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Acoustic Neuroma (Vestibular Schwannoma) Diagnosis and treatment Per Møller Haukeland University Hospital Bergen, Norway Acoustic Neuroma (Vestibular Schwannoma) Diagnosis and treatment Per Møller Haukeland University Hospital Bergen, Norway Møller-2002

Acoustic Neuroma Møller-2002 2 Acoustic Neuroma Møller-2002 2

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

Acoustic neuroma First symptoms / Symptoms: – – – Hearing loss Tinnitus Vertigo Ear Acoustic neuroma First symptoms / Symptoms: – – – Hearing loss Tinnitus Vertigo Ear ache Facial palsy 80 -100 % 5 -10 % 10 -50 % 5% < 1 -2 % – Sudden hearing loss 5% Møller-2002 4

5 CT RI /M GK Møller-2002 He ar ing Pain Outcome Balance Facial Treatment 5 CT RI /M GK Møller-2002 He ar ing Pain Outcome Balance Facial Treatment Su rge ry Diagnosis GK r or mo um Tu Symptoms EN T Ob ser vat ion Acoustic Neuroma

6 Acoustic neuroma l Diagnosis: – ENT exam. – Audiologi – Caloric testing – 6 Acoustic neuroma l Diagnosis: – ENT exam. – Audiologi – Caloric testing – BRA – CT with contrast – MR with contrast ( T 1 + T 2) Møller-2002

7 Acoustic neuroma l Diagnostic problems: – ENT in outpatient findings : 16. 6% 7 Acoustic neuroma l Diagnostic problems: – ENT in outpatient findings : 16. 6% have ear symptoms l MR of all unilat. hearing losses? l Sudden deafness – all to MR ? l Sudden vertigo in Hospital: CT or MR ? l – Quality control : l Follow-up in 6 -9 months Møller-2002

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

9 Acoustic Neuroma – History of surgery Cushing – 1917 - intracaps. removal l 9 Acoustic Neuroma – History of surgery Cushing – 1917 - intracaps. removal l Dandy -1925 - total removal l Olivecrona - 1967 preservation of N 7 l House 1961 – microsurgery l – In Scandinavia microsurgery since 1976 – Leksell Gamma-knife since 1980 -ies Møller-2002

10 Acoustic Neuroma surgery House Ear Institute 1977 l l Bill House Møller-2002 Bill 10 Acoustic Neuroma surgery House Ear Institute 1977 l l Bill House Møller-2002 Bill Hitselberger

11 Acoustic Neuroma Haukeland University Hospital l Experience based on : – Surgery – 11 Acoustic Neuroma Haukeland University Hospital l Experience based on : – Surgery – Gamma-knife – Observation 200 210 135 Møller-2002

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

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

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

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

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

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

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

19 Acoustic Neuroma AC < 20 mm in CP Observation no. 82 > 2 19 Acoustic Neuroma AC < 20 mm in CP Observation no. 82 > 2 years (2 -20 years, age 24 -68 years) Gowth pattern: Growth after diagnosis Growth >2 mm/year No growth after diagnosis : 35 (43%) : 23 (28%) : 47 (57%) Treatment so far of 23 with growt > 2 mm/year: Surgery : 15 Gamma-knife : 5 Møller-2002

Acoustic Neuroma l Results l in Tumors < 20 mm in CP Surgery no. Acoustic Neuroma l Results l in Tumors < 20 mm in CP Surgery no. 104 – Facial function HB gr 1 -2 : 94 l HB gr 3 : 1 l HB gr 4 -6 : 9 ( 7/9 diam. 20 mm ) l – Hearing preservation l In 5 out of 12 subocc. Møller-2002 20

Acoustic Neuroma l Results in Tumors < 20 mm in CP Surgery no. 104 Acoustic Neuroma l Results in Tumors < 20 mm in CP Surgery no. 104 l Complications: l – CSF leakage, reoperated – – 1 Meningitis, 3 Pneumonia, 1 Residual tumor, reoperated 1 Mortality, 0 Møller-2002 21

22 Acoustic Neuroma l Results in Tumors < 20 mm in CP Gamma-knife no. 22 Acoustic Neuroma l Results in Tumors < 20 mm in CP Gamma-knife no. 53, follow-up >4 years ( 4 -10 years) l Tumor control 96% 36% reduced in volume l 60% stable volume l Møller-2002

