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 < 1-2 %

– Sudden hearing loss 5%

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Acoustic Neuroma

EN GK Pain

ion
T

g
in
v at
Symptoms

ar
He
se r

Facial
Diagnosis Treatment Outcome
Ob

er y

Tu
rg

mo
R I

Su
GK
/M

r
CT Balance

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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

> 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 : 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 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 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 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 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 (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 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.

 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 30-
50%

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
Uneventful 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
< 20mm
Diagnosis Observation  Diagnosis
>20mm Growth>2mm pr.  Patient information
year
 Options
Surgery / GK
 Strategy
 Results

Outcome

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