Tumors
43 
Cerebellopontine Angle Tumors
ROBERT S. HELLER, LUKE SILVEIRA, CARL B. HEILMAN
CLINICAL PEARLS
• Comprehensive knowledge of the complex anatomy of the
cerebellopontine (CP) angle is a prerequisite for achieving
good surgical results. The crucial neurovascular structures
should be identified as early as possible during surgery, which
enables their preservation and guides subsequent operative
steps. Whatever the tumor size and extension, the anatomic
relationships of the cranial nerves in the area of the fundus of
the internal auditory canal and in the brainstem exit/entry
zone are constant.
• Most of the CP angle tumors are benign, and their complete
removal leads to excellent long-term outcomes. The only
exception to complete tumor removal is the attempt to
preserve function, such as in surgery for vestibular
schwannoma in the only hearing ear.
• The major principles of CP angle tumor removal include
the following: important neural structures, such as the cochlear
History of Cerebellopontine Angle Surgery
The cerebellopontine angle (CPA) is the most common site for
posterior fossa neoplasms. Tumors occupying this region
account for approximately 10% of all intracranial neoplasms,
with vestibular schwannomas accounting for 80% of these
CPA tumors.1 Other tumors involving this region include
meningiomas, dermoid tumors, arachnoid cysts, lipomas, and
metastases. The cerebellopontine angle is densely inhabited by
vital neurologic tissue. As such, tumor growth in this region
may give rise to significant neurologic dysfunction and, if left
untreated, can ultimately lead to death.
As early as 1777, Dutch physician and anatomist Eduard
Sandifort provided the first documented postmortem descrip-
tion of a CPA tumor. However, no clinical correlation with the
mass was made at the time.2 In 1810, Leveque-Lesource cor-
related symptoms of a CPA mass with postmortem findings.
His clinical description was that of a 38-year-old woman with
vomiting, headache, decreased vision, numbness of the extrem-
ities, dysarthria, and deviation of the tongue. At autopsy,
Lesource documented the deceased patient to have a tumor
adherent to the eighth cranial nerve.3
622
and facial nerves, should be identified early; the tumor
should be initially debulked; the dissection from the
surrounding structures should be performed only after
sufficient internal decompression is achieved; the dissection
should always be performed in the arachnoid plane; and
bipolar coagulation, especially in the vicinity of a cranial nerve,
should be avoided.
• Our preferred method is the retrosigmoid approach. It is safe,
relatively simple, and provides a panoramic view of the CP
angle and petroclival area. Importantly, it is related to a very
low procedure-related morbidity rate. The additional removal
of the suprameatal tubercle provides access to tumors with
extensions into the Meckel cave, the petroclival area, and even
the posterior cavernous sinus.
As the 19th century ended, the clinical manifestations of a
CPA mass, at least in its advanced stages, were becoming
increasingly well known and recognized among clinicians. Sir
Charles Ballance is credited with performing the first successful
complete surgical removal of a CPA tumor in November 1894.
Patient symptomatology, which incited suspicion for a CPA
mass and spurred the operation, included a 1-year history of
vertigo, headache, instability, and unilateral loss of vision. Bal-
lance performed the operation in two stages, set 1 week apart.
In the first stage, a right posterior fossa craniectomy was per-
formed. One week later, Ballance removed the tumor by insert-
ing an ungloved finger between the pons and petrous bone.
The patient, 46 at the time of the operation, went on to live
an additional 18 years, unfortunately suffering from facial
anesthesia, hemifacial paralysis, and delayed corneal ulceration
requiring removal of her right eye.
