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. 2020 Dec 18:10:588260.
doi: 10.3389/fonc.2020.588260. eCollection 2020.

Surgery After Surgery for Vestibular Schwannoma: A Case Series

Łukasz Przepiórka  1 , Przemysław Kunert  1 , Wiktoria Rutkowska  1 , Tomasz Dziedzic  1 , Andrzej Marchel  1
Affiliations

Surgery After Surgery for Vestibular Schwannoma: A Case Series

Łukasz Przepiórka et al. Front Oncol. .

Abstract

Objective: We retrospectively evaluated the oncological and functional effectiveness of revision surgery for recurrent or remnant vestibular schwannoma (rVS).

Methods: We included 29 consecutive patients with unilateral hearing loss (16 women; mean age: 42.2 years) that underwent surgery for rVS. Previous surgeries included gross total resections (GTRs, n=11) or subtotal resections (n=18); mean times to recurrence were 9.45 and 4.15 years, respectively. House-Brackmann (HB) grading of facial nerve (FN) weakness (grades II-IV) indicated that 22 (75.9%) patients had deep, long-lasting FN paresis (HB grades: IV-VI). The mean recurrent tumor size was 23.3 mm (range: 6 to 51). Seven patients had neurofibromatosis type 2.

Results: All patients received revision GTRs. Fourteen small- to medium-sized tumors located at the bottom of the internal acoustic canal required the translabyrinthine approach (TLA); 12 large and small tumors, predominantly in the cerebellopontine angle, required the retrosigmoid approach (RSA); and 2 required both TLA and RSA. One tumor that progressed to the petrous apex required the middle fossa approach. Fifteen patients underwent facial neurorrhaphy. Of these, 11 received hemihypoglossal-facial neurorrhaphies (HHFNs); nine with simultaneous revision surgery. In follow-up, 10 patients (34.48%) experienced persistent deep FN paresis (HB grades IV-VI). After HHFN, all patients improved from HB grade VI to III (n=10) or IV (n=1). No tumors recurred during follow-up (mean, 3.46 years).

Conclusions: Aggressive microsurgical rVS treatment combined with FN reconstruction provided durable oncological and neurological effects. Surgery was a reasonable alternative to radiosurgery, particularly in facial neurorrhaphy, where it provided a one-step treatment.

Keywords: facial nerve; gross total resection; revision; surgery; vestibular schwannoma.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Magnetic resonance T1WI contrast enhanced axial images show treatment results in an 18-year-old man with vestibular schwannoma. (A) Brain scan before the initial surgery; (B) image after the initial surgery; (C) image after revision surgery via a middle fossa approach.
Figure 2
Figure 2
Magnetic resonance T1WI contrast enhanced images and photograph show treatment results in a 54–year old woman with facial nerve paresis after a subtotal resection of a vestibular schwannoma. At one year after the initial surgery, (A) coronal and (B) axial MR images show growth after stereotactic radiosurgery. Then, revision surgery was performed, via a retrosigmoid approach with facial neurorrhaphy; 11 months later, (C) coronal and (D) axial T1WI MR images show the results of a gross total resection with (E) satisfactory facial nerve function.
Figure 3
Figure 3
Images show treatment results in a 53–year old male with right facial nerve and abducens nerve pareses and right-sided deafness, after a partial VS removal. Photographs show the patient with the face (A) at rest, (B) with closed eyes, and (C) when asked to put out his tongue. The latter image is significant, because it shows no visible muscular atrophy and a straight position. (D−F) Magnetic resonance T1WI images with contrast enhancement show the brain (D) before, and (E) after the first surgery, which resulted in a remnant tumor. (F) The brain after revision surgery via a translabyrinthine approach.
See this image and copyright information in PMC

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