Acoustic Neuroma Treatment: Surgery vs. Gamma Knife Radiosurgery

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• Treatment Decision Factors
• Small Tumor Observation
• Large Tumor Surgery
• Medium Tumor Debate
• Surgical Team Approach
• Preserving Nerve Function
• Importance of Surgical Skill

Treatment Decision Factors

Choosing between acoustic neuroma surgery and gamma knife radiosurgery depends primarily on the size and location of the tumor. Dr. Peng Chen, MD, explains that this is a nuanced decision, as these benign but complex tumors often grow in difficult areas near critical nerves. The treatment goal is always to eliminate the tumor while minimizing damage to the patient's brain and preserving vital functions like hearing and facial movement.

Small Tumor Observation

Not all acoustic neuromas require immediate active treatment. Dr. Peng Chen, MD, notes that some very small tumors grow so slowly over many years that a strategy of careful observation and follow-up is reasonable. This approach is often suitable for patients with minimal or no symptoms, such as hearing loss. Regular MRI scans monitor tumor growth, and intervention is only pursued if the acoustic neuroma shows significant enlargement.

Large Tumor Surgery

For very large acoustic neuromas, typically those over 2.5 to 3 centimeters in diameter, open brain neurosurgery is clearly the best treatment method. Dr. Peng Chen, MD, states that these large tumors cause significant brain stem compression, which can lead to facial nerve paralysis, swallowing difficulties, and problems with walking. Surgery can involve a gross total resection to remove the tumor completely or a subtotal resection followed by adjunctive radiosurgery to treat any remaining tissue.

Medium Tumor Debate

The most complex decisions involve medium-sized acoustic neuromas, which are approximately 2 to 2.5 centimeters and often cause some brain stem compression. Dr. Peng Chen, MD, reveals a bias toward surgical treatment for healthy patients, as it offers a high probability of complete removal and a lower long-term risk of recurrence. While gamma knife radiosurgery is very effective for these tumors, it carries a small risk of recurrence several years later, which may then require more complex salvage surgery.

Surgical Team Approach

Successful acoustic neuroma surgery relies on a multidisciplinary team. Dr. Peng Chen, MD, emphasizes that in the United States, skull base neurosurgeons work closely with otolaryngology surgeons who specialize in these tumors, known as neurotologists. This collaboration is essential for navigating the complex anatomy of the skull base. The combined expertise of the team is a critical factor in achieving the best possible outcome for the patient.

Preserving Nerve Function

A paramount goal during any acoustic neuroma treatment is the preservation of neurological function. Dr. Peng Chen, MD, highlights the absolute crucial need to protect the facial nerve and hearing ability. This is achieved through sophisticated intraoperative neuromonitoring, which guides the surgeons during the procedure. The delicate balance is to remove as much tumor as possible while eliminating the risk of permanent facial weakness or complete hearing loss.

Importance of Surgical Skill

The technical skill and experience of the neurosurgeon are among the most important factors in acoustic neuroma treatment success. Dr. Chen, who performs a high volume of procedures, stresses that a detailed pre-operative assessment of the tumor and the patient's functional status is vital. This evaluation directly informs the chosen method of treatment, aiming for maximal tumor removal and prevention of recurrence with the least risk to the patient's quality of life.

Full Transcript

Dr. Anton Titov, MD: Acoustic neuroma surgery or gamma knife radiotherapy is an important decision. How to weigh treatment options for acoustic neuroma?

Acoustic neuroma surgery or gamma knife treatment depends on the size and location of the tumor. Radiosurgery for acoustic neuroma can be very effective in smaller tumors.

Gamma knife treatment for acoustic neuroma carries a small risk of tumor recurrence. This may require repeating radiosurgery for acoustic neuroma, or it may require open brain surgery.

There are side effects associated with open brain surgery. Trigeminal neuralgia could be a symptom of acoustic neuroma.

Treatment of acoustic neuromas is a significant part of your surgical practice. Acoustic neuromas can be very complicated tumors to treat. Even though acoustic neuromas are slowly growing, they are often located in difficult areas of the brain.

It is important to reduce damage to the patient's brain when treating acoustic neuromas. Please tell us about the modern approach in treating acoustic neuromas?

Dr. Peng Chen, MD: Best methods to treat acoustic neuromas are being debated over the last 20 years. Acoustic neuromas are often located in difficult-to-reach and functionally important areas of the brain.

