Massive Vestibular Schwannoma Requiring Serial Debulking and Radiosurgery

Introduction: Vestibular schwannomas (VS) are diagnosed in a wide range of sizes with varying patient presentations. This report discusses a young male with a massive cystic VS in the absence of a genetic mutation who presented due to speech and balance concerns.

Methods: Case report of a patient with a massive vestibular schwannoma.

Results: A 32-year-old male presented with longstanding right unilateral sensorineural hearing loss (SNHL) and recently manifested slurred speech, balance problems, and reduced facial sensation above his right eye. An MRI identified a large, 5.0 × 5.4 × 5.1 cm cystic vestibular schwannoma with resultant brainstem compression and hydrocephalus ([Fig. 1]). A translabyrinthine approach was performed with significant debulking of the tumor. Medially, however, a significant amount of tumor was unable to be resected ([Fig. 2]). A retrosigmoid approach was subsequently performed to further debulk the tumor. His postoperative course was complicated by an infected pseudomeningocele requiring surgical washout and bone cement removal and eventual placement of a ventriculoperitoneal shunt. Residual tumor growth on interval MRI 5 months after the second operation prompted Gamma Knife radiosurgery which the patient tolerated well ([Fig. 3]). Subsequent MRI 4 months after radiosurgery demonstrated stable residual tumor without interval growth ([Fig. 4]). The patient experienced significant improvement in ambulation after tumor removal. He also developed significant facial weakness (House-Brackman V) postoperatively which progressed to full paralysis. Facial reanimation surgery is planned along with continued tumor surveillance.

Conclusion: Although the goal of VS surgery is maximal safe resection, in cases of massive VS, serial debulking may be required utilizing a combination of approaches for maximal tumor removal. Postoperative adjuvant radiation may be considered in tumors with progressive residual disease. This case report provides an example of a particularly large tumor requiring a complex approach to management. Further research into the tumor characteristics predictive of aggressive growth is needed.

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Artikel online veröffentlicht:
07. Februar 2025