Surgery combined with radiosurgery of large acoustic neuromas

The treatment of acoustic neuromas has been improved by advancements in microsurgical techniques and in radiosurgery. To further elucidate the degree of clinical improvement, we evaluated the treatment results of a combination of surgery and radiosurgery for large acoustic neuromas. METHODS: From January 1994 through December 2000, we treated 14 patients with large acoustic neuromas using a combination of surgery and radiosurgery. Of these, 8 were male and 6 were female patients, with an average age of 47 years (range, 18-64). The average maximum diameter of the tumor was 42 mm (range, 30-58 mm). All patients underwent operations using the retrosigmoid approach, and one patient was retreated using the transpetrosal transtentorial approach. The tumors were removed subtotally in thirteen patients and partially in one who had a very large hypervascular acoustic neuroma. There were no mortality and no surgical complications, such as hemorrhage or CSF leakage. Postoperative facial palsy was avoided in 10 patients (71%). Radiosurgery was performed 1 to 6 months (mean, 2.9 months) after surgery. At the time of radiosurgery, the treatment size (mean diameter) became 19.2 mm (range, 9.8-36.1 mm). The average tumor marginal dose was 12.1Gy (range, from 10-14 Gy). The mean follow-up period was 32 months after radiosurgery. RESULTS: The tumor size decreased in 6 patients, unchanged in 5 patients, and increased in 3 patients. Only 1 patient (7%) with extra large tumor needed surgical resection 1 year after radiosurgery. Excellent facial nerve function (House & Brackmann Grade I or II) was preserved in 12 patients (85.7%) in the final follow-up. CONCLUSIONS: In the case of large acoustic neuromas, subtotal removal and subsequent radiosurgery is one option for maintaining cranial nerve function and long-term tumor growth control.