Acoustic Neuroma (Vestibular Schwannoma) Diagnosis and treatment Per Møller Haukeland University...

Acoustic NeuromaAcoustic Neuroma

(Vestibular Schwannoma)

Diagnosis and treatment

Per Møller

Haukeland University Hospital

Bergen, Norway

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Acoustic NeuromaAcoustic Neuroma

Microscopical section :

Typical relation to nerves and vessels

Antoni type 1 and 2

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44Acoustic neuromaAcoustic neuromaFirst 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

erva

tion

Obs

erva

tion

GKGK Sur

gery

Sur

gery

OutcomeOutcome

Hea

ring

Hea

ring

PainPain

Fac

ial

Fac

ial

BalanceBalance

Tumor

Tumor

DiagnosisDiagnosis

ENTENT

Sym

pto

ms

Sym

pto

ms

CT / MRI

CT / MRI

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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 CTMR 20mm tumorConclusion: Obs. initially. If growth Subocc. surgery or GK

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Acoustic NeuromaAcoustic Neuroma

– History of surgery Cushing – 1917- intracaps. removal Dandy -1925- total removal Olivecrona - 1967 preservation of N7 House 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 Neuroma Haukeland 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

Medium 10- 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 CP

Surgery no. 104– Facial function

HB gr 1-2 : 94 HB gr 3 : 1 HB 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 CP Surgery 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-knife no. 53, follow-up >4 years ( 4-10 years)

Tumor control 96% 36% reduced in volume 60% stable volume

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Acoustic NeuromaAcoustic NeuromaResults in Tumors < 20mm in CPGamma-knife no. 53, follow-up >4 years ( 4-10 years)

Complications: Facial reduction

Trancient 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– <19mm in CP :

Observation: no risk ? Surgery and GK, less < 5% for facial reduction > 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 Neuroma Haukeland 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 Neuroma Haukeland 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

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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 or gender.

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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 CP

Brain stem compression

Cystic VS

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Haukeland University HospitalHaukeland University HospitalTotal 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