In 1903 Krause of Berlin set forth the unilateral suboccipital
approach for the removal of vestibular schwannomas. Like
Ballance, Krause utilized his finger as the instrument for tumor
dissection and removal. Krause’s mortality rate was close to
85%, a result of the uncontrollable bleeding he encountered
with this approach. In 1904 Panse attempted the first

translabyrinthine approach for removal of a vestibular schwan-
noma. With limited instrumentation, the approach did not
permit sufficient exposure and was similarly associated with
high mortality rates. In 1905 Victor Horsley performed a
complete removal of a vestibular schwannoma at National
Hospital in London. The patient survived for only a few years
after the operation and suffered from presumed severe brain-
stem ischemia. In the same year, Borchardt performed the first
transsigmoid removal of a vestibular schwannoma, but fatal
hemorrhage from the lateral sigmoid sinus led to the rapid
abandoning of this approach.3 Owing to the extensive bleeding
complications experienced by surgeons attempting to operate
on CPA masses, Harvey Cushing would later refer to the ana-
tomic region as “the bloody angle.”2
Early attempts at CPA tumor resection were complicated
by a lack of diagnostic capabilities or refined surgical instru-
ments coupled with unreliable anesthesia, limited possibilities
for hemostasis, and an incomplete appreciation of the CPA
anatomy. As such, early surgeries were fraught with intra-
operative difficulty and extremely high mortality rates nearing
70% to 85% even among the most practiced surgeons.2 Harvey
Cushing, finding these mortality rates unacceptable, would be
the next pioneer to significantly advance the field of CPA
surgery.
In 1917 Cushing published his famous Tumors of the Nervus
Acusticus and the Syndrome of the Cerebellopontine Angle in
which he documented his operative and perioperative experi-
ences with 30 vestibular schwannoma patient cases. Cushing
reported markedly lower mortality rates than those of his pre-
decessors, with an initial rate of 20% that he would later reduce
to as little as 4%.4 Though his predecessors broadly recognized
the symptomatology, it was during that time that Cushing first
coined the persisting diagnostic entity CP angle syndrome and
first accurately professed the early development of tinnitus
followed by ipsilateral hearing loss in patients afflicted with
CPA tumors.
Cushing’s vastly improved outcomes were made possible by
a number of key factors, starting with his belief that the com-
plete removal of a vestibular schwannoma was simply unattain-
able. Instead, he focused primarily on achieving decompression
of the brainstem and avoiding medullary compression during
his intracapsular subtotal tumor resections. To control intra-
cranial pressure in a patient population that was still univer-
sally plagued by elevated intracranial pressures at the time of
diagnosis, Cushing utilized a ventricular tap. Cushing per-
formed a bilateral suboccipital craniectomy, permitting him
to explore both CPAs and achieve an osseous decompression.
Early access to the cerebellomedullary cistern allowed Cushing
to drain cerebrospinal fluid (CSF) and decompress the cer-
ebellar tonsils.4 In addition to his new approach, Cushing’s
meticulous operative technique included close attention to
patient vital signs and persistence in achieving intraoperative
hemostasis with the implementation of vessel clipping and
electrocautery.
Despite Cushing’s comparatively stellar immediate postop-
erative mortality rates, his intracapsular, partial resection
approach was associated with high recurrence rates and an
CHAPTER 43  Cerebellopontine Angle Tumors 623
overall 5-year mortality rate approaching 54%.4 Cushing’s
student protégé, Walter E. Dandy, found this recurrence rate
intolerable and pursued complete tumor capsule removal after
employing Cushing’s bilateral suboccipital craniectomy and
thorough intracapsular decompression. Dandy also followed
Cushing’s example with respect to careful hemostatic control,
clipping all vessels around the tumor to avoid bleeding com-
plications, and became the first surgeon to achieve complete
tumor removal with low operative mortality.5
In 1934 Dandy abandoned the bilateral approach in favor
of the unilateral suboccipital approach similar to that originally
performed by Krause.6 In addition to his profound surgical
skill, Dandy had the advantage of operating on generally
smaller tumors than those addressed by previous surgeons.
Cushing’s popularized observance of tinnitus preceding ipsilat-
eral hearing loss coupled with Dandy’s invention and utiliza-
tion of pneumoencephalography made earlier and more
accurate diagnosis of CPA masses feasible. Dandy also had the
opportunity to take advantage of other technologic advance-
ments in the surgical realm, including improved cauterization
technology, more reliable anesthesia, and the availability of
blood transfusions. Dandy progressively improved upon his
technique by utilizing ventricular and cisterna magna taps to
lower CSF pressure and achieved adequate CPA access by
resecting the lateral cerebellar hemisphere. In 1941 Dandy
reported on 46 vestibular schwannoma complete resections
with an operative mortality of just 10.8%.7
The modern era of CPA surgery was ushered in by otologist
William House. In 1961 House took full advantage of the
newly minted instrumentation available to him, including the
surgical microscope, otologic drill, and irrigation suction.
