Atormac
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 8862  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
   Next article
   Previous article 
   Table of Contents
  
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (36 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article

 Article Access Statistics
    Viewed3490    
    Printed103    
    Emailed1    
    PDF Downloaded60    
    Comments [Add]    

Recommend this journal

 


 
INVITED COMMENTS
Year : 2005  |  Volume : 53  |  Issue : 1  |  Page : 45

Invited Comments


Department of Neurosurgery, Chief, Division of Neurooncology and Cranial Base Surgery, Penn State College of Medicine, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, India

Correspondence Address:
Jonas M Sheehan
Department of Neurosurgery, Chief, Division of Neurooncology and Cranial Base Surgery, Penn State College of Medicine, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions



How to cite this article:
Sheehan JM. Invited Comments. Neurol India 2005;53:45

How to cite this URL:
Sheehan JM. Invited Comments. Neurol India [serial online] 2005 [cited 2020 Jan 25];53:45. Available from: http://www.neurologyindia.com/text.asp?2005/53/1/45/15053


The landscape of surgery for vestibular schwannomas is changing. Durable, consistently good outcomes have been achieved in patients with small-to-medium sized tumors treated with stereotactic radiosurgery. In addition, the "learning curve" effect on surgical outcomes has been documented to involve a greater number of cases than many previously thought, even in the hands of meticulous, dedicated surgeons. For this reason, many (if not most) patients with radiosurgically appropriate tumor volumes are being managed without surgery. At Penn State University, as in many other centers, vestibular schwannoma surgery is performed almost exclusively on patients with large tumor volumes who are not radiosurgical candidates.

It has long been recognized that tumor size is directly related to the risk of complications in VS surgery. Larger tumors are more likely to cause significant brainstem compression and the potential for decompression and dissection related brainstem injust if greater than with small tumors. Hearing and facial nerve function preservation are both inversely related to tumor size. In addition, blood loss and operation duration increase with larger tumors, both importing additional risk.

This article reports on the remarkable surgical results of a group of surgeons in India caring for patients with large vestibular schwannomas. The selection mechanisms for large tumors in this series are presumably more related to difficulty gaining access to medical care rather than radiosurgical bias. The authors clearly outline the patient population and discuss the causes for such large tumors and delayed medical attention. Aside from delayed diagnosis and healthcare access, these patients were treated in a fashion different from many centers elsewhere. The CUSA, routinely used in many centers for VS surgery, was rarely used. Facial nerve monitoring was not employed, and one assumes that more extensive monitoring was not used. In my practice, I have found neurophysiological monitoring to be of greater importance in resection of large tumors with significant brainstem compression. We routinely employ ABR, SSEP, and facial nerve monitoring on all VS cases. I have found these to be helpful when extensive brainstem compression exists pre-operatively, although certainly there is debate about the utility of such monitoring.

The authors are to be commended on their excellent surgical results overall and in particular in facial nerve preservation without monitoring. Many patients in this series had significant pre-operative deficits likely affecting overall health and perhaps contributing to the 6% mortality rate.

As patients with small/medium tumors are treated more frequently with non-operative techniques, vestibular schwannoma surgeons will find themselves facing larger tumors. The results of this study, along with other series of large tumors, confirm that although the risks are greater than for small tumors, large VS can be operated upon through the conventional suboccipital or translabyrinthine routes with acceptable results.




 

Top
Print this article  Email this article
Previous article Next article
Online since 20th March '04
Published by Wolters Kluwer - Medknow