The level of evidence to provide treatment recommendations for vestibular schwannoma is low compared with other intracranial neoplasms. Therefore, the vestibular schwannoma task force of the European Association of Neuro-Oncology assessed the data available in the literature and composed a set of recommendations for health care professionals. The radiological diagnosis of vestibular schwannoma is made by magnetic resonance imaging. Histological verification of the diagnosis is not always required. Current treatment options include observation, surgical resection, fractionated radiotherapy, and radiosurgery. The choice of treatment depends on clinical presentation, tumor size, and expertise of the treating center. In small tumors, observation has to be weighed against radiosurgery, in large tumors surgical decompression is mandatory, potentially followed by fractionated radiotherapy or radiosurgery. Except for bevacizumab in neurofibromatosis type 2, there is no role for pharmacotherapy.

https://www.zora.uzh.ch/id/eprint/176123/1/Goldbrunner__EANO_Guideline__Vestibular_Schwannoma_Resubmission.pdf

EANO guideline on the diagnosis and treatment of vestibular schwannoma

Neurovascular compression syndromes are usually caused by arteries that directly contact the cisternal portion of a cranial nerve. Not all cases of neurovascular contact are clinically symptomatic. The transition zone between the central and peripheral myelin is the most vulnerable region for symptomatic neurovascular compression syndromes. Trigeminal neuralgia (cranial nerve V) has an incidence of 4-20/100,000, a transition zone of 4 mm, with symptomatic neurovascular compression typically proximal. Hemifacial spasm (cranial nerve VII) has an incidence of 1/100,000, a transition zone of 2.5 mm, with symptomatic neurovascular compression typically proximal. Vestibular paroxysmia (cranial nerve VIII) has an unknown incidence, a transition zone of 11 mm, with symptomatic neurovascular compression typically at the internal auditory canal. Glossopharyngeal neuralgia (cranial nerve IX) has an incidence of 0.5/100,000, a transition zone of 1.5 mm, with symptomatic neurovascular compression typically proximal. The transition zone overlaps the root entry zone close to the brain stem in cranial nerves V, VII, and IX, yet it is more distal and does not overlap the root entry zone in cranial nerve VIII. Although symptomatic neurovascular compression syndromes may also occur if the neurovascular contact is outside the transition zone, symptomatic neurovascular compression syndromes are more common if the neurovascular contact occurs at the transition zone or central myelin section, in particular when associated with nerve displacement and atrophy.

pdf/imaging-of-neurovascular-compression-syndromes-trigeminal-tko4e3hmrt.pdf

Imaging of Neurovascular Compression Syndromes: Trigeminal Neuralgia, Hemifacial Spasm, Vestibular Paroxysmia, and Glossopharyngeal Neuralgia

Object The authors evaluated the behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas (VSs). Methods The case records of all patients who underwent surgical treatment of VSs were analyzed. All patients in whom an incomplete excision had been performed were analyzed. Incomplete excision was defined as near-total resection (NTR), subtotal resection (STR), and partial resection (PR). Tumors in the NTR and STR categories were followed up with a wait-and-rescan approach, whereas the tumors in the PR category were subjected to a second-stage surgery and were excluded from this series. All patients included in the study underwent baseline MRI at the 3rd and 12th postoperative months, and repeat imaging was subsequently performed every year for 7–10 years postoperatively or as indicated clinically. Preoperative and postoperative facial function was noted. Results Of the 2368 patients who underwent surgery for VS, 111 patients who had incomplete excisions of VSs...

The behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas.

Object The object of this study was to evaluate facial nerve outcomes in the surgical treatment of large vestibular schwannomas (VSs; ≥ 2.5 cm maximal or extrameatal cerebellopontine angle diameter) based on both the operative approach and extent of tumor resection. Methods A PubMed search was conducted of English language studies on the treatment of large VSs published from 1985 to 2011. Studies were then evaluated and included if they contained data regarding the size of the tumor, surgical approach, extent of resection, and postoperative facial nerve function. Results Of the 536 studies initially screened, 59 full-text articles were assessed for eligibility, and 30 studies were included for analysis. A total of 1688 tumor resections were reported. Surgical approach was reported in 1390 patients and was significantly associated with facial nerve outcome (ϕ= 0.29, p Conclusions In a pooled patient population from studies evaluating the treatment of large VSs, subtotal and near-total resections were shown to produce better facial nerve outcomes when compared with gross-total resections. The translabyrinthine and retrosigmoid surgical approaches are likely to result in similar rates of good facial nerve outcomes. Both of these approaches show better facial nerve outcomes when compared with the extended translabyrinthine approach, which is typically reserved for especially large tumors. The reported literature on treatment of large VSs is extremely heterogeneous and minimal consistency in reporting outcomes was observed.