Alongside neurosurgeon John B. Doyle, House pursued surgi-
cal resection of small acoustic neuromas via the middle fossa
approach. With advancements in audiometric testing and
improvements in x-ray techniques of the temporal bone, House
and Doyle were able to identify acoustic tumors before the
masses were large enough to incite hydrocephalus and papille-
dema. In cases where the tumor was confined to the internal
auditory canal, tumor extraction and high rates of facial nerve
preservation were feasible via the microsurgical middle fossa
approach. However, in cases where the tumor extended into
the CPA, the middle fossa approach did not permit adequate
exposure for resection. Hence, House went on to partner with
neurosurgeon William E. Hitselberger, and the two pioneered
a microsurgical approach to the formerly abandoned translaby-
rinthine technique.8
By 1968 House had documented 200 cases of microsurgical
neuroma resection with a markedly low mortality rate of 7%
and an astonishing facial nerve preservation of 88%. Neuro-
surgeons of the time, including Rand and Kurze, also aimed
to perfect the microsurgical suboccipital approach. By 1995
collective efforts at technique improvement and the advent of
new diagnostic imaging, including the computed tomography
(CT) and magnetic resonance imaging (MRI), yielded an
overall reduction in the mortality associated with acoustic
neuroma surgery of less than 0.5% and facial nerve preserva-
tion nearing 90%.8
624 PART 6 Tumors
Over time, it became clear that acoustic neuromas are
neither tumors of the cochlear nerve nor have the neuron as
the cell of origin. Rather, the tumor arises from Schwann cells
of the vestibular nerve. To be more accurate, an acoustic
neuroma is now referred to as a vestibular schwannoma.
Cerebellopontine Angle Anatomy
The CPA in the posterior fossa is the region adjoining the
cerebellum, brainstem, and adjacent skull base. The neural
elements of the CPA exit the brainstem and pass through the
cerebellopontine cistern as they course toward the skull base.
The trigeminal, facial, and vestibulocochlear nerves arise
between the superior and inferior limbs of the cerebellopontine
fissure, the sulcus between the pons, middle cerebellar pedun-
cle, and the cerebellum.9 The trigeminal nerve courses anterior
toward Meckel cave, where it divides into its three branches.
The sensory rootlets of the trigeminal nerve, termed portia
major, are lateral and inferior to the motor rootlets, termed
portia minor. The facial and vestibulocochlear nerves exit the
brainstem adjacent to one another in the pontomedullary
fissure with the facial nerve anterior and medial to the vestibu-
locochlear nerve. These two then pass anterolaterally toward
the internal auditory canal. The glossopharyngeal and vagal
nerves are found in the caudal region of the CPA as they course
toward the jugular foramen.
The vascular elements of the cerebellopontine (CP) angle
originate from the basilar artery, which runs along the ventral
aspect of the brainstem. The anterior inferior cerebellar artery
(AICA) is the main artery of the CP angle, though occasionally
the caudal trunk of the superior cerebellar artery (SCA) can
descend into the CP angle. The AICA bifurcates in the cerebel-
lopontine cistern to form a rostral and caudal trunk; the rostral
trunk supplies the middle cerebellar peduncle and superior
surface of the cerebellopontine fissure, whereas the caudal
trunk supplies the inferior ventral surface of the cerebellum.9
The superior petrosal vein, also known as the Dandy vein, is
the largest vein in the CP angle and is located rostrally inferior
to the tentorium. This vein drains into the superior petrosal
sinus, which courses along the petrous ridge.
The internal auditory canal, located in the temporal bone,
is the conduit from the cerebellopontine cistern to the tempo-
ral bone. The porus acousticus is the opening to the internal
auditory canal (IAC) from the CP angle cistern. There are five
nerves in the IAC: the facial nerve, the cochlear nerve, the
superior vestibular nerve, the inferior vestibular nerve, and the
nervus intermedius. The vascular portion of the IAC consists
of the labyrinthine artery, a branch of the AICA, which sup-
plies the cochlea and inner ear. Occasionally, AICA itself can
loop into the IAC.
The location of the nerves within the IAC is constant and
organized by quadrants. The facial nerve is located anterosu-
periorly in the IAC with the cochlear nerve in the anteroinfe-
rior quadrant. Posteriorly, the superior vestibular nerve is
rostral to the inferior vestibular nerve. The transverse crest
delineates the superior and inferior IAC, whereas Bill’s bar
separates the facial nerve in the anterosuperior quadrant from
the superior vestibular nerve in the posterosuperior quadrant.
