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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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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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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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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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High jugular bulb on CT

MR 20mm tumor

Conclusion: Obs. initially.

If growth Subocc. surgery or GK


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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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First patient operated

translab. in Norway by PM

1976

75 years old

Ac. 20mm

Uneventful recovery


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Acoustic neuroma

Internal acoustic

meatus

(ill. from Jackler)


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Acoustic neuroma

10mm in diam.,

intracanalicular left

Dead left ear for

> 3 years

Vertigo last year


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Balance platform

Acoustic neuroma15

10mm intrameatal+vertigo

Preoperative


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Balance platform

Acoustic neuroma

10mm intrameatal

+vertigo

3 weeks postop.

Translab. surgery


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Small

< 10 mm

Medium10- 25 mm

in CP angel

(ill. from Jackler)


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Acoustic neuroma

8mm in CPA

High Freq . Hearing

loss

BRA normal


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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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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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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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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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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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(239 patients)

Conclusion: Facial preservation

HB 1-2

> 20mm in CP: Increased risk with Surgery

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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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Conclusion in Tumors < 20mm in CP(239 patients)

Surgery or GK before > 20mm in CP angle

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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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Surgical anatomy of

posterior fossa and

temporal bone

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Retrosigmoid

surgery

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N. Facialis

relation to tumor

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N. Facialis

Changes in realtion

to tumor

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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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33Acoustic neuromaAcoustic neuroma

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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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

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A ti NA ti N


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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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Results after GK

Acoustic Neuroma

showing necrosis

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(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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Large

25-40mm in CP

(ill. from Jackler)

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Gigant

> 40 mm

Compression of cerebellum and

brain stem

(ill. from Jackler)

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Diagnosis

Patient information

Options

Strategy

Results

Surgery / GK

Diagnosis Observation

Outcome

< 20mm

>20mm Growth>2mm pr.year