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Koos grade IV vestibular schwannomas: considerations on a consecutive series of 60 cases—searching for the balance between preservation of function and maximal tumor removal

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Abstract

Koos grade IV vestibular schwannomas (VS) (maximum diameter > 3 cm) compress the brainstem and displace the fourth ventricle. Microsurgical resection with attention to the right balance between preservation of function and maximal tumor removal is the treatment of choice. Our series consists of 60 consecutive patients with unilateral VS, operated on from December 2010 to July 2019. All patients underwent microsurgical removal via the retrosigmoid approach. The adherence of VS’ capsule to the surrounding nervous structures and the excessive tendency of tumor to bleed during debulking, because of a redundant vascular architecture, was evaluated by reviewing video records. Microsurgical removal of tumor was classified as total (T), near-total (NT: residue < 5%), subtotal (ST: residue 5–10%), or partial (P: residue > 10%). Maximal mean tumor diameter was 3,97 cm (SD ± 1,13; range 3,1–5,8 cm). Preoperative severely impaired hearing or deafness (AAO-HNS classes C–D) was present in 52 cases (86,7%). Total or NT resection was accomplished in 46 cases (76,7%), 65,8% in cases with, and 95,4% without tight adhesion of capsule to nervous structures (p < 0,001). Endoscopic-assisted microsurgical removal of VS in the IAC was performed in 23 patients: in these cases, a T resection was obtained in 78,3% versus 45,9% of microsurgery only (p < 0,001). The capsule of VS was tightly adherent to nervous structures in 63,3% of patients, whereas hypervascular high-bleeding tumors represented 56,7%. Hearing preservation was possible in 2 out of 8 patients with preoperative class B hearing. At last follow-up, 34 (56,7%) patients had a normal postoperative FN outcome (HBI), 9 (15,0%) were HBII, 8 (13,3%) HBIII, and 9 (15,0%) HBIV. The total NT resection of solid and low-bleeding VS, without tight capsule adhesion, was associated with better FN outcome. Mortality was zero; permanent complications were observed in 2 cases (diplopia, hydrocephalus), transient in 9. Microsurgery of Koos grade IV VS seems to be associated with more than acceptable functional results, with high rate of T and NT removal of tumor. Long-term FN results seem to be worse in patients with cystic Koos grade IV VS, in cases with tight capsule adherences to nervous structures and in high-bleeding tumors.

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References

  1. Boublata L, Belahreche M, Ouchtati R, Shabhay Z, Boutiah L, Kabache M, Nadji M, Djenna Z, Bounecer H, Ioualalen N (2017) Facial nerve function and quality of resection in large and giant vestibular schwannomas surgery operated by retrosigmoid transmeatal approach in semi-sitting position with intraoperative facial nerve monitoring. World Neurosurg 103:231–240

    PubMed  Google Scholar 

  2. Campero A, Martins C, Rhoton A, Tatagiba M (2011) Dural landmark to locate the internal auditory canal in large and giant vestibular schwannomas: the Tübingen line02. Neurosurgery 69(1 Suppl Operative):ons99–ons91

    PubMed  Google Scholar 

  3. Carlson ML, Smadbeck JB, Link MJ, Klee EW, Vasmatzis G, Schimmenti LA (2018) Next generation sequencing of sporadic vestibular schwannoma. Otol Neurotol 39:e860–e871

    PubMed  Google Scholar 

  4. Caye-Thomasen P, Baandrup L, Jacobsen GK, Thomsen J, Stangerup SE (2003) Immunohistochemical demonstration of vascular endothelial growth factor in vestibular schwannomas correlates to tumor growth rate. Laryngoscope 113:2129–2134

    PubMed  CAS  Google Scholar 

  5. Charpiot A, Tringali S, Zaouche S, Ferber-Viart C, Dubreuil C (2010) Perioperative complications after translabyrinthine removal of large or giant vestibular schwannoma: outcomes for 123 patients. Acta Otolaryngol 130:1249–1255

    PubMed  Google Scholar 

  6. Chiluwal AK, Rothman A, Svrakic M, Dehdashti AR (2018) Surgical outcome in smaller symptomatic vestibular schwannomas. Is there a role for surgery? Acta Neurochir 160:2263–2275

    PubMed  Google Scholar 

  7. (1995) Committee on Hearing and Equilibrium Guidelines for the Evaluation of Hearing Preservation in Acoustic Neuroma (Vestibular Schwannoma): Committee on Hearing and Equilibrium. Otolaryngol Head Neck Surg 113:179–180

