Original research article
Surgery for sporadic vestibular schwannoma. Part II. Complications (not related to facial and auditory nerves)

https://doi.org/10.1016/j.pjnns.2016.01.002Get rights and content

Abstract

Introduction

The aim of this study was to analyze the frequency and consequences of postoperative complications (PC) after surgery for sporadic vestibular schwannoma and to find factors that increase the risk of PC occurrence.

Materials and methods

The study included 220 consecutive patients (134 women, 86 men; age ranged from 18 to 74) operated on with the retrosigmoid (217) or translabyrinthine (3) approach. Complicated postoperative period was defined as an occurrence of at least one of: cerebrospinal fluid (CSF) leakage, hematoma in the tumor bed, intracerebellar hematoma, cerebellar swelling, brainstem stroke, hydrocephalus (HCP), healing problems, meningitis and cranial nerves (excluding VII–VIII) palsies or cerebellar symptoms. Correlation studies and multivariate regression analysis were performed.

Results

PC occurred in 55 patients (25%). PC included lower cranial nerve (LCN) palsy (8.2%), cerebellar symptoms (7.3%), CSF leakage (5.9%), HCP (5%), CNVI palsy (3.1%), meningitis (1.8%), cerebellar swelling (1.4%), CNV dysfunction (0.9%), intracerebellar hematoma (0.5%) and lethal brainstem stroke (0.5%). In long term follow-up, LCN deficit was present in 2 patients (0.9%), cerebellar syndrome in 4(1.8%) and facial hypoesthesia in 2(0.9%). One patient (0.5%) developed bilateral blindness, secondary to preoperative optic nerve atrophy. As a result of PC, 10 patients (4.5%) required 11 additional surgical procedures. In statistical analysis, PC were independently related to preoperative cerebellar syndrome (p = 0.002) and tumor size (>30 mm vs.<30 mm, p < 0.05). The risk of PC diminished significantly with the increased number of performed procedures from 40% at the beginning to 16.4% in the last 55 cases.

Conclusions

Tumor size, cerebellar syndrome at presentation and experience of the team were the three most important risk factors for PC occurrence. Permanent deficit secondary to PC remained in only 4% of the patients.

Introduction

Patients with small vestibular schwannoma (VS) are less and less frequently operated on by neurosurgeons now. Increasingly often, they are treated by otolaryngology teams or with radiosurgery, or are observed and followed with serial MRI. Despite the improvement in the availability of diagnostic methods, neurosurgeons continue to operate large tumors. Probably in the future, this most challenging subgroup will continue to be referred for neurosurgical treatment. It can be assumed that if the global number of VS operated by neurosurgeons decreases then it will be harder to go further up the learning curve to a level that guarantees a further decrease in the risk of postoperative complications. In this context, a thorough analysis of postoperative complications takes on a new meaning. Currently, the literature rarely focuses on these issues and the main topic of interest is the preservation of auditory and facial nerves. Other neurological deficits, or life-threatening complications (frequent in the past but now extremely rare), indicate the level of difficulty of VS treating. Currently, it is not only a theoretical threat, because surgery for large and giant VS is always risky and gaining the experience in complex cranial base surgery becomes more difficult. In the United States, in recent years, the number of VS surgery has gradually decreased, while hospital stay and the rate of postoperative complications has increased [1]. The aim of this study is to analyze the frequency and consequences of various types of postoperative complications, as well as attempt to find factors that increase the risk of their occurrence.

Section snippets

Materials and methods

This retrospective analysis included 220 consecutive patients operated on for sporadic VS between 1990 and 2011. This group included 7 patients previously treated ineffectively, surgically or radiosurgically, in other centers. The group of patients is analyzed in detail in the paper: “Surgery for sporadic vestibular schwannoma. Part I: General outcome and risk of tumor recurrence”. Complicated postoperative period was defined as an occurrence of at least one of the following events:

Results

Postoperative complications occurred in 55 patients (25%). The most common types of postoperative complications included LCN palsy – 18 (8.2%), cerebellar symptoms – 16 (7.3%), CSF leakage – 13 (5.9%) and hydrocephalus – 11 (5%) (Table 1). Different types of complications often occurred in the same patients. For example, hematoma in the tumor bed was the cause of hydrocephalus and cerebellar syndrome in 6 patients.

Discussion

Postoperative complications occurred in every fourth patient, but persistent neurological consequences remained in only 4% of them. The most common complications were: LCN palsy, cerebellar ataxia, CSF leakage and HCP. Additional surgical procedures due to complications were required by 4.5% of patients. Postoperative complications occurred significantly more often in patients presented with headache (p = 0.04) or cerebellar syndrome (p = 0.01). It can be assumed that headache is a collinear factor

Conclusions

The overall risk of postoperative complications was 25%, however the risk declined from 40% to 16% with increasing experience of the neurosurgical team. The most common complication types were lower cranial nerve palsy (8.2%), cerebellar symptoms (7.3%), CSF leak (5.9%) and hydrocephalus (5%). A few patients required additional surgical procedures (4.5%) and experienced permanent neurological sequelae (4%) as their consequence. The most important risk factors for complications occurrence were

Conflict of interest

None declared.

Acknowledgement and financial support

All authors report no any actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within 3 years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

Ethics

The work described in this article has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; Uniform Requirements for manuscripts submitted to Biomedical journals.

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