Surgical Outcome of Cerebellopontine Angle Tumours by Retrosigmoid Approach

  • Ijaz Hussain Wadd Departments of Neurosurgery, Lahore General Hospital and Mayo Hospital
  • KHAWAR ANWAR Departments of Neurosurgery
  • HABIBULLAH FATIH Departments of Neurosurgery
  • Mehmood . Departments of Neurosurgery
  • Safroz Ansari Departments of Neurosurgery
Keywords: Retrosigmoid approach, cerebellopontine angle, House – Brackmann grading

Abstract

Objective: To determine the microsurgical outcome of cerebellopontine angle tumours by the retrosigmoid approach. Study Design: Quasi experimental study. Place and Duration of Study: Departments of Neurosurgery Lahore General Hospital and mayo hospital, Lahore from January 1998 to June 2015. Materials and Methods: Four hundred and fifty six patients of cerebellopontine angle tumours of various histologies were operated at the Departments of Neurosurgery, Lahore General Hospital and mayo hospital, Lahore, from Jan 1998 to June 2015. All patients with unilateral or bilateral lesions from 15 to 65 yrs of age and with all different pathologies in cerebellopontine angle were included in the study. Complete blood count, X-Ray Chest and MRI Brain plain and with I.V contrast were done. Patients with pre-operative radiosurgery, multiple surgeries and those unfit for surgery were excluded from the study. All patients were operated under general anaesthesia by retrosigmoid approach in park bench position. Preservation of the facial nerve was attempted in all cases. Post op facial nerve status was compared with pre-op grade by House – Brackman grading. Post op development of hydrocephalus and other cranial nerve complications were also noted and overall morbidity and mortality was studied.
Results: Four hundred and fifty six patients, 274 men (60.1%) and 182 women (39.9%), underwent micro-surgical excision of cerebellopontine angle tumours. 410 (89.9%) patients were vestibular schwannomas,22 (4.8%) were meningioma, 9 (1.9%) were epidermoid and 13 (2.8%) were all other pathologies in cerebello-pontine angle tumours. Patient ages ranged from 15 to 65 years (mean 44.11±8.41 years). All patients were operated by the Retrosigmoid approach. Complete resection was achieved in 237 patients (51.9%), subtotal resection (STR) in 209 patients (45.8%), and near-total resection (NTR) in 10 patients (2.1%). Good facial nerve outcomes (House-Brackmann [HB] Grades I-III) were achieved in 82% of the patients who had undergone either NTR or STR, as compared with 73% of patients who had undergone gross-total resection (GTR). Complications included wound infection (2 patients), delayed CSF leakage 10 (2.1% of patients), hydrocephalus requiring VP shunt in 15 (3.2%), basal cranial nerve palsy in 45 patients (9.8%) and mortality in 10 (2.1%). Conclusion: Retrosigmoid approach is relatively easy and safe approach for cerebellopontine angle tumour. Tumours of all sizes can be operated completely and facial nerve can be identified and saved with this approach with less operative time and less chances of CSF leak.

References

1. Moffat D A, Ballagh R H. Rare tumours of the cerebel-lopontine angle. Clin Oncol (R Coll Radiol), 1995; 7: 28–41. 2. Bonneville F, Sarrazin J L, Marsot – Dupuch K, et al. Unusual lesions of the cerebellopontine angle: a seg-mental approach. Radiographics, 2001; 21: 419–438. 3. Thomsen J, Terkildsen K, Tos M. Acoustic neuromas: progression of hearing impairment and function of the eighth cranial nerve. Am J Otol. 1983; 5: 20–33. 4. Mallucci C L, Ward V, Carney A S, O'Donoghue G M, Robertson I. Clinical features and outcomes in patients with non-acoustic cerebellopontine angle tumours. J Neurol Neurosurg Psychiatry, 1999; 66: 768–771. 5. Morantz RA, Walsh JW. Brain tumours, a comprehen-sive text. Informa Health Care, 1994. ISBN:0824788265. 6. Sampath P, Brem H, Hollidaym, Niparko J, Long DM. Facial nerve injury in acoustic neuroma (vestibular sch-wannoma) surgery: etiology and prevention. J Neuro-surg. 1997; 87: 60-66. 7. Gormley et al. (Gormley WB, Sekhar LN, Wright DC, Kamere D, Schessel D. Acoustic neuromas: results of current surgical management of acoustic neuroma. Neu-rosurgery, 1997; 41: 50-58; Discussion 58-60.
8. Lalwani AK, Butt FY, Jackler RK, Pitts LH, Yingling CD. Facial nerve outcome after acoustic neuroma sur-gery: a study from the era of cranial nerve monitoring. Otolaryngol Head Neck Surg. 1994; 111: 561-570. 9. Niparko and Kileny: Neurophysiologic Intraoperative Monitoring: II. Facial Nerve Function. American J of Otology, 1989; 10: 55-71. 10. Kondziolka D, Lunsford LD, McLaughlin MR, Flic-kinger JC. Long-term outcomes after radiosurgery for acoustic neuromas. N Engl J Med. 1998; 339: 1426–1433. doi:10.1056/NEJM1998 11123392003 11. House WF. Acoustic neuroma. Case summaries. Arch Otolaryngol. 1968; 88: 586–591. 12. Gurgel RK, Dogru S, Amdur RL, Monfared A. Facial nerve outcomes after surgery for large vestibular sch-wannomas: do surgical approach and extent of resection matter? Neurosurg Focus, 2012; 33 (3): E16. 13. Kemink JL, Langman AW, Niparko JK, Graham MD. Operative management of acoustic neuromas: the pri-ority of neurologic function over complete resection. Otolaryngol Head Neck Surg. 1991; 104: 96–99. 14. Van Gompel JJ, Patel J, Danner C, et al; Acoustic neu-roma observation associated with an increase in sym-ptomatic tinnitus: results of the 2007 – 2008 Acoustic Neuroma Association survey. J Neurosurg. 2013 Oct; 119 (4): 864-8. doi: 10.3171/2013.5.JNS122301. Epub 2013 Jun 21. 15. Fortnum H, O'Neill C, Taylor R, et al; The role of mag-netic resonance imaging in the identification of suspec-ted acoustic neuroma: a systematic review of clinical and cost effectiveness and natural history. Health Tech-nol Assess, 2009 Mar; 13 (18): iii-iv, ix-xi, 1-154. Doi: 10.3310/hta13180. 16. Nikolopoulos TP, Fortnum H, O'Donoghue G, et al; Acoustic neuroma growth: a systematic review of the evidence. Otol Neurotol. 2010 Apr; 31 (3): 478-85. Doi: 10.1097/MAO.0b013e3181d279a3. 17. Llopez Carratala I, Escorihuela Garcia V, Orts Alborch M, et al; Radiosurgery, a treatment for acoustic neu-roma. Ten years' experience. Acta Otorrinolaringol Esp. 2014 May 17. pii: S0001-6519(14)00087-9. Doi: 10.1016/j.otorri.2014.03.003. 18. Schick B, Dlugaiczyk J; Surgery of the ear and the lateral skull base: pitfalls and complications. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013 Dec 13;12: Doc 05. eCollection 2013. 19. Buchman, Chen, Flannagan, Wilberger, Maroon. The learning curve for acoustic tumour surgery. Laryngo-scope, 1996; 106: 1406-1411. 20. Sampath P, Holliday MJ, Brem H, Niparko JK, Long DM. Facial nerve injury in acoustic neuroma (vestibular schwannoma) surgery: etiology and prevention. J Neu-rosurg. 1997; 87: 60-66.
Published
2018-10-09
Section
Original Articles