====== Large vestibular schwannoma treatment ======

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see also [[Giant vestibular schwannoma treatment]].
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They are generally considered to be an indication for microsurgical excision because of the need of immediate surgical decompression and symptom alleviation.The sole exceptions are patients with major comorbidities, in which [[GKS]] can be used
((Yang HC, Kano H, Awan NR, et al. Gamma Knife radiosurgery for
larger-volume vestibular schwannomas: clinical article.
J Neurosurg 2013;119(Suppl):801–807)).

However, it must be kept in mind that there is a risk of transient tumor expansion during the following 6 to 18 months after GKS, with subsequent risk of additional clinical deterioration
((Nagano O, Higuchi Y, Serizawa T, et al. Transient expansion of
vestibular schwannoma following stereotactic radiosurgery.
J Neurosurg 2008;109(05):811–816))
((Iwai Y, Yamanaka K, Ishiguro T. Surgery combined with radiosurgery
of large acoustic neuromas. Surg Neurol 2003;59(04):
283–289, discussion 289–291)).

===== Two-Stage Surgery =====

[[Large vestibular schwannoma Two-Stage Surgery]]
===== Subtotal removal followed by GKS =====


A combined approach with planned [[subtotal]] [[removal]] followed by GKS has been increasingly adopted as the main strategy for preserving cranial nerve functions along with long-term tumor control, as a paradigm shift in the past decade
((Iwai Y, Yamanaka K, Ishiguro T. Surgery combined with radiosurgery
of large acoustic neuromas. Surg Neurol 2003;59(04):
283–289, discussion 289–291))
((Yang SY, Kim DG, Chung HT, Park SH, Paek SH, Jung HW. Evaluation
of tumour response after Gamma Knife radiosurgery for
residual vestibular schwannomas based on MRI morphological
features. J Neurol Neurosurg Psychiatry 2008;79(04):431–436))
((van de Langenberg R, Hanssens PE, van Overbeeke JJ, et al.
Management of large vestibular schwannoma. Part I. Planned
subtotal resection followed by Gamma Knife surgery: radiological
and clinical aspects. J Neurosurg 2011;115(05):875–884))
((Pan HC, Sheehan J, Sheu ML, Chiu WT, Yang DY. Intracapsular
decompression or radical resection followed by Gamma Knife
surgery for patients harboring a large vestibular schwannoma.
J Neurosurg 2012;117(Suppl):69–77))
((Iwai Y, Ishibashi K, Watanabe Y, Uemura G, Yamanaka K. Functional
preservation after planned partial resection followed by
Gamma Knife radiosurgery for large vestibular schwannomas.
World Neurosurg 2015;84(02):292–300))
((Radwan H, Eisenberg MB, Sandberg Knisely JP, Ghaly MM,
Schulder M. Outcomes in patients with vestibular schwannoma
after subtotal resection and adjuvant radiosurgery. Stereotact
Funct Neurosurg 2016;94(04):216–224))
((Daniel RT, Tuleasca C, George M, et al. Preserving normal facial
nerve function and improving hearing outcome in large vestibular
schwannomas with a combined approach: planned subtotal
resection followed by Gamma Knife radiosurgery. Acta Neurochir
(Wien) 2017;159(07):1197–1211))
((Rujimethapass S, Ananthanandorn A, Karnchanapandh K, Wongsirisuwan M, Gunnarat I, Segkhaphant N. Surgical Outcomes After Total or Subtotal Resection of Large Vestibular Schwannoma: A Single-Institution Experience. Brain Tumor Res Treat. 2022 Apr;10(2):108-112. doi: 10.14791/btrt.2021.0028. PMID: 35545830.))
((van de Langenberg R, Hanssens PE, van Overbeeke JJ, Verheul JB, Nelemans PJ, de Bondt BJ, Stokroos RJ. Management of large vestibular schwannoma. Part I. Planned subtotal resection followed by Gamma Knife surgery: radiological and clinical aspects. J Neurosurg. 2011 Nov;115(5):875-84. doi: 10.3171/2011.6.JNS101958. Epub 2011 Aug 12. PMID: 21838510.))

The mechanical stress related with direct dissection can be reduced or avoided in case of subtotal resection and represents the “nerve-centered” tumor surgery approach inherent in this treatment philosophy
((Daniel RT, Tuleasca C, George M, et al. Preserving normal facial
nerve function and improving hearing outcome in large vestibular
schwannomas with a combined approach: planned subtotal
resection followed by Gamma Knife radiosurgery. Acta Neurochir
(Wien) 2017;159(07):1197–1211)).
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Data suggest that large VS management, with planned subtotal resection followed by GKRS, might yield an excellent clinical outcome, allowing the normal facial nerve and a high level of cochlear nerve functions to be retained. Our functional results with this approach in large VS are comparable with those obtained with GKRS alone in small- and medium-sized VS. Longer term follow-up is necessary to fully evaluate this approach, especially regarding tumor control
((Daniel RT, Tuleasca C, George M, Pralong E, Schiappacasse L, Zeverino M, Maire
R, Levivier M. Preserving normal facial nerve function and improving hearing
outcome in large vestibular schwannomas with a combined approach: planned
subtotal resection followed by gamma knife radiosurgery. Acta Neurochir (Wien).
2017 Jul;159(7):1197-1211. doi: 10.1007/s00701-017-3194-0. Epub 2017 May 17.
PubMed PMID: 28516364; PubMed Central PMCID: PMC5486604.
)).
Daniel et al. published a consecutive series of 47 patients.The data showed excellent results in large VS management with a combined approach of microsurgical subtotal resection and GKS on the residual tumor, with regard to the functional outcome and tumor control. Longer term follow-up is necessary to fully evaluate this approach, especially regarding tumor control
((Daniel RT, Tuleasca C, Rocca A, George M, Pralong E, Schiappacasse L, Zeverino
M, Maire R, Messerer M, Levivier M. The Changing Paradigm for the Surgical
Treatment of Large Vestibular Schwannomas. J Neurol Surg B Skull Base. 2018
Oct;79(Suppl 4):S362-S370. doi: 10.1055/s-0038-1668540. Epub 2018 Aug 23. PubMed 
PMID: 30210991; PubMed Central PMCID: PMC6133697.
)).