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

2. Acoustic Neuroma
Møller-2002

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

4. Acoustic neuroma First symptoms / Symptoms: Hearing loss 80-100 %
Tinnitus %
Vertigo %
Ear ache %
Facial palsy < 1-2 %
Sudden hearing loss 5%
Møller-2002

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

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

7. 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

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

9. Acoustic Neuroma History of surgery Cushing – 1917- intracaps. removal
Dandy total removal
Olivecrona preservation of N7
House 1961 – microsurgery
In Scandinavia microsurgery since 1976
Leksell Gamma-knife since 1980-ies
Møller-2002

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

11. Acoustic Neuroma Haukeland University Hospital
Experience based on :
Surgery
Gamma-knife
Observation
Møller-2002

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

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

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

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

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

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

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

19. 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

20. 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

21. Acoustic Neuroma Results in Tumors < 20mm in CP Surgery no. 104
Complications:
CSF leakage, reoperated
Meningitis,
Pneumonia,
Residual tumor, reoperated 1
Mortality,
Møller-2002

22. 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

23. 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 %
Hearing preservation 77%
Møller-2002

24. 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

25. Acoustic neuroma Results in Tumors < 20mm in CP (235 patients)
Conclusion: Hearing preservation
GK > 3 years %
Observation >2(mean 6) years 64%
Surgery > 1 year %
Møller-2002

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

27. Acoustic Neuroma Haukeland University Hospital
VS treated by surgery
No ( translab : 63, so : 52) (age 52 , years)
Size of VS ( Tos class)
Intracan (16%)
Small ( 1-10mm) (10%)
Medium ( 11-25mm) (34%)
Large (26-40mm) (38%)
Giant (> 41mm) (2%)
Møller-2002

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

29. Acoustic neuroma
Retrosigmoid
surgery
Møller-2002

30. Acoustic neuroma
N. Facialis
relation to tumor
Møller-2002

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

32. Acoustic Neuroma Haukeland University Hospital
VS treated by surgery
No ( translab : 63, so : 52) (age 52 , years)
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

33. 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

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

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

36. Acoustic Neuroma Haukeland University Hospital Total report:
Gamma-knife no. 210
Volume: – 18.8 ccm ( 3 VS > 20mm in CP)
Dose periphery : Gy ( 86% got 12 Gy)
Isodose 30 – 50%
Møller-2002

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

38. Acoustic Neuroma (Vestibular Schwannoma)
Gamma.knife – 2 cases with growth after 3 years – Surgery
To left: VS 20mm -91
(f: HB ) 30mm-95
Facial paralysis HB gr 6
Pons infarction
To right :VS 25mm- -95
(f: LF ) 35mm-97
Uneventful surgery
Møller-2002

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

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

41. 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