International Neuroscience Institute, Hannover, Germany.
J Neurosurg. 2012 Apr;116(4):713-20. doi: 10.3171/2011.12.JNS111682. Epub 2012 Jan 20.
An increasing number of patients with vestibular schwannomas (VSs) are being treated with radiosurgery. Treatment failure or secondary regrowth after radiosurgery, however, has been observed in 2%-9% of patients. In large tumors that compress the brainstem and in patients who experience rapid neurological deterioration, surgical removal is the only reasonable management option.
The authors evaluated the relevance of previous radiosurgery for the outcome of surgery in a series of 28 patients with VS. The cohort was further subdivided into Group A (radiosurgery prior to surgery) and Group B (partial tumor removal followed by radiosurgery prior to current surgery). The functional and general outcomes in these 2 groups were compared with those in a control group (no previous treatment, matched characteristics). RESULTS There were 15 patients in Group A, 13 in Group B, and 30 in the control group. The indications for surgery were sustained tumor enlargement and progression of neurological symptoms in 12 patients, sustained tumor enlargement in 15 patients, and worsening of neurological symptoms without evidence of tumor growth in 1 patient. Total tumor removal was achieved in all patients in Groups A and B and in 96.7% of those in the control group. There were no deaths in any group. Although no significant differences in the neurological morbidity or complication rates after surgery were noted, the risk of new cranial nerve deficits and CSF leakage was highest in patients in Group B. Patients who underwent previous radiosurgical treatment (Groups A and B) tended to be at higher risk of developing postoperative hematomas in the tumor bed or cerebellum. The rate of facial nerve anatomical preservation was highest in those patients who were not treated previously (93.3%) and decreased to 86.7% in the patients in Group A and to 61.5% in those in Group B. Facial nerve function at follow-up was found to correlate to the previous treatment; excellent or good function was seen in 87% of the patients from the control group, 78% of those in Group A, and 68% of those in Group B.
Complete microsurgical removal of VSs after failed radiosurgery is possible with an acceptable morbidity rate. The functional outcome, however, tends to be worse than in nontreated patients. Surgery after previous partial tumor removal and radiosurgery is most challenging and related to worse outcome.
越来越多的前庭神经鞘瘤（VS）患者接受放射外科治疗。然而，有 2%-9%的患者在放射外科治疗后出现治疗失败或二次复发。对于压迫脑干的大肿瘤和神经功能迅速恶化的患者，手术切除是唯一合理的治疗选择。
作者评估了 28 例 VS 患者中，先前放射外科治疗对手术结果的相关性。该队列进一步分为 A 组（手术前放射外科治疗）和 B 组（部分肿瘤切除后放射外科治疗，然后是当前手术）。将这两组的功能和一般结果与对照组（无先前治疗，匹配特征）进行比较。结果：A 组 15 例，B 组 13 例，对照组 30 例。手术指征为 12 例患者肿瘤持续增大且神经症状进展，15 例患者肿瘤持续增大，1 例患者神经症状恶化但无肿瘤生长证据。A 组和 B 组所有患者均行全切除肿瘤，对照组 96.7%患者行全切除肿瘤。各组均无死亡病例。尽管术后神经发病率或并发症发生率无显著差异，但 B 组患者新颅神经损伤和 CSF 漏的风险最高。接受过先前放射外科治疗（A 组和 B 组）的患者术后发生肿瘤床或小脑血肿的风险较高。未接受先前治疗的患者面神经解剖保留率最高（93.3%），A 组患者降至 86.7%，B 组患者降至 61.5%。随访时面神经功能与先前治疗相关；对照组患者中 87%的患者功能良好或优秀，A 组患者中 78%的患者，B 组患者中 68%的患者。
在放射外科治疗失败后，完全行显微外科切除 VS 是可能的，且发病率可接受。然而，功能结果往往不如未治疗的患者。先前部分肿瘤切除和放射外科治疗后的手术最具挑战性，且相关结果较差。
