• Vestibular Schwannoma Resection With Facial Nerve Displaced Dorsally

    Case Presentation

    • 62-year-old woman
      • Right-sided nonpulsatile tinnitus x 1 year
      • Progressive hearing loss
      • Longstanding episodic positional vertigo
    • Exam
      • Awake, alert, and oriented on exam
      • Hearing loss worse on right side
      • Symmetric facial function

    Alternatives

    • Continued observation
    • Translabyrinthine approach
    • Radiosurgery

    Approach

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    Positioning

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    Anatomy

    • Transverse and sigmoid sinuses
    • Cranial nerves V, VII, IX, and X
    • Porus acousticus
    • Anterior inferior cerebellar artery

    Incision

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    Operation

    • Position in park-bench position
      • Affected side up (Secure the patient to allow for rotation, if needed.)
    • Incision
      • Linear incision
    • Craniotomy
      • Neuronavigation to find transverse-sigmoid junction
    • Dura opened in linear fashion with extension toward the sinus junction
    • Cisterna magna opened
    • CPA cistern dissection
    • Neuromonitoring to identify course of facial nerve
    • Tumor debulking
    • Dissection of tumor away from brainstem
    • Drilling of porus and removal of intracanalicular tumor
    • Final tumor removal
    • Closure

    Post Op

    • The patient had an uneventful recovery.
      • Overnight stay in ICU
      • Discharged home on post-op day 3 with HB-1
      • MRI with gross total resection
    • Pathology: schwannoma

    Outcome

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    Pearls and Pitfalls

    • Neuromonitoring with direct stimulation can identify an unexpected position of the facial nerve and maintain the nerve boundary during dissection.
    • Debulking followed by sharp dissection and gentle mobilization allows for preservation of facial nerve function.
    • Tumor dissection toward the porus acousticus is simplified after the medial boundary with the brainstem and the lateral boundary in the canal are identified.

    Discussion

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    References

    • Mastronardi L, Cacciotti G, Roperto R, Di Scipio E, Tonelli MP, Carpineta E: Position and Course of Facial Nerve and Postoperative Facial Nerve Results in Vestibular Schwannoma Microsurgery. World Neurosurgery 94:174180, 2016
    • Nejo T, Kohno M, Nagata O, Sora S, Sato H: Dorsal displacement of the facial nerve in acoustic neuroma surgery: clinical features and surgical outcomes of 21 consecutive dorsal pattern cases. Neurosurgical Review 39:277288, 2016

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