquirúrgica endoscópica. Objetivo: Describir el rol del tratamiento multimodal en los schwanomas vestibulares. Métodos: Se realizó una búsqueda sistemática de literatura médica para la identificación e inclusión de artículos en las siguientes bases de datos: PubMed/Medline, SciELO y Google Scholar, además de los servidores de preprints BioRvix y MedRvix. Se usaron los siguientes descriptores: vestibular schwanoma OR acoustic neuroma AND nerve centered approach OR combined approach AND partial resection OR subtotal resection OR near total resection. Se excluyeron editoriales, cartas al editor, libros, revisiones, metaanálisis y aquellos artículos con método deficiente de más de 20 años de publicación o sin mención al tema de interés. Fueron incluidos 16 artículos. Desarrollo: Los artículos incluyeron un total de 699 pacientes, de los cuales solo 228 (32,6 porciento) recibieron radioterapia en el período posoperatorio. El período de seguimiento promedió 49,6 meses. La preservación de la función facial se logró en el 88,3 porciento de los casos y el control tumoral en el 80,7 porciento. El estado de la preservación auditiva solo fue informado en el 50 porciento de los estudios. El uso de la radioterapia adyuvante mostró gran variabilidad. Conclusiones: El tratamiento multimodal para los schwanomas vestibulares grandes -compuesto por la resección subtotal, vaciamiento intratumoral, seguido de radiocirugía- se ha convertido en una opción plausible. Se necesita la publicación de mayor cantidad de reportes para ofrecer recomendaciones y estratificar la conducta(AU)

Introduction: Vestibular schwannomas are lesions classified as grade I by the World Health Organization. Behavioral options include observation, radiosurgery or endoscopic microsurgical resection. Objective: To describe the role of multimodal treatment for vestibular schwannomas. Methods: A systematic search of medical literature, for the identification and inclusion of articles, was carried out in the databases PubMed/Medline, SciELO and Google Scholar, as well as in the preprint servers BioRvix and MedRvix. The following descriptors were used: vestibular schwannoma OR acoustic neuroma AND nerve centered approach OR combined approach AND partial resection OR subtotal resection OR near total resection. Editorials, letters to the editor, books, reviews and metaanalyses were excluded, as well as articles with deficient method of more than 20 years of publication or not mentioning the topic of interest. Sixteen articles were included. Development: The articles included a total of 699 patients, of which only 228 (32.6 ) received radiotherapy in the postoperative period. The average follow-up period was 49.6 months. Preservation of facial function was achieved in 88.3 percent of cases; and tumor control, in 80.7 percent. Hearing preservation status was reported in only 50 percent of the studies. The usage of adjuvant radiotherapy showed great variability. Conclusions: Multimodal treatment for large vestibular schwannomas -composed of subtotal resection and intratumoral draining, followed by radiosurgery- has become a plausible option. The publication of a greater amount of reports is necessary to provide recommendations and stratify the behavior(AU)

Resección microquirúrgica de schwannoma vestibular grado IVa con preservación de la función facial / Microsurgical resection of vestibular schwannoma grade IVa with preservation of facial function

Introducción: La cirugía de los schwannoma vestibulares constituye un desafío para los neurocirujanos. Debido a que se trata de un tumor benigno la resección completa de la lesión implica la curación del paciente. Sin embargo, este objetivo no siempre es fácil de lograr preservando la función de los nervios facial y acústico, especialmente en tumores de gran tamaño. Objetivos: Presentar detalles técnicos de la cirugía de resección de un schwannoma vestibular de gran tamaño (IVa) en el que se pudo preservar la función facial. Materiales y métodos: Se presenta el caso de una paciente femenina de 36 años que consultó por hipoacusia izquierda. En la RM preoperatoria se evidenciaba una lesión ocupante de espacio del ángulo pontocerebeloso izquierdo compatible con schwannoma vestibular con compresión del tronco encefálico y sin efecto de masa sobre el IV ventrículo (grado IVa). Mediante un abordaje suboccipital retromastoideo en posición de decúbito lateral se realizó la resección de la lesión en forma completa asistida por monitoreo del nervio facial. En todo momento se pudo preservar el plano aracnoideo que separaba el tumor de los nervios adyacentes. Resultados: Se logró una resección macroscópicamente completa con preservación de la función del nervio facial. La paciente permaneció internada por 96 hs en el postoperatorio sin complicaciones derivadas del procedimiento. Conclusión: La preservación del plano aracnoideo es un detalle técnico de mucha importancia para disminuir las posibilidades de lesión de los nervios facial y auditivo en la cirugía de resección de los schwannoma vestibulares.

