Acoustic Neuroma

1
Acoustic Neuroma

• (Vestibular Schwannoma)
• Diagnosis and treatment
• Per Møller
• Haukeland University Hospital
• Bergen, Norway

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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 80-100
• Tinnitus 5-10
• Vertigo 10-50
• Ear ache 5
• Facial palsy lt 1-2
• Sudden hearing loss 5

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Acoustic Neuroma
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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

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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
• Surgery 200
• Gamma-knife 210
• Observation 135

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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
• gt 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
• lt 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 lt 20mm in CP
• Observation no.82 gt 2 years (2-20 years, age
  24-68years)
• Gowth pattern
• Growth after diagnosis 35 (43)
• Growth gt2mm/year 23 (28)
• No growth after diagnosis 47 (57)
• Treatment so far of 23 with growt gt 2mm/year
• Surgery 15
• Gamma-knife 5

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Acoustic Neuroma

• Results in Tumors lt 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 Neuroma

• Results in Tumors lt 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 Neuroma

• Results in Tumors lt 20mm in CP
• Gamma-knife no. 53, follow-up gt4 years ( 4-10
  years)
• Tumor control 96
• 36 reduced in volume
• 60 stable volume

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Acoustic Neuroma

• Results in Tumors lt 20mm in CP
• Gamma-knife no. 53, follow-up gt4 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 lt 20mm in CP
• 
  (239 patients)
• Conclusion Facial preservation
• lt19mm in CP
• Observation no risk ?
• Surgery and GK, less lt 5 for facial reduction gt
  HB 1-2
• gt 20mm in CP
• Increased risk with Surgery

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Acoustic neuroma

• Results in Tumors lt 20mm in CP (235 patients)
• Conclusion Hearing preservation
• GK gt 3 years 77
• Observation gt2(mean 6) years 64
• Surgery gt 1 year 5

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Acoustic Neuroma

• Conclusion in Tumors lt 20mm in CP
• 
  (239 patients)
• Surgery or GK before gt 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 (16)
• Small ( 1-10mm) 12 (10)
• Medium ( 11-25mm) 39 (34)
• Large (26-40mm) 44 (38)
• Giant (gt 41mm) 2 (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 67
• HB 2 7.5
• HB 3 9.5
• HB 4 4.5
• HB 5 3
• HB 6 8.5

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Acoustic neuroma Haukeland 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 Neuroma

• Isodose 30-50
• 12 Gy to periphery

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Acoustic Neuroma (Vestibular Schwannoma VS)

• Gamma-knife
• Contraindications
• VS gt 30mm in CP
• Brain stem compression
• Cystic VS

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Acoustic Neuroma Haukeland University
HospitalTotal report

• Gamma-knife no. 210
• Volume 0.11 18.8 ccm ( 3 VS gt 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
• Uneventful surgery

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Acoustic neuroma

• Large
• 25-40mm in CP
• (ill. from Jackler)

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Acoustic neuroma

• Gigant
• gt 40 mm
• Compression of cerebellum and brain stem
• (ill. from Jackler)

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Acoustic Neuroma
Diagnosis
Observation
lt 20mm

• Diagnosis
• Patient information
• Options
• Strategy
• Results

gt20mm
Growthgt2mm pr. year
Surgery / GK
Outcome