  8. Corrivetti F, Cacciotti G, Scavo CG, Roperto R, Mastronardi L (2018) Flexible endoscopic-assisted microsurgical radical resection of intracanalicular vestibular schwannomas by retrosigmoid approach: operative technique. World Neurosurg 115:229–233

    PubMed  Google Scholar 

  9. Corrivetti F, Cacciotti G, Scavo CG, Roperto R, Stati G, Sufianov A, Mastronardi L (2019) Flexible endoscopic assistance in the surgical management of vestibular schwannomas. Neurosurg Rev 44:363–371. https://doi.org/10.1007/s10143-019-01195-0

    Article  PubMed  Google Scholar 

  10. Desgeorges M, Sterkers JM (1984) Surgery of large neurinomas of the acoustic nerve performed only by the translabyrinthine approach. Apropos of 50 cases. Neurochirurgie 30:355–364

    PubMed  CAS  Google Scholar 

  11. Di Maio S, Malebranche AD, Westerberg B, Akagami R (2011) Hearing preservation after microsurgical resection of large vestibular schwannomas. Neurosurgery 68:632–640

    PubMed  Google Scholar 

  12. Eiras J, Gomez J, Carcavilla L (1984) Suboccipito-transmeatal microsurgical approach in giant acoustic neuromas. Results in 12 consecutive cases. Neurochirurgie 30:17–24

    PubMed  CAS  Google Scholar 

  13. Eser Ocak P, Dogan I, Ocak U, Dinc C, Baskaya MK (2018) Facial nerve outcome and extent of resection in cystic versus solid vestibular schwannomas in radiosurgery era. Neurosurg Focus 44(3):E3

    PubMed  Google Scholar 

  14. Ferrara N, Gerber H-P, LeCouter J (2003) The biology of VEGF and its receptors. Nat Med 9:669–676

    PubMed  CAS  Google Scholar 

  15. Fundová P, Charabi S, Tos M, Thomsen J (2000) Cystic vestibular schwannoma: surgical outcome. J Laryngol Otol 114:935–939

    PubMed  Google Scholar 

  16. Giordano AI, Domenech I, Torres A, Skufca J, Callejo A, Palomino L, Aparicio A, Junyent J, Mañós M (2012) Results in the surgical treatment of giant acoustic neuromas. Acta Otorrinolaringol Esp 63:194–199

    PubMed  Google Scholar 

  17. Hoshide R, Faulkner H, Teo M, Teo C (2018) Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes. Neurosurg Focus 44:E2

    PubMed  Google Scholar 

  18. House JW, Brackmann DE (1985) Facial nerve grading system. Otolaryngol Head Neck Surg 93:146–147

    PubMed  CAS  Google Scholar 

  19. Huang X, Xu J, Xu M, Chen M, Ji K, Ren J, Zhong P (2017) Functional outcome and complications after the microsurgical removal of giant vestibular schwannomas via the retrosigmoid approach: a retrospective review of 16-year experience in a single hospital. BMC Neurol 17:18

    PubMed  PubMed Central  Google Scholar 

  20. Huang X, Ji KY, Xu J, Shao CH, Wang W, Xu M, Chen DQ, Chen MY, Zhong P (2016) The surgical management of giant intracranial vestibular schwannoma via retrosigmoid approach: a retrospective review of 657 cases. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 51:401–407

    PubMed  CAS  Google Scholar 

  21. Huang X, Ren J, Xu J, Xu M, Chen D, Chen M, Ji K, Wang H, Chen H, Cao L, Shao Y, Zhong P, Ballena R, Zhou L, Mao Y (2018) The utility of “low current” stimulation threshold of intraoperative electromyography monitoring in predicting facial nerve function outcome after vestibular schwannoma surgery: a prospective cohort study of 103 large tumors. J Neuro-Oncol 138:383–390

    Google Scholar 

  22. Iwai Y, Ishibashi K, Watanabe Y, Uemura G, Yamanaka K (2015) Functional preservation after planned partial resection followed by Gamma Knife radiosurgery for large vestibular schwannomas. World Neurosurg 84:292–300

    PubMed  Google Scholar 

  23. Kanzaki J, Tos M, Sanna M, Moffat DA (2003) New and modified reporting systems from the consensus meeting on systems for reporting results in vestibular schwannoma. Otology & Neurotology 24:642–649