Acoustic neuromas frequently grow close to the facial nerve, but they grow slowly and are benign. There are two main methods to treat acoustic neuromas.

Open brain neurosurgery has been used for many decades. Recent acoustic neuroma treatment is radiosurgery. Gamma knife is one example of radiosurgery technology to treat acoustic neuromas.

The debate has been going on for many years whether neurosurgery or radiosurgery is the best method to treat acoustic neuromas. It is similar to recent developments in cerebrovascular surgery.

We can now combine two methods to treat acoustic neuromas together. We can determine the best treatment method.

Some acoustic neuromas are best treated by neurosurgery. Other patients are best treated by radiosurgery. We can also include the wishes of the patient in the decision of acoustic neuroma treatment method.

First, we have to determine if we have to actively treat a small acoustic neuroma. Some acoustic neuromas grow very slowly over many years, so we can monitor and observe the patients closely.

Some patients will have hearing loss from acoustic neuromas. Other patients do not have any hearing loss.

It is reasonable to offer some patients careful observation and follow-up. Their acoustic neuromas are small and grow very slowly.

Some patients have very large tumors when they first visit the doctor. The size of the tumor could be more than 2.5 or 3 centimeters in diameter.

Such patients may have significant brain stem compression. They may have facial nerve paralysis.

Some patients with large acoustic neuromas have problems swallowing. Some patients may have problems walking.

In those patients with large acoustic neuromas, the best method of treatment is clearly open neurosurgery. Open brain surgery can remove the tumor completely, or the surgeon can do a subtotal partial resection of the tumor.

Then we can use an additional method of radiosurgery to treat the large acoustic neuroma. So very small acoustic neuromas and very large acoustic neuromas are located at different ends of the treatment spectrum.

We know what to do in these situations. We know how to treat very small or very large acoustic neuromas.

However, medium-size acoustic neuromas are in the middle of the spectrum—2 to 2.5 centimeters in diameter. They usually cause some compression of the brain stem.

As neurosurgeons, we are biased towards surgical treatment of acoustic neuromas. This is especially true if the patient’s overall health is good.

In most cases, these tumors can be completely removed (gross total resection). Surgical treatment of acoustic neuroma can decrease the probability of tumor recurrence.

Radiosurgery treatment of medium-size acoustic neuromas is also very effective. However, there is a small risk of tumor recurrence several years after the radiation treatment.

Patients with acoustic neuroma recurrence will need neurosurgery to treat their tumor. There is still some debate among doctors about the best treatment of recurrent acoustic neuromas.

But I am in favor of neurosurgical treatment of acoustic neuromas if the brain tumor grew to a larger size. Sometimes the patient can tolerate the surgical operation.

I generally recommend treating acoustic neuromas surgically. It is very important for best results in surgical treatment of acoustic neuromas to have a team-based approach to treating the patient.

In the United States, neurosurgeons who specialize in skull base neurosurgery work as a team together with otolaryngology surgeons ("ENT surgeons"). These "ENT surgeons" who specialize in acoustic neuroma treatment are called "neurootologists".

It is also very important to have good neuromonitoring of the patient during the surgery. This preserves the function of the patient's facial nerve and hearing ability.

So it is absolutely crucial to preserve as much function of the patient as possible. Hearing and facial nerve function has to be preserved.

At the same time, we have to eliminate as much acoustic neuroma tumor as possible. So for patients with acoustic neuromas, it is most important to do a detailed assessment of the tumor.

We must understand the functional status of hearing and facial nerve function of the patient. It is crucial to determine the best method of treatment to remove as much of the tumor as possible and to prevent recurrence.

Surgical skill of the neurosurgeon is most important to treat acoustic neuroma successfully.

Dr. Anton Titov, MD: Yes, absolutely.

Dr. Chen, thank you very much for this very interesting discussion about cerebrovascular neurosurgery. Thank you for sharing the latest developments in the neurosurgical field.

You have a very extensive neurosurgical practice. You perform 700 neurosurgical operations in a year. This is a very large volume of surgical operations.

We and our viewers are very fortunate that you shared with us your vast expertise in the field of neurosurgery. Thank you very much!

Thank you very much for this interview. I will be delighted to help with healthcare of any patient from anywhere in the world. Thank you.

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