Mastronardi Luciano, Di Scipio Ettore, Cacciotti Guglielmo, Roperto Raffaelino
San Filippo Neri Hospital, Department of Neurological Sciences, Division of Neurosurgery and *Unit of Neurophysiopathology, Roma, Italy.
San Filippo Neri Hospital, Department of Neurological Sciences, Division of Neurosurgery and *Unit of Neurophysiopathology, Roma, Italy.
Clin Neurol Neurosurg. 2018 Feb;165:108-115. doi: 10.1016/j.clineuro.2018.01.011. Epub 2018 Jan 10.
Decision-making regarding the therapy of vestibular schwannoma (VS) changed over the last decades, during which curative microsurgery has been promoted. Goals of VS microsurgery are: extensive resection, facial nerve (FN) preservation and, in selected cases, hearing preservation (HP). The aim of this study is to evaluate postoperative HP with reference to tumor size in patients operated on with Level Specific (LS)-CE-Chirp® ABR monitoring.
Twentyfive consecutive patients with socially useful hearing (SUH) underwent VS microneurosurgery by retrosigmoid (RS) approach. Selection criteria were: pure tone audiogram <50dB loss and speech discrimination score >50% (50/50 criterion; AAO-HNS class A-B). In relation to maximum diameter, we identified 2 size-groups: A) ≤2cm (13 cases); B) >2cm (12 cases). HP attempt was assisted by intraoperative ABR evoked by LS CE-Chirp® acoustic stimuli.
Mean age was 44,3 years (20-64); average maximum diameter 2,04cm (8 40mm). Total and nearly-total (>95%) resection was possible in all. Mortality and major morbidity were zero. In all, FN was anatomically and functionally preserved; in 10 an incomplete FN deficit (House-Brackmann II and III) was followed by complete recovery (House-Brackmann I). SUH preservation rate was 52%, with significant differences in relation to size: 61,5% group A and 41,7% group B (p = 0,014). Postoperative AAO-HNS C (serviceable) hearing was observed in 36%, deafness in 12%.
Microsurgery represents a valid therapeutic option for small growing VS with SUH. Our data confirm that RS removal of VS with intraoperative ABR monitoring allows good rate of SUH preservation, especially if maximum diameter does not exceed 2cm. LS-CE-Chirp ABR represent a safe and effective method for monitoring cochlear nerve, with fast and clear intraoperative neurophysiological feedback.
在过去几十年中，关于前庭神经鞘瘤（VS）治疗的决策发生了变化，在此期间，根治性显微手术得到了推广。VS显微手术的目标是：广泛切除、保留面神经（FN），在特定情况下保留听力（HP）。本研究的目的是参照肿瘤大小，评估采用特定水平（LS）-CE-Chirp®听性脑干反应（ABR）监测进行手术的患者术后的听力保留情况。
连续25例具有社会实用听力（SUH）的患者通过乙状窦后（RS）入路接受VS显微神经外科手术。选择标准为：纯音听力图听力损失<50dB且言语辨别得分>50%（50/50标准；美国耳鼻咽喉头颈外科学会（AAO-HNS）A-B级）。根据最大直径，我们确定了2个大小组：A）≤2cm（13例）；B）>2cm（12例）。术中通过LS CE-Chirp®声刺激诱发ABR辅助进行听力保留尝试。
平均年龄为44.3岁（20 - 64岁）；平均最大直径2.04cm（8 - 40mm）。所有患者均可行全切除及近全切除（>95%）。死亡率和严重并发症发生率为零。总体而言，FN在解剖和功能上均得以保留；10例患者出现不完全FN功能缺损（House-Brackmann II级和III级），随后完全恢复（House-Brackmann I级）。SUH保留率为52%，大小组间存在显著差异：A组为61.5%，B组为41.7%（p = 0.014）。术后AAO-HNS C级（可用）听力的患者占36%，耳聋患者占12%。
显微手术是治疗生长缓慢的小VS伴SUH的有效治疗选择。我们的数据证实，术中ABR监测下行RS切除VS可实现较高的SUH保留率，尤其是最大直径不超过2cm时。LS-CE-Chirp ABR是监测蜗神经的一种安全有效的方法，术中神经生理反馈快速且清晰。
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