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Examples of surgical treatment
vestibular schwannoma. neuroma. large. craniotomy. resection. retrosigmoid. monitoring.
vestibular schwannoma. neurinoma. large. craniotomy. resection. retrosigmoid. monitoring.
Schwannoma of the VIIIth nerve on the right
54-year-old patient, in perfect health, almost total hearing loss on the right side.
The patient underwent tumor removal using a retrosigmoid approach (craniotomy of no more than 2 cm behind the ear). The tumor was completely removed and the facial nerve, after a period of approximately 8 months of malfunction, began to function perfectly again (on the right is the postoperative MRI image documenting the total removal).
vestibural schwannoma. neurinoma. resection. translabyrinthine.
Schwannoma of the VIIIth nerve on the left
A 39-year-old patient with a small schwannoma of the left vestibular nerve (1 cm) (left image). Deafness in the left ear. After discussing all possible treatments, the patient opted for surgical removal.
A translabyrinthine approach was performed with complete tumor removal. No facial nerve damage was observed (right image).
vestibular schwannoma. neurinoma. large tumor. retrosigmoid. resection. monitoring.
vestibular schwannoma. neurinoma. large tumor. retrosigmoid. resection. monitoring.

Neurinomas or schwannomas are benign tumors that arise from the sheath that surrounds nerves.

The most common ones at the central nervous system level are those that originate from the vestibular nerve, that is, the nerve transmits the impulses from the inner ear that allow us to stay balanced and move with ease.

 

This nerve is closely associated with the acoustic nerve (the nerve of hearing or cranial nerve VIII) and the facial nerve (cranial nerve VII), the nerve that allows us to smile and wink. All three form a thin string (the acoustic/facial bundle) that connects the ear to the brain. Therefore, a vestibular neuroma will always affect the other two nerves as well.

 

The most frequent symptoms that a patient may experience are:

 

hearing loss

dizziness

tinnitus

 

Obviously, when a neurinoma reaches considerable dimensions (>3 cm), other symptoms may also appear due to the contact of the tumor with areas surrounding the acoustic/vestibular/facial nerve.

 

difficulty swallowing

double vision (diplopia)

difficulty walking in a straight line

facial pain

severe headache

 

 

How is it treated?

 

Modern treatment of this disease requires a completely patient-specific approach. This means that each individual case presents unique characteristics, and therefore the therapeutic indications will vary.

 

The most important parameters that are taken into consideration in the therapeutic choice are

 

the dimensions

the symptoms

the position in relation to the brainstem and internal auditory canal

the age

the state of hearing ability

the presence of associated pathologies

 

Broadly speaking, there are three types of choices that can be made

 

1. observation (especially indicated in small tumors <1cm)

2. surgery (example of retrosigmoid approach)

3. radiosurgery

 

These strategies each have advantages and disadvantages which, once again, must be contextualized to the specific case.

 

Certainly, the patient must be able to understand all the therapeutic options in order to be best guided in his choice.

 

In our hospital, there is close collaboration between the neurosurgeon, ENT specialist, and radiotherapist/radiosurgeon, and all therapeutic options are offered and explained to the patient.

 

 

VESTIBULAR NEURINOMAS

In-depth analysis

 

Intraoperative electrophysiological monitoring

 

This technique requires the presence in the operating room of a Neurophysiologist, i.e. a doctor who is an expert in monitoring

electrophysiology of nerves and brain.

 

Monitoring allows for highly precise and safe real-time information on the functional status of a nerve. The principle is based on the application of a series of receiving electrodes (microscopic needles inserted into the muscles corresponding to the nerve being monitored, such as the facial muscles) and the application of very low-voltage currents to the nerve being examined. This provides information not only on the extent to which the nerve is being manipulated and irritated, but also on its functional integrity.

 

Surgery for tumors of the posterior cranial fossa and posterior skull base requires these monitoring procedures.

 

Our hospital offers a dedicated and highly experienced team of intraoperative electrophysiological monitoring specialists.

A 32-year-old woman presented to the emergency room with severe dizziness and the inability to walk straight. She also reported deafness on the left side, difficulty swallowing, and double vision.
 
The MRI shows a very large neuroma (5cm) which occupies the entire cerebellopontine angle up to the foramen magnum.
The patient underwent removal of the mass with a retrosigmoid approach in the sitting position.
During the procedure, nerves V, VII, IX, X, XI, XII and cerebral nerve conduction (somatosensory evoked potentials) were monitored.
 
Postoperative MRI 4 months after surgery shows a total resection with minimal tumor fragments left on the nerve structures to avoid permanent damage.
At the moment the young woman has a continuously improving deficit of the facial nerve and an incomplete deficit of the VI nerve.
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