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Contemporary Surgical Management of Vestibular Schwannomas: Analysis of Complications and Lessons Learned Over the Past Decade

Nonaka, Yoichi MD, PhD*; Fukushima, Takanori MD, DMSc*,‡; Watanabe, Kentaro MD*; Friedman, Allan H. MD*; Sampson, John H. MD, PhD*; Mcelveen, John T. Jr MD§; Cunningham, Calhoun D. III MD§; Zomorodi, Ali R. MD*

doi: 10.1227/NEU.0b013e3182752b05
Operative Nuances: EDITOR'S CHOICE
Editor's Choice

BACKGROUND: Despite advanced microsurgical techniques, more refined instrumentation, and expert team management, there is still a significant incidence of complications in vestibular schwannoma surgery.

OBJECTIVE: To analyze complications from the microsurgical treatment of vestibular schwannoma by an expert surgical team and to propose strategies for minimizing such complications.

METHODS: Surgical outcomes and complications were evaluated in a consecutive series of 410 unilateral vestibular schwannomas treated from 2000 to 2009. Clinical status and complications were assessed postoperatively (within 7 days) and at the time of follow-up (range, 1-116 months; mean, 32.7 months).

RESULTS: Follow-up data were available for 357 of the 410 patients (87.1%). Microsurgical tumor resection was performed through a retrosigmoid approach in 70.7% of cases. Thirty-three patients (8%) had intrameatal tumors and 204 (49.8%) had tumors that were <20 mm. Gross total resection was performed in 306 patients (74.6%). Hearing preservation surgery was attempted in 170 patients with tumors <20 mm, and good hearing was preserved in 74.1%. The main neurological complication was facial palsy (House-Brackmann grade III-VI), observed in 14% of patients (56 cases) postoperatively; however, 59% of them improved during the follow-up period. Other neurological complications were disequilibrium in 6.3%, facial numbness in 2.2%, and lower cranial nerve deficit in 0.5%. Nonneurological complications included cerebrospinal fluid leaks in 7.6%, wound infection in 2.2%, and meningitis in 1.7%.

CONCLUSION: Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed.

ABBREVIATIONS: ABR, auditory brainstem response

AICA, anterior inferior cerebellar artery

CN, cranial nerve

CPA, cerebellopontine angle

FN, facial nerve

GTR, gloss total resection

H-B, House-Brackmann

HPS, hearing preservation surgery

NTR, near-total resection

SRT, stereotactic radiation therapy

STR, subtotal resection

VAFE, vascular, adherent, fibrous, and engulfing

VS, vestibular schwannoma

*Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina;

Carolina Neuroscience Institute, Raleigh, North Carolina;

§Carolina Ear and Hearing Clinic, PC, Raleigh, North Carolina

Correspondence: Yoichi Nonaka, MD, PhD,Department of Neurosurgery, Fukushima Skull Base Center, Shin-yurigaoka General Hospital, 255 Furusawa Asao-ku, Kawasaki, Kanagawa, Japan 215-0026. E-mail: or

Received April 04, 2012

Accepted September 05, 2012

Copyright © by the Congress of Neurological Surgeons