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

Acoustic Neuroma Møller-2002

Acoustic Neuroma Microscopical section : Typical relation to nerves and vessels Antoni type 1 and 2 Møller-2002

Acoustic 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% Møller-2002

Acoustic Neuroma Diagnosis ENT Symptoms CT / MRI Treatment GK Observation Surgery Outcome Hearing Pain Facial Balance Tumor Møller-2002

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

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 Møller-2002

Acoustic neuroma High jugular bulb on CT MR 20mm tumor Conclusion: Obs. initially. If growth Subocc. surgery or GK Møller-2002

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 Møller-2002

Acoustic Neuroma surgery House Ear Institute 1977 Bill House Bill Hitselberger Translab surgery 1977 for acoustic neuroma. Møller-2002

Acoustic Neuroma Haukeland University Hospital Experience based on : Surgery 200 Gamma-knife 210 Observation 135 Møller-2002

Acoustic Neuroma First patient operated translab. in Norway by PM 1976 75 years old Ac. 20mm Uneventful recovery Møller-2002

Acoustic Neuroma Acoustic neuroma Internal acoustic meatus (ill. from Jackler) Møller-2002

Acoustic Neuroma Acoustic neuroma 10mm in diam., intracanalicular left Dead left ear for > 3 years Vertigo last year Møller-2002

Acoustic Neuroma Balance platform Acoustic neuroma15 10mm intrameatal +vertigo Preoperative Møller-2002

Acoustic Neuroma Balance platform Acoustic neuroma 10mm intrameatal +vertigo 3 weeks postop. Translab. surgery Møller-2002

Acoustic neuroma Small < 10 mm Medium 10- 25 mm in CP angel (ill. from Jackler) Møller-2002

Acoustic Neuroma Acoustic neuroma 8mm in CPA High Freq . Hearing loss BRA normal Møller-2002

Acoustic 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 Møller-2002

Acoustic 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. Møller-2002

Acoustic 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 Møller-2002

Acoustic 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 Møller-2002

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% Møller-2002

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 Møller-2002

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% Møller-2002

Acoustic Neuroma Conclusion in Tumors < 20mm in CP (239 patients) Surgery or GK before > 20mm in CP angle Møller-2002

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 (> 41mm) 2 (2%) Møller-2002

Acoustic neuroma Surgical anatomy of posterior fossa and temporal bone Møller-2002

Acoustic neuroma Retrosigmoid surgery Møller-2002

Acoustic neuroma N. Facialis relation to tumor Møller-2002

Acoustic neuroma N. Facialis Changes in realtion to tumor Møller-2002

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 Møller-2002

Acoustic neuroma Haukeland University Hospital RESULTS AFTER SURGICAL TREATMENT WITH 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. Møller-2002

Acoustic Neuroma Isodose 30-50% 12 Gy to periphery Møller-2002

Acoustic Neuroma (Vestibular Schwannoma : VS) Gamma-knife Contraindications: VS > 30mm in CP Brain stem compression Cystic VS Møller-2002

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% Møller-2002

Acoustic Neuroma Results after GK Acoustic Neuroma showing necrosis Møller-2002

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 Møller-2002

Acoustic neuroma Large 25-40mm in CP (ill. from Jackler) Møller-2002

Acoustic neuroma Gigant > 40 mm Compression of cerebellum and brain stem (ill. from Jackler) Møller-2002

Acoustic Neuroma Diagnosis Patient information Options Strategy < 20mm Observation Diagnosis Patient information Options Strategy Results >20mm Growth>2mm pr. year Surgery / GK Outcome Møller-2002