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![]() ![]() Two chances at an ABI double your opportunity at getting a good (usable) position.The best chance for a successful ABI is at the initial surgery when the lateral recess is not scarred.In general, if we are removing a large tumor with no or sacrificed hearing, we place an auditory brainstem implant at the time of surgery, even if the patient has residual hearing in the contralateral ear.Remove smaller tumor and preserve hearing or auditory nerve for cochlear implant.In general, preserve acoustic hearing as long as possible, and observe tumors too large for middle fossa or retrosigmoid removal.Type 2 neurofibromatosis with bilateral vestibular schwannomas.Medically unfit for surgery with stable tumor on serial MRI scanning.Age over 65 years with stable tumor on serial MRI scanning.Cerebellar retraction or resection required.Also indicated for vascular loop decompression, vestibular nerve section. ![]() For large medial tumors that do not extend more than 1/3rd laterally into the internal auditory canal (IAC).Limited lateral exposure can be increased by going transcrural and sacrificing the posterior semicircular canal.For select smaller medial tumors that do not extend more than 1/3rd laterally into the internal auditory canal (IAC).Enlarging tumor in patient over the age of 65 years.Also, the aged brain does not tolerate retraction well. The dura is more fragile and more adherent to the skull as the brain ages. Age greater than 60 years should be considered in context of side of surgery (left is higher risk of aphasia), and patient’s general medical condition.Previous stroke, hydrocephalus, traumatic brain injury, or seizure disorder would be contraindications.Tumor less than 2 cm, not in contact with brainstem.Facial nerve dysfunction, imbalance/vertigo, or desire for hearing preservation would also be indications for proceeding with surgical treatment versus observation.An urgent indication for removal would be hydrocephalus or ventricular compression.Smaller tumors, especially in older patients, may grow more slowly (2 mm a year) or may appear quiescent.Larger tumors may grow faster (>4 mm/year) and are subject to cystic degeneration.The natural history of schwannomas is slow but steady growth.The general indication for tumor removal is the presence of a tumor.General Considerations for Acoustic Neuroma Management ![]()
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