    Google Scholar 

  24. Kohno M, Sato H, Sora S, Miwa H, Yokoyama M (2011) Is an acoustic neuroma an epiarachnoid or subarachnoid tumor? Neurosurgery 68:1006–1017

    PubMed  Google Scholar 

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

    PubMed  CAS  Google Scholar 

  26. Li JM, Yuan XR, Liu Q, Ding XP, Peng ZF (2011) Facial nerve preservation following microsurgical removal of large and huge acoustic neuroma. Zhonghua Wai Ke Za Zhi 49:240–244

    PubMed  Google Scholar 

  27. Mamikoglu B, Wiet RJ, Esquivel CR (2002) Translabyrinthine approach for the management of large and giant vestibular schwannomas. Otol Neurotol 23:224–227

    PubMed  Google Scholar 

  28. Mastronardi L, Cacciotti G, Roperto R, Di Scipio E, Tonelli MP, Carpineta E (2016) Position and course of facial nerve and postoperative facial nerve results in vestibular schwannoma microsurgery. World Neurosurg 94:174–180

    PubMed  Google Scholar 

  29. Mastronardi L, Fukushima T, Campione A (2019) Advances in vestibular schwannoma microneurosurgery. Springer International Publishing, Cham, p 174

    Google Scholar 

  30. Mehrotra N, Behari S, Pal L, Banerji D, Sahu RN, Jain VK (2008) Giant vestibular schwannomas: focusing on the differences between the solid and the cystic variants. Br J Neurosurg 22:550–556

    PubMed  CAS  Google Scholar 

  31. Mendelsohn D, Westerberg BD, Dong C, Akagami R (2016) Clinical and radiographic factors predicting hearing preservation rates in large vestibular schwannomas. J Neurol Surg B Skull Base 77:193–198

    PubMed  Google Scholar 

  32. Menke H, Klein A, John KD, Junginger T (1993) Predictive value of ASA classification for the assessment of the perioperative risk. Int Surg 78:266–270

    PubMed  CAS  Google Scholar 

  33. Møller MN, Werther K, Nalla A, Stangerup SE, Thomsen J, Bøg-Hansen TC, Nielsen HJ, Cayé-Thomasen P (2010) Angiogenesis in vestibular schwannomas: expression of extracellular matrix factors MMP-2, MMP-9, and TIMP-1. Laryngoscope 120:657–662

    PubMed  Google Scholar 

  34. Nutik SL (1994) Facial nerve outcome after acoustic neuroma surgery. Surg Neurol 41:28–33

    PubMed  CAS  Google Scholar 

  35. Nutik SL, Babb MJ (2001) Determinants of tumor size and growth in vestibular schwannomas. J Neurosurg 94:922–926

    PubMed  CAS  Google Scholar 

  36. Ohata K, Tsuyuguchi N, Morino M, Takami T, Goto T, Hakuba A, Hara M (2002) A hypothesis of epiarachnoidal growth of vestibular schwannoma at the cerebello-pontine angle: surgical importance. J Postgrad Med 48:253–258

    PubMed  CAS  Google Scholar 

  37. Ojemann RG (2001) Retrosigmoid approach to acoustic neuroma (vestibular schwannoma). Neurosurgery 48:553–558

    PubMed  CAS  Google Scholar 

  38. Peris-Celda M, Graffeo CS, Perry A, Kerezoudis P, Tombers NM, Carlson ML, Link MJ (2019) Main symptom that led to medical evaluation and diagnosis of vestibular schwannoma and patient-reported tumor size: cross-sectional study in 1,304 patients. J Neurol Surg B Skull Base 80:316–322

    PubMed  Google Scholar 

  39. Plotkin SR, Stemmer-Rachamimov AO, Barker FG 2nd, Halpin C, Padera TP, Tyrrell A, Sorensen AG, Jain RK, di Tomaso E (2009) Hearing improvement after bevacizumab in patients with neurofibromatosis type 2. N Engl J Med 361:358–367

    PubMed  PubMed Central  CAS  Google Scholar 

  40. Reznitsky M, Petersen MMBS, West N, Stangerup SE, Cayé-Thomasen P (2019) Epidemiology of vestibular schwannomas - prospective 40-year data from an unselected national cohort. Clin Epidemiol 11:981–986

    PubMed  PubMed Central  Google Scholar 

  41. Roberti F, Sekhar LN, Kalavakonda C, Wright DC (2001) Posterior fossa meningiomas: surgical experience in 161 cases. Surg Neurol 56:8–20