/pdf/facial-nerve-outcomes-after-surgery-for-large-vestibular-2k1aur9scl.pdf

Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

OBJECTIVE During the last decade, the primary objective for large vestibular schwannoma (VS) management has progressively shifted, from tumor excision to nerve preservation by using a combined microsurgical and radiosurgical approach. The aim of this study was to provide a systematic review and meta-analysis of the available literature regarding the combined strategy of subtotal resection (STR) followed by stereotactic radiosurgery (SRS) for large VSs. METHODS The authors performed a systematic review and meta-analysis in compliance with the PRISMA guidelines for article identification and inclusion using the PubMed, Embase, and Cochrane databases. Established inclusion criteria were used to screen all identified relevant articles published before September 2017 without backward date limit. RESULTS The authors included 9 studies (248 patients). With a weighted mean follow-up of 46 months (range 28-68.8 months), the pooled rate of overall tumor control was 93.9% (95% CI 91.0%-96.8%). Salvage treatment (second STR and/or SRS) was necessary in only 13 (5.24%) of 18 patients who experienced initial treatment failure. According to the House-Brackmann (HB) grading scale, functional facial nerve preservation (HB grade I-II) was achieved in 96.1% of patients (95% CI 93.7%-98.5%). Serviceable hearing after the combined approach was preserved in 59.9% (95% CI 36.5%-83.2%). CONCLUSIONS A combined approach of STR followed by SRS was shown to have excellent clinical and functional outcomes while still achieving a tumor control rate comparable to that obtained with a total resection. Longer-term follow-up and larger patient cohorts are necessary to fully evaluate the rate of tumor control achieved with this approach.

/pdf/systematic-review-and-meta-analysis-of-the-technique-of-1ytsd965fk.pdf

Systematic review and meta-analysis of the technique of subtotal resection and stereotactic radiosurgery for large vestibular schwannomas: a "nerve-centered" approach.

Background.

We investigated the incremental diagnostic value of short tau inversion recovery (STIR) MRI to detect cervical nodal metastases in head and neck squamous cell carcinoma.



Methods.

Thirty-six patients with cervical nodal metastases underwent MRI preceding neck dissection. Two readers evaluated MRI versus MRI with STIR. Level-based analysis was performed: interobserver agreements (kappa) for detecting normal and metastatic lymph nodes; sensitivities and specificities for detecting at least 1 metastatic lymph node per level; linear regression analysis to determine performances of MRI with STIR in detecting correct numbers of normal and metastatic lymph nodes. Histopathology was the reference standard.



Results.

One hundred eighty neck levels were evaluated. MRI with STIR showed better kappas for metastatic and normal lymph nodes, was more accurate to estimate numbers of metastatic and normal lymph nodes, and showed improvement of sensitivities and specificities.



Conclusion.

Incorporation of STIR into the conventional MR protocol significantly improves the detection of cervical lymph node metastases. © 2009 Wiley Periodicals, Inc. Head Neck, 2009

Clinical impact of short tau inversion recovery MRI on staging and management in patients with cervical lymph node metastases of head and neck squamous cell carcinomas.

Object In large vestibular schwannoma (VS), microsurgery is the main treatment option, and complete resection is considered the primary goal However, previous studies have documented suboptimal facial nerve outcomes in patients who undergo complete resection of large VSs Subtotal resection is likely to reduce the risk of facial nerve injury but increases the risk of lesion regrowth Gamma Knife surgery (GKS) can be performed to achieve long-term growth control of residual VS after incomplete resection In this study the authors report on the results in patients treated using planned subtotal resection followed by GKS with special attention to volumetric growth, control rate, and symptoms Methods Fifty consecutive patients who underwent the combined treatment strategy of subtotal microsurgical removal and GKS for large VSs between 2002 and 2009 were retrospectively analyzed Patients with neurofibromatosis Type 2 were excluded Patient charts were reviewed for clinical symptoms Audiograms were evaluate

Management of large vestibular schwannoma. Part I. Planned subtotal resection followed by Gamma Knife surgery: radiological and clinical aspects

The aim of this study was to determine the prevalence of persistent trigeminal artery (PTA) associated with trigeminal neuralgia (TN). From January 1998 to January 2004, 288 MRI scans of patients examined for trigeminal deficits were retrospectively evaluated. MRI was performed at 1.5 T. Scan protocols included cerebral TSE T2-weighted imaging, contrast enhanced SE T1-weighted imaging and thin-section 3D T2-weighted imaging of the temporal bones, 3D TOF pre- and postcontrast MR angiography. TN was defined as episodes of intense stabbing, electric shock-like pain in areas of the face supplied by the trigeminal branches. Neurovascular compression (NVC) was assumed to be present if the patient showed clinical features of TN, if there was contact between an artery and the trigeminal nerve on the affected side, and if other pathology had been excluded. The prevalence and confidence intervals were calculated (95% CI of the prevalence was based on the exact binomial distribution). Of 288 patients, 136 matched the criteria for TN. In this series a PTA was detected in three patients, which in all patients was on the same side as the TN. The prevalence of a PTA in patients presenting with TN was 2.2% (CI 0.005–0.06). Previous studies have shown PTA as an incidental finding in 0.1–0.6% of cerebral angiograms. The prevalence of a PTA in patients with TN was 2.2%. With respect to the clinical significance, a PTA has to be considered in TN and the diagnosis of a PTA can easily be made using MR imaging/angiography.

Persistent trigeminal artery associated with trigeminal neuralgia: hypothesis of neurovascular compression

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Papers

Clinical impact of short tau inversion recovery MRI on staging and management in patients with cervical lymph node metastases of head and neck squamous cell carcinomas.

Management of large vestibular schwannoma. Part I. Planned subtotal resection followed by Gamma Knife surgery: radiological and clinical aspects

Persistent trigeminal artery associated with trigeminal neuralgia: hypothesis of neurovascular compression