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Surgical outcomes in large vestibular schwannomas: should cerebellopontine edema be considered in the grading systems?

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Abstract

Purpose

Large (> 3 cm) vestibular schwannomas pose complexity in surgical management because of narrow working corridors and proximity to the cranial nerves, brainstem, and inner ear structures. With current vestibular schwannoma classifications limited in information regarding cerebellopontine edema, our retrospective series examined this radiographic feature relative to clinical outcomes and its possible role in preoperative scoring.

Methods

Of 230 patients who underwent surgical resection of vestibular schwannoma (2014–2020), we identified 107 patients with Koos grades 3 or 4 tumors for radiographic assessment of edema in the middle cerebellar peduncle (MCP), brainstem, or both. Radiographic images were graded and patients grouped into Koos grades 3 or 4 or our proposed grade 5 with edema. Tumor volumes, radiographic features, clinical presentations, and clinical outcomes were evaluated.

Results

The 107 patients included 22 patients with grade 3 tumors, 39 with grade 4, and 46 with grade 5. No statistical differences were noted among groups for demographic data or complication rates. Unlike grades 3 and 4 patients, grade 5 patients presented with worse hearing (p < 0.001), larger tumors (p < 0.001), lower rates of gross total resection (GTR), longer hospital stays, and higher rates of balance dysfunction.

Conclusion

With edema detected in 43% of this cohort, special considerations are warranted for grade 5 vestibular schwannomas given the preoperative findings of worse hearing, lower GTR rates, longer hospital stays, and 96% who pursued postoperative balance therapy. We propose that grade 5 with edema offers a more nuanced interpretation of a radiographic feature that holds relevance to treatment selection and patient outcomes.

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Data Availability

Data available on request.

Change history

  • 30 June 2023

    The ORCID of A. Samy Youssef is corrected.

Abbreviations

AAO-HNS:

American Academy of Otolaryngology—Head and Neck Surgery

ADC:

Apparent diffusion coefficient

MCP:

Middle cerebellar peduncle

HB:

House-Brackmann

LOS:

Length of stay

MRI:

Magnetic resonance imaging

ROI:

Region of interest

3D:

Three-dimensional

References

  1. Atchley TJ, Erickson N, Chagoya G, Fort M, Walters BC, McGrew B, Fisher WS 3rd (2022) Hannover classification of vestibular schwannomas: a reliability study. World Neurosurg 158:e179–e183

    Article  PubMed  Google Scholar 

  2. Chen X, Gao XL, Chai Y, Shi MM, Zhang JN, Yue SY (2020) Use of a compact high-definition two-dimensional exoscope in surgical treatment of large vestibular schwannoma. Chin Med J (Engl) 133(11):1292–1297

    Article  PubMed  Google Scholar 

  3. Committee on Hearing and Equilibrium guidelines for the evaluation of hearing preservation in acoustic neuroma (vestibular schwannoma). American Academy of Otolaryngology-Head and Neck Surgery Foundation (1995) Otolaryngol Head Neck Surg 113(3):179–180

  4. Daming C, Yiwen S, Bin Z, Yajun X, Jia Y, Rui S et al (2014) Large vestibular schwannoma resection through the suboccipital retrosigmoid keyhole approach. J Craniofac Surg 25(2):463–468

    Article  PubMed  Google Scholar 

  5. d’Avella D, Mazzoni A, Zanoletti E, Martini A (2013) Microsurgical endoscopy-assisted presigmoid retrolabyrinthine approach as a minimally invasive surgical option for the treatment of medium to large vestibular schwannoma. Acta Neurochir (Wien) 155:671–673

    Article  PubMed  Google Scholar 

  6. Erickson NJ, Schmalz PGR, Agee BS, Fort M, Walters BC, McGrew BM, Fisher WS (2019) Koos classification of vestibular schwannomas: a reliability study. Neurosurgery 85(3):409–414

    Article  PubMed  Google Scholar 

  7. Friedmann DR, Grobelny B, Golfinos JG, Roland JT Jr (2015) Nonschwannoma tumors of the cerebellopontine angle. Otolaryngol Clin North Am 48(3):461–475

    Article  PubMed  Google Scholar 

  8. Goldbrunner R, Weller M, Regis J, Lund-Johansen M, Stavrinou P, Reuss D et al (2020) EANO guideline on the diagnosis and treatment of vestibular schwannoma. Neuro Oncol 22(1):31–45

    Article  PubMed  Google Scholar 

  9. Giordano M, Gerganov V, Metwali H, Gallieni M, Samii M, Samii A (2020) Imaging features and classification of peritumoral edema in vestibular schwannoma. Neuroradiol J 33(2):169–173

    Article  PubMed  Google Scholar 

  10. House JW, Brackmann DE (1985) Facial nerve grading system. Otolaryngol Head Neck Surg 93(2):146–1477

    Article  CAS  PubMed  Google Scholar 

  11. Jacob JT, Carlson ML, Driscoll CL, Link MJ (2016) Volumetric analysis of tumor control following subtotal and near-total resection of vestibular schwannoma. Laryngoscope 126(8):1877–1882

    Article  CAS  PubMed  Google Scholar 

  12. Jung S, Kim S, Kim H et al (1998) Prediction of facial nerve displacement in extralarge vestibular schwannoma. Acta Neurochir (Wien) 140:1143–1145

    Article  CAS  PubMed  Google Scholar 

  13. Kiyofuji S, Neff BA, Carlson ML, Driscoll CLW, Link MJ (2021) Large and small vestibular schwannomas: same, yet different tumors. Acta Neurochir (Wien) 163:2199–2207