    PubMed  CAS  Google Scholar 

  42. Roosli C, Linthicum FH Jr, Cureoglu S, Merchant SN (2012) What is the site of origin of cochleovestibular schwannomas? Audiol Neurootol 17:121–125

    PubMed  Google Scholar 

  43. Sameshima T, Morita A, Tanikawa R, Fukushima T, Friedman AH, Zenga F, Ducati A, Mastronardi L (2013) Evaluation of variation in the course of the facial nerve, nerve adhesion to tumors, and postoperative facial palsy in acoustic neuroma. J Neurol Surg B Skull Base 74:39–43

    PubMed  Google Scholar 

  44. Sameshima T, Mastronardi L, Friedman AH, Fukushima T (2007) Fukushima’s microanatomy and dissection of the temporal bone, Second edn. AF-Neurovideo, Inc., Raleigh, p 115

    Google Scholar 

  45. Samii M, Gerganov VM, Samii A (2010) Functional outcome after complete surgical removal of giant vestibular schwannomas. J Neurosurg 112:860–867

    PubMed  Google Scholar 

  46. Samprón N, Altuna X, Armendáriz M, Urculo E (2014) Treatment of giant acoustic neuromas. Neurocirugia (Astur) 25:247–260

    Google Scholar 

  47. Sanna M, Agarwal M, Mancini F, Taibah A (2004) Transapical extension in difficult cerebellopontine angle tumors. Ann Otol Rhinol Laryngol 113:676–682

    PubMed  Google Scholar 

  48. Sasaki T, Shono T, Hashiguchi K, Yoshida F, Suzuki SO (2009) Histological considerations of the cleavage plane for preservation of facial and cochlear nerve functions in vestibular schwannoma surgery. J Neurosurg 110:648–655

    PubMed  Google Scholar 

  49. Sato Y, Mizutani T, Shimizu K, Freund HJ, Samii M (2018) Retrosigmoid intradural suprameatal-inframeatal approach for complete surgical removal of a giant recurrent vestibular schwannoma with severe petrous bone involvement: technical case report. World Neurosurg 110:93–98

    PubMed  Google Scholar 

  50. Silva J, Cerejo A, Duarte F, Silveira F, Vaz R (2012) Surgical removal of giant acoustic neuromas. World Neurosurg 77:731–735

    PubMed  Google Scholar 

  51. Stangerup SE, Tos M, Caye-Thomasen P, Tos T, Klokker M, Thomsen J (2004) Increasing annual incidence of vestibular schwannoma and age at diagnosis. J Laryngol Otol 118:622–627

    PubMed  Google Scholar 

  52. Starnoni D, Giammattei L, Cossu G, Link MJ, Roche PH, Chacko AG, Ohata K, Samii M, Suri A, Bruneau M, Cornelius JF, Cavallo L, Meling TR, Froelich S, Tatagiba M, Sufianov A, Paraskevopoulos D, Zazpe I, Berhouma M, Jouanneau E, Verheul JB, Tuleasca C, George M, Levivier M, Messerer M, Daniel RT (2020) Surgical management for large vestibular schwannomas: a systematic review, meta-analysis, and consensus statement on behalf of the EANS skull base section. Acta Neurochir 162:2595–2617

    PubMed  Google Scholar 

  53. Tos M, Stangerup SE, Cayé-Thomasen P, Tos T, Thomsen J (2004) What is the real incidence of vestibular schwannoma? Arch Otolaryngol Head Neck Surg 130:216–220

    PubMed  Google Scholar 

  54. Tos M, Thomsen J, Charabi S (1992) Incidence of acoustic neuromas. Ear Nose Throat J 71:391–393

    PubMed  CAS  Google Scholar 

  55. Tos M, Thomsen J, Harmsen A (1988) Results of translabyrinthine removal of 300 acoustic neuromas related to tumour size. Acta Otolaryngol Suppl 452:38–51

    PubMed  CAS  Google Scholar 

  56. Troude L, Boucekine M, Montava M, Lavieille JP, Regis 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

    PubMed  Google Scholar 

  57. Turel MK, D'Souza WP, Chacko AG, Rajshekhar V (2016) Giant vestibular schwannomas: surgical nuances influencing outcome in 179 patients. Neurol India 64:478–484

