title: The outermost "dura-like membrane" of vestibular schwannoma.
abstract: BACKGROUND
  The membranous structure of vestibular schwannoma is an important factor in its surgical treatment. Herein, we report intraoperative and microscopic findings relating to an outermost dura-like membrane in cases of vestibular schwannoma and the importance of these findings.
  
  
  METHODS
  Intraoperative findings of 16 cases of vestibular schwannoma treated with an initial surgery were studied with an aim to determine if the cases had a dura-like membrane. Then we studied microscopic findings of the dura-like membrane using hematoxylin and eosin, Masson trichrome, and immunohistochemical staining in 2 cases.
  
  
  RESULTS
  The dura-like membrane was observed in 8 out of 16 cases. The average tumor size of the cases that had a dura-like membrane was 30 ± 8.1 mm, and Koos grading 4 was in 7 out of 8 cases, and one was grade 3. In cases without a dura-like membrane, these values were significantly smaller, with an average tumor size of 12.8 ± 5.2 mm, and Koos grading 4 was only in 1 of 8 cases, grade 3 was in 2 cases, and other 5 cases were grade 2. The outermost dura-like membrane enveloped the vestibular schwannoma around the internal acoustic meatus and was continuous with the dura mater. Reactive angiogenesis was observed in the dura mater. Microscopic findings proved its continuity with the dura mater. In one case, the facial nerve was damaged before it was identified during subcapsular dissection. In that case, the dura-like membrane negatively affected our ability to identify the facial nerve.
  
  
  CONCLUSIONS
  A dura-like membrane sometimes envelops vestibular schwannoma around the internal acoustic meatus. Recognition of this membranous structure is important for the surgical preservation of facial and acoustic nerves.
authors.affiliation: Department of Neurosurgery, School of Medicine, Keio University, Tokyo, Japan.
authors.forename: Ryosuke
authors.initials: R
authors.lastname: Tomio
authors.affiliation: Department of Neurosurgery, School of Medicine, Keio University, Tokyo, Japan.
authors.forename: Kazunari
authors.initials: K
authors.lastname: Yoshida
authors.affiliation: Department of Neurosurgery, School of Medicine, Keio University, Tokyo, Japan.
authors.forename: Maya
authors.initials: M
authors.lastname: Kohno
authors.affiliation: Department of Neurosurgery, School of Medicine, Keio University, Tokyo, Japan.
authors.forename: Dai
authors.initials: D
authors.lastname: Kamamoto
authors.affiliation: Division of Diagnostic Pathology, Keio University Hospital, Tokyo, Japan.
authors.forename: Shuji
authors.initials: S
authors.lastname: Mikami
keywords: Acoustic neurinoma; acoustic neuroma; dura mater; operation; surgery; vestibular schwannoma