Surgical Outcomes following Vestibular Schwannoma Resection in Patients Older than 65 Years

Objective: Vestibular schwannomas (VSs) are benign skull base neoplasms. Due to their relatively slow rate of tumor growth, some institutions will opt for observation or radiosurgery in patients of advanced age as opposed to surgical resection. We aimed to analyze surgical outcomes following vestibular schwannoma resection in patients over the age of 65 that were either not candidates for or refused radiosurgery.

Methods: We queried our institutional database of VS patients undergoing microsurgical resection of VS between 1988 and 2020. Patient demographics, tumor characteristics, extent of resection, complications, facial nerve outcomes, tumor control rates, and adjuvant therapies were recorded. Patient preference for surgery as opposed to gamma knife radiosurgery (GKRS) was recorded in the event that patients were offered both. Facial nerve outcomes were quantified using House-Brackmann (HB) scores. Tumor growth was defined using the San Francisco criteria.

Results: A total of 64 patients met inclusion criteria, with an average age of 72.4 years [65–84 years]. Most presented with hearing loss (84.4%, n = 54) and/or gait instability (59.4%, n = 38). The average maximum tumor diameter was 29 mm [13–55 mm], and 28.1% (n = 18) of VS had a cystic component. Nearly half (n = 27, 42.2%) of patients were not optimal GKRS candidates due to tumor size >30 mm. Forty-five patients were offered surgery or GKRS, and elected surgical resection due to an aversion to radiation (48.4%) or wanting expedited relief of symptoms (9.4%). A translabrynthine approach was used in 73.4% (n = 47) of cases, with the remaining 26.6% (n = 17) performed via a retrosigmoid approach. Gross total resection (GTR) was achieved in 39.1% (n = 25), near total resection (NTR) in 32.8% (n = 21), and subtotal resection (STR) in 28.1% (n = 18). Average hospital length of stay was five days [2–17] with 75% (n = 48) of patients being discharged home. Complications included sinus injury (n = 2), cerebellar infarct (n = 2), wound infection (n = 3), cerebrospinal fluid leak (n = 1), respiratory distress (n = 2), and hemorrhage (n = 1). Postoperative HB scores were good (HB1-2) in 43.8%, moderate (HB3-4) in 32.8%, and poor (HB5-6) in 23.4%. At time of most recent follow-up, HB scores had improved to good in 51.6%, moderate in 31.3%, and poor in 17.1%, marking a rate of facial nerve improvement of 10.9%. Tumor control was achieved in 95.3% of cases at an average follow-up time of 37.8 months, with three STR cases exhibiting tumor growth at two years and undergoing GKRS.

Conclusion: Microsurgical resection of VS can be performed in patients over the age of 65 with good outcomes. Length of stay, disposition to home, and complications are at expected levels for an older patient population. Facial nerve palsy is less likely to recover in older patients. Advanced age should not preclude a symptomatic VS patient from being considered for surgical resection when GKRS may not be optimal or preferable.

Publication History

Article published online:
12 February 2021