The nervus intermedius runs in close association with the facial
nerve in the anterosuperior quadrant, and it exits the IAC
alongside the facial nerve through the facial canal.
Surgical Approaches to the
Cerebellopontine Angle
Retrosigmoid
Perhaps the most versatile of the available approaches, the
retrosigmoid approach provides excellent visualization of the
CP angle, brainstem, and IAC. After the induction of general
anesthesia, the patient is positioned supine with the head
turned to the contralateral side and fixated using 3-point May-
field pins. Use of a blanket or gel roll can aid in turning the
body to allow greater lateral rotation of the head if needed.
Although under-rotation of the head can limit visualization of
the CP angle, over-rotation carries the risk of venous occlusion
at the level of the internal jugular vein in the neck.
Neuromonitoring during surgery in the CP angle can
provide vital information. Facial nerve motor function is moni-
tored through electrodes inserted into the orbicularis oculi and
orbicularis oris muscles. Brainstem auditory evoked response
(BAER) monitoring can follow hearing function during the
operation (Fig. 43.1). The normal BAER waveforms consist of
seven waves: I, cochlear nerve; II, cochlear nucleus; III, supe-
rior olivary nucleus; IV, lateral lemniscus; V, inferior colliculus;
VI, medial geniculate body of the thalamus; and VII, auditory
radiations and cortex. It remains unknown whether monitor-
ing of the auditory brainstem response (ABR) during surgery
for a vestibular schwannoma improves hearing preservation
rates. Routine monitoring of the ABR in all cases where hearing
preservation is attempted may inform the surgeon over time
of the surgical maneuvers that result in hearing loss, thus
improving outcomes.
The incision is planned approximately 2 cm posterior to the
mastoid, extending from the level of the superior aspect of the
pinna to 2 cm below the occiput. Typically, this leads to an
incision 1 cm behind the hairline at the level of the midpinna.
The incision can be made in either a straight line or slightly
6.03
+
5
+
2.84 6.84 (0.21)
+ 3.81 6.5 +
1.5 + +
+
5.4
+
2.93
1.56
+
4.15 7.28 (0.26)
+ +
+
• Figure 43.1  Intraoperative snapshot of BAER recording during resec-
tion of a left vestibular schwannoma. Waves I through VI are identified, VII
not shown. See text for correlation of BAER wave and neuroanatomic
structure.

semilunar fashion to aid in scalp retraction, depending on the
surgeon’s preference, and dissection using electrocautery is
made down through the periosteum. The mastoid emissary
vein is controlled with bone wax. This hole in the outer table
of the skull can be a useful landmark, as it usually exits the
skull about 1 cm below the transverse sinus and 1 cm behind
the sigmoid sinus.
Using a high-speed drill, a trough is drilled through the
skull along the inferior edge of the transverse sinus and along
the posterior edge of the sigmoid sinus. The mastoid emissary
vein typically enters in the posterior aspect of the sigmoid sinus
at its junction with the posterior fossa dura. If the emissary
vein is large, the bone around it can be carefully removed with
the drill and then the vein ligated with a suture; smaller veins
can be controlled with bipolar coagulation. Once the mastoid
emissary vein is ligated and the edges of the transverse and
sigmoid sinus are exposed, the dura is dissected off the inner
aspect of the occipital bone.
The craniotomy is made extending from the transverse sinus
on the superior border, the sigmoid sinus on the lateral border,
and 3 to 5 cm medially. The dura can then be opened along
the sigmoid and transverse sinuses, leaving a small cuff for
suturing on closure. Once the dura has been opened, the cer-
ebellum is gently elevated with a brain ribbon, exposing the
arachnoid at the foramen magnum. Opening the arachnoid
and patiently draining CSF from the cisterna magna provides
significant cerebellar relaxation. This reduces the need for
excess retraction and subsequent edema. Telfa or Biocol is then
placed over the cerebellum for protection, and then a retractor
is placed along the cerebellar hemisphere if needed in order to
expose the CP angle.
