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XXII Congreso Nacional de la Sociedad Española de Neurocirugía
Toledo, 16-18 Mayo 2018
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V0459 - THE TRANS-CANALAR APPROACH: AN INNOVATIVE SURGICAL TECHNIQUE FOR THE REMOVAL OF IAC VESTIBULAR SCHWANNOMA

B. Masotto1, M. Giarletta1, D. Marchioni2 and G. Pinna1

1Neurosurgery Department; 2ENT Department, Verona University Hospital, Verona, Italy.

Objectives: Up to date, there are 3 surgical approaches to vestibular schwannomas: retro-sigmoid, trans-labyrinthine and middle fossa. Although there are specific indications for each, surgeon’s experience and personal preferences remains one of the determining factors in the choice. We, together with the ENT group of the Modena and Verona hospitals, propose a new surgical approach trough a trans-canalar access, which in selected patients may be a viable alternative therapeutic option. Trans-canalar approach allows a direct corridor from external to internal auditory meatus, with minimal invasiveness and maximal efficacy, for excision of small intra-meatal schwannomas.

Methods: From September 2014 to December we have treated 275 vestibular schwannomas, 61 of which trough the trans-canalar approach. The inclusion criteria were: small tumour (limited to inner acoustic canal -IAC- or with minimal cisternal extension) and unserviceable hearing (AAO-HNS grade B or superior; Gardner-Robertson grade III or more). The 11 cases limited to IAC underwent surgery with endoscopic technique; those with extra-canalar involvement required a widened approach and use of the surgical microscope. Intra-operative facial nerve neurophysiological monitoring was used in all cases.

Results: Complete resection with facial nerve preservation was achieved in all patients, with no mortality and minimal morbidity. In none of the cases we have observed CSF fistulas. Compared to traditional approaches, we observed a higher incidence of disequilibrium. Hearing loss was present in all cases.

Conclusions: The proposed approach is innovative because it allows a totally intra-osseous dissection, without any manipulation of cerebral or cerebellar parenchyma, and without use of retractor. This way, we avoided all complications related to CSF drainage and pneumatocephalus. This approach therefore allows a safe and minimally invasive way to excise vestibular schwannomas, although it requires good anatomical knowledge and endoscopic experience. We think that, despite the actual limited indications, there is a great potential for future development.