Complex Vestibular Schwannomas: Case Illustrations of Surgical Technique

Surgical approaches for the treatment of complex vestibular schwannoma (VS) cases are discussed with a case-based discussion. Subtotal resection or staged resection should be considered to minimize the risk of cranial nerve and/or other neural injury in complex cases. Complicating factors include anatomical variations such as a high-riding jugular bulb, a forward-riding sigmoid sinus which narrows the presigmoid exposure, small and/or contracted mastoid bone, a previously thrombosed or absent sigmoid sinus on the contralateral side. Additional factors may include cystic schwannomas, tumors with brainstem compression and associated hydrocephalus, comorbid diseases that complicate anesthesia, prior history of VS surgery or radiation therapy, and rapid tumor progression associated with intratumoral hemorrhage. We have discussed and provided examples of the surgical approaches and considerations for the treatment of complex vestibular schwannomas through five case illustrations. The surgical team should consider, especially when difficulties arise, if the surgery should be staged to improve surgical exposure, and/or if the surgery should be terminated without achieving total resection to reduce the potential of damage to the critical structures.