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Vestibular schwannoma

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of vestibular schwannoma are prepared by our editorial team based on guidelines from the American Cochlear Implant Alliance (ACI Alliance 2022), the American Physical Therapy Association (APTA 2022), and the Congress of Neurological Surgeons (CNS 2018)....
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Diagnostic investigations

MRI: as per CNS 2018 guidelines, Obtain high-resolution T2-weighted and contrast-enhanced T1-weighted MRI to detect vestibular schwannomas.
A
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Medical management

Expectant management: as per CNS 2018 guidelines, Consider offering expectant management with observation in patients with intracanalicular vestibular schwannomas and small tumors (< 2 cm) if tinnitus is not observed at presentation.
B

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Nonpharmacologic interventions

Vestibular rehabilitation: as per APTA 2022 guidelines, Offer vestibular physical therapy in patients with acute, subacute, or chronic unilateral vestibular hypofunction.
A
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Therapeutic procedures

Stereotactic radiosurgery: as per CNS 2018 guidelines, Perform radiosurgery as a treatment option in patients with neurofibromatosis type 2 with enlarging tumor and/or causing hearing loss.
A
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Perioperative care

Preoperative vestibular rehabilitation: as per CNS 2018 guidelines, Offer preoperative vestibular rehabilitation to aid in postoperative mobility after vestibular schwannoma surgery.
A

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  • Perioperative nimodipine

  • Preoperative gentamicin ablation

Surgical interventions

Microsurgical resection
As per CNS 2018 guidelines:
Consider performing hearing preservation surgery via the middle fossa or the retrosigmoid approach in patients with small tumor size (< 1.5 cm) and good preoperative hearing.
B
Consider performing surgical resection rather than stereotactic radiosurgery for better control of trigeminal neuralgia symptoms.
B

Patient education

General counseling: as per CNS 2018 guidelines, Counsel adult patients with cystic vestibular schwannomas that this type of tumor may be associated with rapid growth, lower rates of complete resection, and facial nerve outcomes that may be inferior in the immediate postoperative period, but similar to noncystic schwannomas over time.
A

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  • Counseling before expectant management

  • Counseling before stereotactic radiosurgery

  • Counseling before microsurgery

Follow-up and surveillance

Surveillance imaging, post-operative: as per CNS 2018 guidelines, Obtain a postoperative postcontrast 3D T1 magnetization prepared rapid acquisition gradient echo, with nodular enhancement considered suspicious for recurrence.
B
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