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Acoustic NeuromaAcoustic Neuroma
(Vestibular Schwannoma)
Diagnosis and treatment
Per Mller
Haukeland University Hospital
Bergen, Norway
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2Acoustic NeuromaAcoustic Neuroma
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Acoustic NeuromaAcoustic Neuroma
Microscopical section :
Typical relation to nerves and vessels
Antoni type 1 and 2
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4Acoustic neuromaAcoustic neuroma
First symptoms / Symptoms:
Hearing loss 80-100 %
Tinnitus 5-10 %
Vertigo 10-50 %
Ear ache 5 %
Facial palsy < 1-2 %
Sudden hearing loss 5%
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Acoustic NeuromaAcoustic Neuroma
TreatmentTreatment
GKGK
Obs
ervation
Observation
GKGK Surg
ery
Surg
ery
OutcomeOutcome
Hearing
Hearing
PainPain
Fac
ial
Fac
ial
Balance
Balance
Tumor
Tum
or
DiagnosisDiagnosis
ENTENT
Symp
toms
Symp
toms
CT/M
RI
CT/M
RI
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Acoustic neuromaAcoustic neuroma
Diagnosis:
ENT exam.
Audiologi
Caloric testing
BRA
CT with contrast
MR with contrast ( T1 + T2)
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Acoustic neuromaAcoustic neuroma
Diagnostic problems:
ENT in outpatient findings :16.6% have ear symptoms
MR of all unilat. hearing losses?
Sudden deafness all to MR ?
Sudden vertigo in Hospital: CT or MR ?
Quality control :Follow-up in 6-9 months
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Acoustic neuromaAcoustic neuroma
High jugular bulb on CT
MR 20mm tumor
Conclusion: Obs. initially.
If growth Subocc. surgery or GK
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Acoustic NeuromaAcoustic Neuroma
History of surgeryCushing 1917- intracaps. removal
Dandy -1925- total removal
Olivecrona - 1967 preservation of N7House 1961 microsurgery
In Scandinavia microsurgery since 1976
Leksell Gamma-knife since 1980-ies
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Acoustic Neuroma surgeryAcoustic Neuroma surgery
House Ear Institute 1977 Bill House Bill Hitselberger
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Acoustic NeuromaAcoustic NeuromaHaukeland University HospitalHaukeland University Hospital
Experience based on :
Surgery 200
Gamma-knife 210
Observation 135
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Acoustic NeuromaAcoustic Neuroma
First patient operated
translab. in Norway by PM
1976
75 years old
Ac. 20mm
Uneventful recovery
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Acoustic NeuromaAcoustic Neuroma
Acoustic neuroma
Internal acoustic
meatus
(ill. from Jackler)
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Acoustic NeuromaAcoustic Neuroma
Acoustic neuroma
10mm in diam.,
intracanalicular left
Dead left ear for
> 3 years
Vertigo last year
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Acoustic NeuromaAcoustic Neuroma
Balance platform
Acoustic neuroma15
10mm intrameatal+vertigo
Preoperative
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Acoustic NeuromaAcoustic Neuroma
Balance platform
Acoustic neuroma
10mm intrameatal
+vertigo
3 weeks postop.
Translab. surgery
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Acoustic neuromaAcoustic neuroma
Small
< 10 mm
Medium10- 25 mm
in CP angel
(ill. from Jackler)
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Acoustic NeuromaAcoustic Neuroma
Acoustic neuroma
8mm in CPA
High Freq . Hearing
loss
BRA normal
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Acoustic NeuromaAcoustic Neuroma
AC < 20mm in CP
Observation no.82 > 2 years (2-20 years, age 24-68years)
Gowth pattern:
Growth after diagnosis : 35 (43%)Growth >2mm/year : 23 (28%)
No growth after diagnosis : 47 (57%)
Treatment so far of 23 with growt > 2mm/year:
Surgery : 15
Gamma-knife : 5
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Acoustic NeuromaAcoustic Neuroma
Results in Tumors < 20mm in CPSurgery no. 104
Facial functionHB gr 1-2 : 94
HB gr 3 : 1HB gr4-6 : 9 ( 7/9 diam. 20mm )
Hearing preservation
In 5 out of 12 subocc.