23 Acoustic Neuroma Results in Tumors < 20 mm in CP Gamma-knife no. 53, 23 Acoustic Neuroma Results in Tumors < 20 mm in CP Gamma-knife no. 53, follow-up >4 years ( 4 -10 years) Complications: Facial reduction l Trancient 4, permanent 4 (2: HB 2, 2: HB 3) – Trigeminal reduction 6% – Hydrocephalus 8% – Hearing preservation 77% Møller-2002

24 Acoustic neuroma Results in Tumors < 20 mm in CP (239 patients) l 24 Acoustic neuroma Results in Tumors < 20 mm in CP (239 patients) l Conclusion: Facial preservation – <19 mm in CP : l l Observation: no risk ? Surgery and GK, less < 5% for facial reduction > HB 1 -2 – > 20 mm in CP: l Increased risk with Surgery Møller-2002

25 Acoustic neuroma Results in Tumors < 20 mm in CP (235 patients) – 25 Acoustic neuroma Results in Tumors < 20 mm in CP (235 patients) – Conclusion: Hearing preservation GK > 3 years 77% l Observation >2(mean 6) years 64% l Surgery > 1 year 5% l Møller-2002

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

27 Acoustic Neuroma Haukeland University Hospital l VS treated by surgery 1988 -1999 l 27 Acoustic Neuroma Haukeland University Hospital l VS treated by surgery 1988 -1999 l No. 115 ( translab : 63, so : 52) (age 52 , 23 -83 years) l Size of VS ( Tos class) Intracan. 18 Small ( 1 -10 mm) 12 Medium ( 11 -25 mm) 39 Large (26 -40 mm) 44 Giant (> 41 mm) 2 l l l (16%) (10%) (34%) (38%) (2%) Møller-2002

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

29 Acoustic neuroma Retrosigmoid surgery Møller-2002 29 Acoustic neuroma Retrosigmoid surgery Møller-2002

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

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

32 Acoustic Neuroma Haukeland University Hospital l VS treated by surgery 1988 -1999 No. 32 Acoustic Neuroma Haukeland University Hospital l VS treated by surgery 1988 -1999 No. 115 ( translab : 63, so : 52) (age 52 , 23 -83 years) l Facial outcome (HB-class. ) in % l l l l HB 1 : HB 2 : HB 3 : HB 4 : HB 5 : HB 6 : % 67 7. 5 9. 5 4. 5 3 8. 5 Møller-2002

Acoustic neuroma Haukeland University Hospital – RESULTS AFTER SURGICAL TREATMENT WITH SPECIAL EMPHASIS ON Acoustic neuroma Haukeland University Hospital – RESULTS AFTER SURGICAL TREATMENT WITH SPECIAL EMPHASIS ON QUALITY OF LIFE. l 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 33

34 Acoustic Neuroma Isodose 3050% 12 Gy to periphery Møller-2002 34 Acoustic Neuroma Isodose 3050% 12 Gy to periphery Møller-2002

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

Acoustic Neuroma Haukeland University Hospital Total report: Gamma-knife no. 210 Volume: 0. 11 – Acoustic Neuroma Haukeland University Hospital Total report: Gamma-knife no. 210 Volume: 0. 11 – 18. 8 ccm ( 3 VS > 20 mm in CP) Dose periphery : 8 -20 Gy ( 86% got 12 Gy) Isodose 30 – 50% Møller-2002 36

37 Acoustic Neuroma Results after GK Acoustic Neuroma showing necrosis 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 38 Acoustic Neuroma (Vestibular Schwannoma) – Gamma. knife – 2 cases with growth after 3 years – Surgery l l To left: VS 20 mm -91 (f: HB 010252) 30 mm-95 Facial paralysis HB gr 6 Pons infarction To right : VS 25 mm- -95 (f: LF 270147) 35 mm-97 Uneventful surgery Møller-2002

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

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

41 Acoustic Neuroma Diagnosis < 20 mm l Growth>2 mm pr. year >20 mm 41 Acoustic Neuroma Diagnosis < 20 mm l Growth>2 mm pr. year >20 mm Observation l Surgery / GK l l l Outcome Møller-2002 Diagnosis Patient information Options Strategy Results