title: Staged resection of large vestibular schwannomas.
abstract: OBJECTIVE
  Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection.
  
  
  METHODS
  A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors' institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications.
  
  
  RESULTS
  Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2-7 cm) in the 2-stage group and 3.9 cm (range 3.1-5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4%) of 28 patients in the 2-stage group and 15 (79%) of 19 patients in the single-stage group (p < 0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7%), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82%) of 28 patients in the 2-stage group and 10 (53%) of 19 patients in the single-stage group (p < 0.01). Cerebrospinal fluid leak-related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group.
  
  
  CONCLUSIONS
  The authors' results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections.
authors.affiliation: Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA.
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Raslan
authors.forename: James K
authors.initials: JK
authors.lastname: Liu
authors.forename: Sean O
authors.initials: SO
authors.lastname: McMenomey
authors.forename: Johnny B
authors.initials: JB
authors.lastname: Delashaw
mesh_terms: D000328:Adult; D000368:Aged; D007758:Ear, Inner / Q000601:surgery; D020220:Facial Nerve Injuries / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D006261:Headache / Q000209:etiology; D046088:Hearing Loss, Unilateral / Q000209:etiology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009464:Neuroma, Acoustic / Q000150:complications / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D012189:Retrospective Studies; D016896:Treatment Outcome; D014717:Vertigo / Q000209:etiology