Facial nerve sparing surgery for large vestibular schwannomas
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Nowadays, there is a general trend in vestibular schwannoma (VS) surgery favoring near-total or subtotal tumor resection (NTR/STR) with facial nerve (FN) function preservation rather than gross total resection (GTR) with high risk of FN damage.
The surgical technique of FN sparing in large VS includes patient-tailored image-guided craniotomy, continuous intraoperative neurophysiological monitoring (INM), intracapsular wide tumor debulking, and only final extracapsular dissection with FN course identification and brainstem decompression. A small amount of residual tumor along the FN is accepted in order to not damage the nerve. Postoperative radiosurgery workup is then recommended.
NTR/STR resection with FN function sparing is a valid option for large VS.
KeywordsVestibular schwannoma Facial nerve Retrosigmoid approach Intraoperative monitoring Cerebellopontine angle Posterior fossa
Gross total resection
Internal acoustic canal
Intraoperative neurophysiological monitoring
Superior petrosal veins
Compliance with ethical standards
Conflict of interest
The manuscript has not been previously published in whole or in part or submitted for publication in any form.
The video shows the surgical technique for FN sparing during VS resection; preoperative MR shows a 3-cm right-side VS. Following position, neuronavigation, and craniotomy, the tumor is removed with intracapsular debulking under continuous functional FN INM. When the tumor becomes smaller and softer, it can be gently dissected from the brainstem. Before final tumor removal, the FN course is identified from its origin to the IAC and a small amount of tumor is left along the FN in order not to damage it. Postoperative MR confirms NTR of the tumor. Three weeks after surgery, the patient does not present any FN deficit. (MP4 162,834 kb)
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