Guidelines for Vestibular Schwannoma Management


Managing vestibular schwannoma patients requires a multidisciplinary team approach that incorporates neurosurgery, otolaryngology, and radiation oncology. Neuro-radiology, pathology, intra-operative monitoring, and neuro-oncology are also important components. The Guidelines for the Treatment of Adults with Vestibular Schwannoma were recently introduced, providing 45 recommendations from 8 topics. These topics include audiology and radiologic monitoring, surgical resection with intraoperative monitoring, radiation therapy, and emerging chemotherapy treatments. Only 1 recommendation is based on level 2 evidence while the remainder are based on level 3 evidence. The guidelines do not include recommendations in many key areas due to lack of evidence, despite well-designed questions and appropriate literature searches. For instance, no recommendations are provided on how pathological features such as various light microscopic characteristics and Ki67 labeling index predict clinical behaviors. In addition, the recommendations have limited clinical value. For instance, audiology screening is recommended for patients who meet certain clinical criteria, but there is low yield in diagnosing vestibular schwannoma with such screening.  Despite these limitations, clinically relevant recommendations regarding MR imaging, surgical resection and radiation, and potential benefits of some chemotherapy agents are presented. Clinicians still need to use practical experience in specific clinical settings to derive treatment algorithms. The full set of guidelines are available at

Jonathan Sherman, MD
Washington, D.C.
J. Bradley Elder, MD
Columbus, OH