title: Gamma Knife radiosurgery in the treatment of abducens nerve schwannomas: a retrospective study.
abstract: OBJECTIVE Of the intracranial schwannomas, those arising from the vestibular nerves are the most common. Abducens nerve (AN) schwannomas are very rare, and there is limited literature on their optimal management. Therapeutic options include surgery and/or stereotactic radiosurgery. The aim of this study was to evaluate the role of Gamma Knife radiosurgery (GKRS) in these sixth cranial nerve (CN) schwannomas. METHODS The authors performed a retrospective analysis of patients who had undergone GKRS for intracranial tumors at their institute in the period from 2003 to 2010. Inclusion criteria were as follows: isolated AN paresis on presentation, a lesion along the course of the sixth CN, and imaging features characteristic of a schwannoma. Patients with other CN deficits and neurofibromatosis Type 2 were excluded. Symptomatic improvement was defined as the resolution of or an improvement in diplopia noted on a subjective basis or as an improvement in lateral eyeball excursion noted objectively on follow-up. A reduction in tumor volume by at least 20%, as noted by comparing the pre- and post-GKRS images, was deemed significant. RESULTS Six patients with a mean age of 37.1 years (range 17-55 years) underwent primary GKRS. There were 2 prepontine cistern, 3 cavernous sinus, and 1 cisterno-cavernous tumor. The mean duration of symptoms was 6.1 months (range 3-12 months). The mean tumor volume was 3.3 cm3(range 1.5-4.8 cm3). The mean tumor margin radiation dose was 12.5 Gy (range 12-14 Gy), while the median margin dose was 12 Gy (50% isodose line). The median number of isocenters used was 5 (range 4-8). The brainstem received an average 8.35-Gy radiation dosage (range 5.5-11 Gy). The mean follow-up duration was 44.3 months (range 24-78 months). Symptoms remained stable in 1 patient, improved in 3, and resolved in 2 (total improvement 83%). Magnetic resonance imaging at the last follow-up showed a stable tumor size in 3 patients (50%) and a reduction in the other 3. Thus, the tumor control rate achieved was 100%. No new CN deficits were noted. CONCLUSIONS Abducens nerve schwannomas are rare intracranial tumors. They can be cavernous, cisternal, or cisterno-cavernous in location. Excellent tumor control rates and symptomatic improvement can be achieved with GKRS, which appears to be a safe and effective, minimally invasive modality for the treatment of such lesions. Therefore, it is reasonable to consider GKRS as the initial treatment of choice for this rare pathology. Long-term follow-up will be essential for further recommendations.
authors.affiliation: Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Govindaraju Lakshmi
authors.initials: GL
authors.lastname: Prasad
authors.affiliation: Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Manish Singh
authors.initials: MS
authors.lastname: Sharma
authors.affiliation: Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Shashank S
authors.initials: SS
authors.lastname: Kale
authors.affiliation: Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Deepak
authors.initials: D
authors.lastname: Agrawal
authors.affiliation: Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Manmohan
authors.initials: M
authors.lastname: Singh
authors.affiliation: Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Bhawani Shankar
authors.initials: BS
authors.lastname: Sharma
mesh_terms: D020434:Abducens Nerve Diseases / Q000532:radiotherapy*; D000293:Adolescent; D000328:Adult; D003390:Cranial Nerve Neoplasms / Q000532:radiotherapy*; D005260:Female; D005720:Gamma Rays; D006801:Humans; D008297:Male; D008875:Middle Aged; D009442:Neurilemmoma / Q000532:radiotherapy*; D016634:Radiosurgery / Q000009:adverse effects; D012189:Retrospective Studies; D055815:Young Adult
keywords: AN = abducens nerve; CN = cranial nerve; GKRS = Gamma Knife radiosurgery; Gamma Knife; abducens nerve; schwannomas; sixth nerve; stereotactic radiosurgery