    Article  PubMed  Google Scholar 

  14. Klironomos G, Dehdashti AR (2019) Surgical strategy in large vestibular schwannoma. J Neurol Surg Part B Skull Base 80:S272–S273

    Article  Google Scholar 

  15. Koos WT, Day JD, Matula C, Levy DI (1998) Neurotopographic considerations in the microsurgical treatment of small acoustic neurinomas. J Neurosurg 88:506–512

    Article  CAS  PubMed  Google Scholar 

  16. Kunigelis KE, Hosokawa P, Arnone G, Raban D, Starr A, Gurau A et al (2020) The predictive value of preoperative apparent diffusion coefficient (ADC) for facial nerve outcomes after vestibular schwannoma resection: clinical study. Acta Neurochir (Wien) 162(8):1995–2005

    Article  PubMed  Google Scholar 

  17. Landry AP, Yang K, Wang JZ, Gao AF, Zadeh G (2022) Outcomes in vestibular schwannoma treated with primary microsurgery: Clinical landscape. J Clin Neurosci 96:138–146

    Article  PubMed  Google Scholar 

  18. Li D, Tsimpas A, Germanwala AV (2015) Analysis of vestibular schwannoma size: A literature review on consistency with measurement techniques. Clin Neurol Neurosurg 138:72–77

    Article  PubMed  Google Scholar 

  19. Macielak RJ, Driscoll CLW, Link MJ, Haynes DS, Lohse CM, Carlson ML (2020) Vestibular schwannoma practice patterns: an international cross-specialty survey. Otol Neurotol 41(10):e1304–e1313

    Article  PubMed  Google Scholar 

  20. Matthies C, Samii M (1997) Management of 1000 Vestibular schwannomas (acoustic neuromas): clinical presentation. Neurosurgery 40:1–10

    CAS  PubMed  Google Scholar 

  21. Samii M, Giordano M, Metwali H, Almarzooq O, Samii A, Gerganov VM (2015) Prognostic significance of peritumoral edema in patients with vestibular schwannomas. Neurosurgery 77(1):81–86

    Article  PubMed  Google Scholar 

  22. Satyarthee GD (2017) Predicting shape, location, and course of facial nerve in relation to large vestibular schwannoma on diffusion tensor imaging with intraoperative correlation: important surgical adjunct. World Neurosurg 105:1002

    Article  PubMed  Google Scholar 

  23. Song G, Liu D, Wu X, Wang X, Zhou Y, Li M et al (2021) Outcomes after semisitting and lateral positioning in large vestibular schwannoma surgery: A single-center comparison. Clin Neurol Neurosurg 207:106768

    Article  PubMed  Google Scholar 

  24. Troude L, Boucekine M, Montava M, Lavieille JP, Régis JM, Roche PH (2019) Predictive factors of early postoperative and long-term facial nerve function after large vestibular schwannoma surgery. World Neurosurg 127:e599–e608

    Article  PubMed  Google Scholar 

  25. Yushkevich PA, Piven J, Hazlett HC, Smith RG, Ho S, Gee JC, Gerig G (2006) User-guided 3D active contour segmentation of anatomical structures: significantly improved efficiency and reliability. Neuroimage 31(3):1116–1128

    Article  PubMed  Google Scholar 

  26. Zumofen DW, Guffi T, Epple C, Westermann B, Krähenbühl AK, Zabka S et al (2018) Intended near-total removal of Koos Grade IV vestibular schwannomas: reconsidering the treatment paradigm. Neurosurgery 82(2):202–210

    Article  PubMed  Google Scholar 

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Acknowledgements

Mary Kemper provided medical editing of this paper.

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Authors and Affiliations

  1. Departments of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA

    Timothy H. Ung, Lindsey Freeman, Lisa Hirt, Michael Kortz, Katherine Belanger, Eliza Baird-Daniel, Patrick Hosokawa, John A. Thompson & A. Samy Youssef

  2. Departments of Radiology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA

    Ashesh Thaker

  3. Departments of Otolaryngology–Head & Neck Surgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA

    A. Samy Youssef

Authors
  1. Timothy H. Ung
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  2. Lindsey Freeman
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Contributions

Study supervision: A. Samy Youssef.

Concept and design: Timothy Ung, A. Samy Youssef

Acquisition of data: Timothy Ung, Lindsey Freeman, Lisa Hirt, Michael Kortz, Katherine Belanger, Eliza Baird Daniel, Ashesh Thaker, John Thompson, A. Samy Youssef.

Analysis and interpretation of data: Timothy Ung, Lindsey Freeman, Lisa Hirt, Michael Kortz, Katherine Belanger, Eliza Baird Daniel, Patrick Hosokawa, Ashesh Thaker, John Thompson, A. Samy Youssef.

Drafting the paper: all authors.

Review of submitted version: Timothy Ung, Lindsey Freeman, Lisa Hirt, Michael Kortz, Katherine Belanger, Eliza Baird Daniel, Patrick Hosokawa, Ashesh Thaker, John Thompson, A. Samy Youssef.

Corresponding author

Correspondence to A. Samy Youssef.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the (place name of institution and/or national research committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Ung, T.H., Freeman, L., Hirt, L. et al. Surgical outcomes in large vestibular schwannomas: should cerebellopontine edema be considered in the grading systems?. Acta Neurochir 165, 1749–1755 (2023). https://doi.org/10.1007/s00701-023-05627-1

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