    PubMed  Google Scholar 

  58. Turel MK, Thakar S, Rajshekhar V (2015) Quality of life following surgery for large and giant vestibular schwannomas: a prospective study. J Neurosurg 122:303–311

    PubMed  Google Scholar 

  59. Uesaka T, Shono T, Suzuki SO, Nakamizo A, Niiro H, Mizoguchi M, Iwaki T, Sasaki T (2007) Expression of VEGF and its receptor genes in intracranial schwannomas. J Neuro-Oncol 83:259–266

    CAS  Google Scholar 

  60. Wanibuchi M, Fukushima T, Friedman AH, Watanabe K, Akiyama Y, Mikami T, Iihoshi S, Murakami T, Sugino T, Mikuni N (2014) Hearing preservation surgery for vestibular schwannomas via the retrosigmoid transmeatal approach: surgical tips. Neurosurg Rev 37:431–444

    PubMed  Google Scholar 

  61. Wanibuchi M, Fukushima T, McElveen JT, Friedman AH (2009) Hearing preservation in surgery for large vestibular schwannomas. J Neurosurg 111:845–854

    PubMed  Google Scholar 

  62. Yang X, Zhang Y, Liu X, Ren Y (2014) Microsurgical treatment and facial nerve preservation in 400 cases of giant acoustic neuromas. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 28:79–84

    PubMed  CAS  Google Scholar 

  63. Yang P, Sun D, Jiang F (2018) Ailanthone Promotes human vestibular schwannoma cell apoptosis and autophagy by downregulation of miR-21. Oncol Res 26:941–948

    PubMed  PubMed Central  Google Scholar 

  64. Zhang S, Liu W, Hui X, You C (2016) Surgical treatment of giant vestibular schwannomas: facial nerve outcome and tumor control. World Neurosurg 94:137–144

    PubMed  Google Scholar 

  65. Zou P, Zhao L, Chen P, Xu H, Liu N, Zhao P, Lu A (2014) Functional outcome and postoperative complications after the microsurgical removal of large vestibular schwannomas via the retrosigmoid approach: a meta-analysis. Neurosurg Rev 37:15–21

    PubMed  Google Scholar 

  66. Zumofen DW, Guffi T, Epple C, Westermann B, Krähenbühl AK, Zabka S, Taub E, Bodmer D, Mariani L Intended near-total removal of Koos grade IV vestibular schwannomas: reconsidering the treatment paradigm. Neurosurgery 82:202–210

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Authors and Affiliations

  1. Department of Neurosurgery, San Filippo Neri Hospital/ASLRoma1, Rome, Italy

    Luciano Mastronardi, Alberto Campione, Fabio Boccacci, Carlo Giacobbo Scavo, Ettore Carpineta, Guglielmo Cacciotti & Raffaelino Roperto

  2. Department of Neurosurgery, The State Education Institution of Higher Professional Training, The First Sechenov Moscow State Medical University under Ministry of Health, Moscow, Russian Federation

    Luciano Mastronardi & Albert Sufianov

  3. Federal Centre of Neurosurgery, Tyumen, Russian Federation

    Albert Sufianov

  4. Vascular Neurosurgery Medical Director, Co-Director of Skull Base Surgery Center, Duke University Medical Center, Durham, NC, USA

    Ali Zomorodi

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  1. Luciano Mastronardi
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Contributions

L.M.: Study design, study conception, data extraction, data analysis, and manuscript writing

A.C.: Data extraction, data analysis, and statistical analysis

F.B.: Data extraction, data analysis, and literature analysis

C.G.S.: Data extraction, data analysis, and radiological measurement

E.C.: Data extraction, data analysis, and radiological measurement

G.C.: Data extraction, data analysis, and literature analysis

R.R.: Data analysis, statistical analysis, and critical review of the manuscript

A.S.: Critical review of the manuscript and study supervision

A.Z.: Critical review of the manuscript and study supervision

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Correspondence to Luciano Mastronardi.

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The study involves human participants: for this reason, it has been reviewed and approved by local Ethics committee of the Hospital (Lazio1, ASLRoma1). A written consent for scientific treatment of personal data was obtained from any patient before surgery. No potentially identifiable human images or data are presented in this study.

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Mastronardi, L., Campione, A., Boccacci, F. et al. Koos grade IV vestibular schwannomas: considerations on a consecutive series of 60 cases—searching for the balance between preservation of function and maximal tumor removal. Neurosurg Rev 44, 3349–3358 (2021). https://doi.org/10.1007/s10143-021-01501-9

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