Careful identification of the cranial nerves early in the
operation is crucial to preserve function. A nerve stimulator
can be used to locate the motor fibers of the facial nerve, which
are usually located anterior to vestibular schwannomas but can
rarely be found within or posterior to a tumor. Early tumor
debulking can also aid in exposure and visualization of normal
anatomy, especially in cases of large tumors. The posterior wall
of the IAC is drilled when visualization of the IAC contents is
necessary. The tumor is then removed with a combination of
bipolar cautery, tumor forceps, ultrasonic aspiration, and
suction.
Following tumor removal, the dura is closed in watertight
fashion. Mastoid air cells exposed during drilling should be
sealed with either bone wax or bone cement to reduce the risk
of CSF leak. The bone flap is then replaced, and the fascia and
subcutaneous layers are closed according to surgeon’s preferred
method.
Middle Fossa
The middle fossa approach to tumors of the CP angle is most
useful when tumors isolated to the IAC, as the approach poorly
visualizes the cistern of the CP angle and the brainstem.
The patient is positioned in a manner similar to that used
for the retrosigmoid approach and again fixed in the Mayfield
3-point system. Neuromonitoring should be used as in the
CHAPTER 43  Cerebellopontine Angle Tumors 625
retrosigmoid approach. An incision is made approximately
1 cm anterior to the tragus, extending superiorly as needed.
Dissection is carried through the temporalis fascia and under-
lying muscle and down through the periosteum. To ensure that
the craniotomy is flush with the floor of the middle fossa,
dissection should be carried inferiorly to the root of the
zygoma. The craniotomy is then made approximately 4 to
5 cm in diameter. The dura is lifted from the middle fossa floor
in a posterior to anterior direction to avoid injury to or eleva-
tion of the greater superficial petrosal nerve. Once the middle
fossa floor has been exposed, the roof of the internal auditory
canal is removed with a high-speed drill. Selecting the mid-
point of the angle between the greater superficial petrosal nerve
and the arcuate eminence at the level of the petrous ridge helps
guide the surgeon to the location of the IAC. Once the IAC
has been opened, tumor removal can proceed as before with
careful attention paid to preserving neural function.
Translabyrinthine
The translabyrinthine approach, often preferred by neuro-
otologists, is favored for its early identification of the facial
nerve and excellent visualization of the IAC. Removal of the
contents of the inner ear makes it unsuitable for patients with
serviceable hearing.
The patient is positioned in a supine position with head
turned toward the contralateral side. Mayfield pin fixation is
not necessary, though many surgeons will employ it. A post-
auricular C-shaped incision is made, with the apex of the C
approximately 2 cm behind the postauricular crease for small
tumors and farther back for large tumors. The dissection is
carried to the periosteum and the limit of the external auditory
canal, following which a mastoidectomy is performed. Once
the lateral semicircular canal and the mastoid segment of the
facial nerve are identified, the labyrinth can be removed and
the IAC exposed.
The facial nerve is most often identified at its genu and
followed proximally to the labyrinthine segment. The jugular
bulb is then skeletonized so that it can be mobilized to afford
greater visibility into the IAC. Extension of the bony opening
should be carried until the surgeon can identify Bill’s bar and
thus the facial nerve in the anterosuperior quadrant of the IAC.
The dura to the posterior fossa is then opened, and tumor
resection carried out per routine.
Closure of the translabyrinthine approach requires packing
of the inner ear defect, usually with a combination of fascia,
muscle, and fat. The eustachian tube can be occluded with
muscle or fascia, followed by insertion of the incus, which is
inserted as a plug. The remainder of the closure is then per-
formed according to the surgeon’s preferred method.
Mass Lesions of the Cerebellopontine Angle
The differential diagnosis of mass lesions in the CP angle is
vast: vestibular schwannoma, meningioma, epidermoid cyst,
arachnoid cyst, metastasis, vascular malformations such as a
thrombosed, saccular aneurysm, exophytic brainstem gliomas,
626 PART 6 Tumors
ependymoma, trigeminal schwannoma, facial schwannoma,
lipoma, neurosarcoidosis, endolymphatic sac tumor, choroid
plexus papilloma, hemangioblastoma, chordoma with dural
erosion, chondrosarcoma with dural erosion, and cholesterol
granuloma. Distinguishing between these can be difficult. The
following section details the most common mass lesions of the
CP angle.
