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.

 

MissingLinkText

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
07 February 2025