Removal of grade IV vestibular schwannomas by retrosigmoid approach: results of a cumulative series of two European centers.

Introduction: The aim of our study was to study the association between end-of-surgery facial nerve stimulation threshold and extent of tumor resection in case of grade IV vestibular schwannomas.

Materials And Methods: Grade IV VSs represent a surgical challenge as a risk/benefit ratio must be considered in balancing a satisfactory extent of resection against a good postoperative functional outcome. We reviewed a cumulative series of 57 patients with large/giant VSs who were operated on by retrosigmoid approach in the period from 2008 to 2018 in two European centers, namely San Filippo Neri Hospital, Rome, Italy and Masaryk Hospital, Usti nad Labem, Czech Republic. Extent of resection, intraoperative direct electrical stimulation threshold of facial nerve and postoperative facial outcome were examined.

Results: Total or near-total resection was accomplished in 40 (75.5%) cases. Two groups were compared: total or near-total resection (T + NT) and subtotal resection (ST); the end-of-surgery facial nerve stimulation threshold significantly differed (T + NT: 0.24 mA, ST: 0.44 mA, A critical cutoff was found at 0.2mA; values similar or inferior to this correctly predicted total or near-total resection in 86.7% of cases. Thirty (56.6%) patients had a normal postoperative facial outcome (HB1). Among the 40 patients in T + NT group, 32 (80%) retained an acceptable facial function (HB1-2).

Conclusions: Lower facial nerve stimulation thresholds positively predict a broader extent of resection and total or -near total resection should be accomplished in such cases. Judicious (subtotal) resection is preferred if threshold values increase while dissecting firmly adherent tumors.