Cranial Nerve Preservation in Surgery for Large Acoustic Neuromas

 

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The authors review their experience with surgical resection of acoustic neuromas over a 9-year period at the New York University Medical Center. All tumors were larger than 3 cm. Their results are consistent with what would be expected from a contemporary neurosurgical series at most experienced centers. Total tumor resection was achieved in 73%, and best subtotal removal was achieved in 18%. In 9% an intraoperative decision was made to perform a near-total tumor resection to minimize risk to the cranial nerves, especially the facial nerve. The facial nerve was cut in three cases.

Final facial nerve outcome of grade III or better was achieved in 90% of the patients and grade II or better was achieved in 84%. It appears that patients who underwent unplanned near-total removal had the worst facial nerve outcomes, most likely because control of the facial nerve was lost intraoperatively. Clearly, patients who underwent planned subtotal resection had better facial nerve outcomes. Therein lies the thrill of this study. Surgeons should consider more frequent planned subtotal removal with adjunct postoperative radiotherapy, especially in patients over the age of 65 years. As a result, facial and other cranial nerve outcomes would likely be much improved and major complications (e.g., intracranial or hemorrhage) would occur less frequently.