Histological considerations of the cleavage plane for preservation of facial and cochlear nerve functions in vestibular schwannoma surgery.
ABSTRACT The authors analyzed the tumor capsule and the tumor-nerve interface in vestibular schwannomas (VSs) to define the ideal cleavage plane for maximal tumor removal with preservation of facial and cochlear nerve functions.
Surgical specimens from 21 unilateral VSs were studied using classical H & E, Masson trichrome, and immunohistochemical staining against myelin basic protein.
The authors observed a continuous thin connective tissue layer enveloping the surfaces of the tumors. Some nerve fibers, which were immunopositive to myelin basic protein and considered to be remnants of vestibular nerve fibers, were also identified widely beneath the connective tissue layer. These findings indicated that the socalled "tumor capsule" in VSs is the residual vestibular nerve tissue itself, consisting of the perineurium and underlying nerve fibers. There was no structure bordering the tumor parenchyma and the vestibular nerve fibers. In specimens of tumors removed en bloc with the cochlear nerves, the authors found that the connective tissue layer, corresponding to the perineurium of the cochlear nerve, clearly bordered the nerve fibers and tumor tissue.
Based on these histological observations, complete tumor resection can be achieved by removal of both tumor parenchyma and tumor capsule when a clear border between the tumor capsule and facial or cochlear nerve fibers can be identified intraoperatively. Conversely, when a severe adhesion between the tumor and facial or cochlear nerve fibers is observed, dissection of the vestibular nerve-tumor interface (the subcapsular or subperineurial dissection) is recommended for preservation of the functions of these cranial nerves.
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ABSTRACT: The preservation of facial nerve function is one of the primary objectives in acoustic neuroma surgery. We detail our method of continuous intraoperative facial motor evoked potential (MEP) monitoring and present criteria for the preservation of facial nerve function to avoid postoperative facial nerve palsy. Our study population was comprised of 15 patients who did not (group 1), and 20 who did (group 2) undergo facial MEP monitoring during surgery to remove acoustic neuromas. In group 2, we continuously stimulated the facial motor cortex at 5- or 10-s intervals throughout surgery. Electromyograms (EMGs) were recorded from the contralateral orbicularis oculi- and orbicularis oris muscles. Optimal anode and cathode placement was at the facial motor cortex and the vertex, respectively. Postoperative facial palsy occurred in 8 of the 15 group 1 patients; in 2 it improved to grade II at 6 months after the operation. Of the 20 group 2 patients, 7 suffered postoperative facial palsy. At 6 months after the operation, their facial nerve function was normal. At the end of the operation, the ratio of the amplitude of the supramaximal EMG to the amplitude at the dural opening was 39.6 % in patients with- and 94.3 % in patients without transient postoperative facial palsy. Continuous facial MEP monitoring not only alerts to surgical invasion of the facial nerves but also helps to predict postoperative facial nerve function. To preserve a minimum amplitude ratio of 50 %, even transient postoperative facial palsy must be avoided. MEP monitoring is an additional useful modality for facial nerve monitoring during acoustic neuroma surgery.Neurosurgical Review 07/2014; · 1.97 Impact Factor
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ABSTRACT: Vestibular schwannoma, the commonest form of intracranial schwannoma, arises from the Schwann cells investing the vestibular nerve. At present, the surgery for vestibular schwannoma remains one of the most complicated operations demanding for surgical skills in neurosurgery. And the trend of minimal invasion should also be the major influence on the management of patients with vestibular schwannomas. We summarized the microsurgical removal experience in a recent series of vestibular schwannomas and presented the operative technique and cranial nerve preservation in order to improve the rates of total tumor removal and facial nerve preservation. A retrospective analysis was performed in 145 patients over a 7-year period who suffered from vestibular schwannomas that had been microsurgically removed by suboccipital retrosigmoid transmeatus approach with small craniotomy. CT thinner scans revealed the tumor size in the internal auditory meatus and the relationship of the posterior wall of the internal acoustic meatus to the bone labyrinths preoperatively. Brain stem evoked potential was monitored intraoperatively. The posterior wall of the internal acoustic meatus was designedly drilled off. Patient records and operative reports, including data from the electrophysiological monitoring, follow-up audiometric examinations, and neuroradiological findings were analyzed. Total tumor resection was achieved in 140 cases (96.6%) and subtotal resection in 5 cases. The anatomical integrity of the facial nerve was preserved in 91.0% (132/145) of the cases. Intracranial end-to-end anastomosis of the facial nerve was performed in 7 cases. Functional preservation of the facial nerve was achieved in 115 patients (Grade I and Grade II, 79.3%). No patient died in this series. Preservation of nerves and vessels were as important as tumor removal during the operation. CT thinner scan could show the relationship between the posterior wall of the internal acoustic meatus and bone labyrinths, that is helpful for a safe drilling of the posterior wall of the internal acoustic meatus. The goal of every surgery should be the preservation of function of all cranial nerves. Using the retrosigmoid approach with small craniotomy is possible even for large schwannomas. Knowing the microanatomy of the cerebellopontine angle and internal auditory meatus, intraoperating neurophysiological monitoring of the facial nerve function, and the microsurgical techniques of the surgeons are all important factors for improving total tumor removal and preserving facial nerve function.Chinese medical journal 02/2010; 123(3):274-80. · 0.90 Impact Factor
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ABSTRACT: Facial nerve (CN VII) palsy or even its transient paresis causes physical disability but is also a psychosocial problem. Immediately after vestibular schwannoma removal, different degrees of CN VII paresis occur in 20-70% of patients. Facial nerve paresis is observed in 10-40% after surgery of cerebellopontine angle meningiomas. Postoperative facial nerve weakness significantly reduces or completely withdraws with time in the majority of cases. However, even if prognosis for CN VII regeneration is good, proper management is needed because of the potential for serious ophthalmic complications. In this paper, the authors raise the issue of perioperative prophylaxis and comprehensive treatment of postoperative paresis of CN VII. Prophylaxis and treatment of ophthalmic complications are discussed. Current trends in the treatment of intraoperative loss of facial nerve continuity, management of facial paresis with good prognosis and dealing with facial palsy with no spontaneous recovery are also described in the paper.Neurologia i neurochirurgia polska 01/2011; 45(5):480-8. · 0.49 Impact Factor