Acoustic Neuroma (Vestibular Schwannoma) Diagnosis and treatment Per Møller Haukeland University...
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Transcript of 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
Møller-2002
22Acoustic Neuroma Acoustic Neuroma
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Acoustic NeuromaAcoustic Neuroma
Microscopical section :
Typical relation to nerves and vessels
Antoni type 1 and 2
Møller-2002
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