Acoustic Neuroma

(Vestibular Schwannoma) Diagnosis and treatment

Per Mller

Haukeland University Hospital Bergen, Norway

Acoustic Neuroma

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Acoustic Neuroma

Microscopical section : Typical relation to nerves and vessels Antoni type 1 and 2
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Acoustic neuroma
First symptoms / Symptoms:

Hearing loss Tinnitus Vertigo Ear ache Facial palsy

80-100 % 5-10 % 10-50 % 5% < 1-2 %

Sudden hearing loss 5%

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Acoustic Neuroma
Ob se r v at ion
EN T

Symptoms

He ar in g

GK

Pain

Su rg er y

Diagnosis
I R /M

Treatment

Outcome
r mo Tu

CT

GK

Balance

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Facial

Acoustic neuroma
Diagnosis:
ENT exam. Audiologi Caloric testing BRA CT with contrast MR with contrast ( T1 + T2)
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Acoustic 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 Mller-2002

Acoustic neuroma

High jugular bulb on CT MR 20mm tumor Conclusion: Obs. initially. If growth Subocc. surgery or GK

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Acoustic 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 surgery

House Ear Institute 1977

Bill House Bill Hitselberger

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Acoustic Neuroma
Haukeland University Hospital
Experience

based on :
200 210 135

Surgery Gamma-knife Observation

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Acoustic Neuroma
First patient operated

translab. in Norway by PM 1976 75 years old Ac. 20mm Uneventful recovery

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Acoustic Neuroma
Acoustic neuroma Internal acoustic meatus

(ill. from Jackler)

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Acoustic Neuroma
Acoustic neuroma 10mm in diam., intracanalicular left Dead left ear for > 3 years Vertigo last year
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Acoustic Neuroma
Balance platform Acoustic neuroma15 10mm intrameatal +vertigo Preoperative

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Acoustic Neuroma
Balance platform Acoustic neuroma 10mm intrameatal +vertigo 3 weeks postop. Translab. surgery
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Acoustic neuroma
Small < 10 mm Medium 10- 25 mm
in CP angel

(ill. from Jackler)

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Acoustic Neuroma
Acoustic neuroma 8mm in CPA High Freq . Hearing loss BRA normal
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Acoustic Neuroma
AC < 20mm in CP Observation no.82 > 2 years (2-20 years, age 24-68years) Gowth pattern:
Growth after diagnosis Growth >2mm/year No growth after diagnosis : 35 (43%) : 23 (28%) : 47 (57%)

Treatment so far of 23 with growt > 2mm/year: Surgery : 15 Gamma-knife : 5 Mller-2002

Acoustic Neuroma
Results
Surgery

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in Tumors < 20mm in CP

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 Neuroma
Results
Surgery

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in Tumors < 20mm in CP

no. 104 Complications:

CSF leakage, reoperated Meningitis,

1 3 Pneumonia, 1 Residual tumor, reoperated 1 Mortality, 0

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Acoustic Neuroma
Results

in Tumors < 20mm in CP Gamma-knife no. 53, follow-up >4 years ( 4-10 years)
Tumor
36%

control 96%

reduced in volume 60% stable volume

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Acoustic Neuroma
Results in Tumors < 20mm in CP Gamma-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 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 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 Neuroma
Conclusion in Tumors < 20mm in CP
(239 patients)

Surgery or GK before > 20mm in CP angle

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Acoustic Neuroma
Haukeland 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 Small ( 1-10mm) 12 Medium ( 11-25mm) 39 Large (26-40mm) 44 Giant (> 41mm) 2

(16%) (10%) (34%) (38%) (2%)

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Acoustic neuroma
Surgical anatomy of posterior fossa and temporal bone

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Acoustic neuroma
Retrosigmoid surgery

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Acoustic neuroma
N. Facialis relation to tumor

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Acoustic neuroma
N. Facialis Changes in realtion to tumor

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Acoustic Neuroma
Haukeland 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 : HB 2 : HB 3 : HB 4 : HB 5 : HB 6 : % 67 7.5 9.5 4.5 3 8.5

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Acoustic neuroma
Haukeland University Hospital
RESULTS AFTER SURGICAL TREATMENT WITH

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SPECIAL EMPHASIS ON QUALITY OF LIFE.

CONCLUSION

Surgery 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 Neuroma
Isodose 3050% 12 Gy to periphery

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Acoustic Neuroma (Vestibular Schwannoma : VS)

Gamma-knife
Contraindications: VS > 30mm in CP Brain stem compression Cystic VS

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Acoustic Neuroma
Haukeland University Hospital Total report: Gamma-knife no. 210
Volume: 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 Neuroma
Results after GK Acoustic Neuroma showing necrosis

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Acoustic Neuroma (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 Mller-2002Uneventful surgery

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Acoustic neuroma
Large 25-40mm in CP

(ill. from Jackler)

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Acoustic neuroma
Gigant > 40 mm Compression of cerebellum and brain stem

(ill. from Jackler)

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Acoustic Neuroma
Diagnosis < 20mm
Observation

Diagnosis Patient

>20mm

Growth>2mm pr. year

Surgery / GK

information Options Strategy Results

Outcome

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