Introduction: The surgery of vestibular schwannomas is a challenge for neurosurgeons.Because it is a benign tumor, complete resection of the lesion involves healing the patient. However, this objective is not always easy to achieve, preserving the function of both the facial and acoustic nerves, especially when dealing with large tumors. Objective: The objective of the video is to present some technical details of a large vestibular schwannoma (IVa) surgery in which the facial function could be preserved. Materials and methods: We present the case of a 36-year-old female patient who consulted for left hearing loss. The preoperative MRI showed a space- occupying lesion of the left pontocerebellar angle, which was compatible with vestibular schwannoma, with compression of the brainstem but with no mass effect on the IV ventricle (grade IVa). By means of a retromastoid suboccipital approach in the lateral prone position, the lesion was completely resected assisted by neurophysiological monitoring of the facial nerve. At all times, the arachnoid plane separating the tumor from the adjacent nerves was preserved. Results: A macroscopically complete resection was achieved preserving the facial nerve function. The patient stayed hospitalized for 96 hours during the postoperative period without any complication from the procedure. Conclusion: Preserving the arachnoid plane is a very important technical detail to reduce the possibilities of injury of the facial and auditory nerves in the vestibular schwannoma resection surgery.

The extracisternal approach in vestibular schwannoma surgery and facial nerve preservation / A abordagem extracisternal na cirurgia de schwannoma vestibular e preservação do nervo facial

The classical surgical technique for the resection of vestibular schwannomas (VS) has emphasized the microsurgical anatomy of cranial nerves. We believe that the focus on preservation of the arachnoid membrane may serve as a safe guide for tumor removal. Method The extracisternal approach is described in detail. We reviewed charts from 120 patients treated with this technique between 2006 and 2012. Surgical results were evaluated based on the extension of resection, tumor relapse, and facial nerve function. Results Overall gross total resection was achieved in 81% of the patients. The overall postoperative facial nerve function House-Brackmann grades I-II at one year was 93%. There was no recurrence in 4.2 years mean follow up. Conclusion The extracisternal technique differs from other surgical descriptions on the treatment of VS by not requiring the identification of the facial nerve, as long as we preserve the arachnoid envelope in the total circumference of the tumor. .

A técnica cirúrgica clássica para ressecção de schwannomas vestibulares enfatiza a anatomia microcirúrgica dos nervos cranianos. Acreditamos que o foco na preservação da membrana aracnóide pode servir como parâmetro seguro para a remoção do tumor. Método A abordagem extracisternal é descrita em detalhe. Analisamos o prontuário de 120 pacientes tratados com esta técnica entre 2006 e 2012. Os resultados cirúrgicos foram baseados em extensão de ressecção, recorrência tumoral e função do nervo facial. Resultados Ressecção total foi obtida em 81% dos pacientes. O resultado global da função do nervo facial (House-Brackmann graus I-II) após um ano da cirurgia foi de 93%. Não houve recidiva em um seguimento médio de 4,2 anos. Conclusão A técnica extracisternal difere de outras descrições cirúrgicas no tratamento de schwannoma vestibular pois não requer a identificação do nervo facial, contanto que o plano de aracnóide seja preservado em toda circunferência do tumor. .

Neurinoma del acústico diagnosticado durante el embarazo: reporte de un caso / Acoustic neurinoma during pregnancy: a case report

Los tumores cerebrales son infrecuentes durante el embarazo. Los neurinomas del acústico pueden ser sintomáticos por primera vez durante la gestación y representan el 6-8 por ciento de las neoplasias intracraneales. El objetivo de esta comunicación es presentar el caso de una primigesta adolescente que presentó sintomatología neurológica de afectación del VIII par y de fosa posterior, característica de la neurofibromatosis tipo 2.

Brain tumors are infrequent during pregnancy. Neurinomas of auditive nerve can get to be symptomatic during gestation, representing 6-8 percent of the intracranial neoplasias. The objective is to report a case of a pregnant adolescent who present a neurological symptoms of VIII pair affectation and posterior cranial fossa, characteristic of the neurofibromatosis type 2.