MANAGEMENT OF 1000 VESTIBULAR SCHWANNOMAS (ACOUSTIC NEUROMAS) - SURGICAL-MANAGEMENT AND RESULTS WITH AN EMPHASIS ON COMPLICATIONS AND HOW TO AVOID THEM

OBJECTIVE: To identify the actual benefits and persisting problems in treating vestibular schwannomas by the suboccipital approach, the resu lts and complications in a consecutive series of 1000 tumors surgicall y treated by the senior author were analyzed and compared with experie nces involving other treatment modalities. METHODS: Pre- and postopera tive clinical statuses were determined and radiological and surgical f indings were collected and evaluated in a large database for 962 patie nts undergoing 1000 vestibular schwannoma operations at Nordstadt's ne urosurgical department from 1978 to 1993. RESULTS: By the suboccipital transmeatal approach, 979 tumors were completely removed; in 21 cases , deliberate partial removal was performed either in severely ill pati ents for decompression of the brain stem or in an attempt to preserve hearing in the last hearing ear. Anatomic preservation of the facial n erve was achieved in 93% of the patients and of the cochlear nerve in 68%. Major neurological complications included 1 case of tetraparesis, 10 cases of hemiparesis, and caudal cranial nerve palsies in 5.5% of the cases. Surgical complications included hematomas in 2.2% of the ca ses, cerebrospinal fluid fistulas in 9.2%, hydrocephalus in 2.3%, bact erial meningitis in 1.2%, and wound revisions in 1.1%. There were 11 d eaths occurring at 2 to 69 days postoperatively (1.1%). The techniques that were developed for avoidance of complications are reported. The analysis identifies preexisting severe general and/or neurological mor bidity, cystic tumor formation, and major caudal cranial nerve deficit s as relevant risk factors. CONCLUSION: The current treatment options of complete tumor resection with ongoing reduction of morbidity are we ll fulfilled by the suboccipital approach. By careful patient selectio n, the mortality rate should be further reduced to below 1%.