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Acoustic NeuromaAcoustic Neuroma
Results in Tumors < 20mm in CPSurgery no. 104
Complications:
CSF leakage, reoperated 1
Meningitis, 3
Pneumonia, 1
Residual tumor, reoperated 1
Mortality, 0
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Acoustic NeuromaAcoustic Neuroma
Results in Tumors < 20mm in CP
Gamma-knifeno. 53, follow-up >4 years ( 4-10 years)
Tumor control 96%
36% reduced in volume
60% stable volume
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Acoustic NeuromaAcoustic Neuroma
Results in Tumors < 20mm in CP
Gamma-knifeno. 53, follow-up >4 years ( 4-10 years)
Complications:
Facial reductionTrancient 4, permanent 4 (2: HB 2, 2: HB 3)
Trigeminal reduction 6%
Hydrocephalus 8%
Hearing preservation 77%
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Acoustic neuromaAcoustic neuroma
Results in Tumors < 20mm in CP
(239 patients)
Conclusion: Facial preservation
HB 1-2
> 20mm in CP: Increased risk with Surgery
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Acoustic neuromaAcoustic neuroma
Results in Tumors < 20mm in CP (235 patients)
Conclusion: Hearing preservation
GK > 3 years 77%
Observation >2(mean 6) years 64%
Surgery > 1 year 5%
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Acoustic NeuromaAcoustic Neuroma
Conclusion in Tumors < 20mm in CP(239 patients)
Surgery or GK before > 20mm in CP angle
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Acoustic NeuromaAcoustic NeuromaHaukeland University HospitalHaukeland University Hospital
VS treated by surgery 1988-1999 No. 115 ( translab : 63, so : 52) (age 52 , 23-83years)
Size of VS ( Tos class) Intracan. 18 (16%)
Small ( 1-10mm) 12 (10%)
Medium ( 11-25mm) 39 (34%)
Large (26-40mm) 44 (38%) Giant (> 41mm) 2 (2%)
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Acoustic neuromaAcoustic neuroma
Surgical anatomy of
posterior fossa and
temporal bone
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Acoustic neuromaAcoustic neuroma
Retrosigmoid
surgery
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Acoustic neuromaAcoustic neuroma
N. Facialis
relation to tumor
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Acoustic neuromaAcoustic neuroma
N. Facialis
Changes in realtion
to tumor
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Acoustic NeuromaAcoustic NeuromaHaukeland University HospitalHaukeland University Hospital
VS treated by surgery 1988-1999 No. 115 ( translab : 63, so : 52) (age 52 , 23-83years)
Facial outcome (HB-class.) in % %
HB 1 : 67
HB 2 : 7.5
HB 3 : 9.5
HB 4 : 4.5
HB 5 : 3
HB 6 : 8.5
33A tiA ti
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Haukeland University HospitalHaukeland University Hospital RESULTS AFTER SURGICAL TREATMENT WITH
SPECIAL EMPHASIS ON QUALITY OF LIFE.
CONCLUSIONSurgery for VS has a significant (mainly negative)impact on the everyday life of the patients.Quality of life is not significantly affected by age orgender.
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Acoustic NeuromaAcoustic Neuroma
Isodose 30-
50%
12 Gy to
periphery
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Acoustic NeuromaAcoustic Neuroma((Vestibular Schwannoma : VS)Vestibular Schwannoma : VS)
Gamma-knifeContraindications:
VS > 30mm in CPBrain stem compression
Cystic VS
36
A ti NA ti N
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Acoustic NeuromaAcoustic NeuromaHaukeland University HospitalHaukeland University Hospital
Total report:Total report:Gamma-knife no. 210Volume: 0.11 18.8 ccm ( 3 VS > 20mm in CP)
Dose periphery : 8-20 Gy ( 86% got 12 Gy)
Isodose 30 50%
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Acoustic NeuromaAcoustic Neuroma
Results after GK
Acoustic Neuroma
showing necrosis
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Acoustic NeuromaAcoustic Neuroma
(Vestibular Schwannoma)(Vestibular Schwannoma) Gamma.knife 2 cases with
growth after 3 years Surgery
To left: VS 20mm -91
(f: HB 010252) 30mm-95
Facial paralysis HB gr 6
Pons infarction
To right :VS 25mm- -95
(f: LF 270147) 35mm-97
Uneventful surgery
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Acoustic neuromaAcoustic neuroma
Large
25-40mm in CP
(ill. from Jackler)
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Acoustic neuromaAcoustic neuroma
Gigant
> 40 mm
Compression of cerebellum and
brain stem
(ill. from Jackler)
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Acoustic NeuromaAcoustic Neuroma
Diagnosis
Patient information
Options
Strategy
Results
Surgery / GK
Diagnosis Observation
Outcome
< 20mm
>20mm Growth>2mm pr.year