Vestibular Schwannomas
Vestibular schwannomas (VSs) are benign, slow-growing neo-
plasms arising from Schwann cells that account for approxi-
mately 10% of all primary brain neoplasms.10 The majority of
vestibular schwannomas arise from the inferior vestibular
nerve.11 The incidence of symptomatic VSs is approximately
1.2 per 100,000 population, evenly divided among males and
females.12,13 Routine magnetic resonance studies obtained for
purposes other than audiovestibular symptoms or evaluation
for vestibular schwannoma detected incidental VSs with a two-
to fourfold higher incidence, indicating that a significant
portion of vestibular schwannomas remain asymptomatic.14,15
The incidence of vestibular schwannomas in patients with
neurofibromatosis type 2 (NF2) is considerably higher than
that of the general population. Up to 95% of NF2 patients
will develop vestibular schwannomas, 90% being bilateral and
5% being unilateral.16
Reviews have shown wide ranges with regard to the percent-
age of VSs that grow from 7% to 85%.17,18 This heterogeneity
was decreased in a review of prospective studies where the
estimated tumor growth frequency was 29% over a 41-month
period.17 The annual tumor growth rate of vestibular schwan-
nomas averages 1 to 2 mm per year across several studies;
however, this increases to 2 to 4 mm per year when the growth
rate calculation is restricted to only those tumors that grow.18–20
Presenting symptoms for patients with vestibular schwan-
nomas are related to loss of function of adjacent neural
• Figure 43.2  Magnetic resonance imaging of a right-sided vestibular schwannoma. The tumor is avidly
enhancing with cystic areas and expansile of the internal auditory canal; it extends into the CPA cistern.
Postgadolinium axial T1-weighted image in the left panel, axial T2-weighted image in the center panel,
and postgadolinium axial T1-weighted image in the right panel.
structures due to direct compression by the tumor. Most com-
monly patients present with unilateral hearing loss, though
symptoms of tinnitus, vertigo, and gait disturbances are fre-
quent as well.21–23 Atypical symptoms are more frequent when
vestibular schwannomas reach a size greater than 3 cm and can
include facial numbness, diplopia, and headache.24 Audiomet-
ric evaluation of patients with vestibular schwannomas show
characteristic findings of sensorineural hearing loss in the ear
ipsilateral to the tumor, with a descending pattern and loss of
high-frequency hearing first.25
Radiology has greatly improved the ability to accurately
diagnosis vestibular schwannomas, and MRI has become the
gold standard imaging test (Fig. 43.2). VSs are isointense to
the adjacent pons and brainstem on T1-weighted MR images
and slightly hyperintense on T2-weighted MR images. These
tumors enhance avidly with the administration of gadolinium
contrast and may contain cystic components.26 They may have
a characteristic “ice cream cone” appearance due to contain-
ment within the IAC and expansion in the extracanalicular
space. VSs tend to expand and dilate the IAC compared to a
contralateral normal IAC. Advanced MRI techniques such as
diffusion tensor imaging have been shown to accurately predict
the spatial relationship between the facial nerve and tumor,
thus assisting in surgical planning.27
Vestibular schwannomas are histopathologically char-
acterized by the presence of Antoni A regions and Antoni
B regions.28,29 Antoni A regions consist of uniform, densely
packed cells arranged in fascicles, whereas Antoni B regions
consist of small, hyperchromatic cells with large extracellu-
lar matrices. Verocay bodies are formed by the palisading of
nuclei in Antoni A regions (Fig. 43.3). VSs from patients
with NF2 are histologically more active with greater cellular-
ity and an increased number of growth patterns and Verocay
bodies.30
Management and decision making for vestibular schwan-
nomas have become increasingly complex as smaller tumors

*
**
• Figure 43.3  Hematoxylin and eosin preparation of a vestibular schwan-
noma specimen with Antoni A (*) and Antoni B (**) regions. Adjacent
Verocay bodies are illustrated in the inset. The authors thank Knarik Arkun,
M.D., for her assistance with pathologic slides.
are more prevalent due to earlier diagnosis.31 The majority of
patients with VSs are treated in a multidisciplinary fashion
with a combination of neurosurgeons, neuro-otologists, and
radiation oncologists.32
Conservative management for vestibular schwannomas has
been advocated for a larger percentage of patients with these
tumors. Ideal patients for whom conservative therapy is pre-
ferred are older patients with higher surgical risks, small tumor
size, minimal symptom severity, and patient preference.33
Tumors that are not treated at the time of diagnosis can be
expected to grow in 35% to 50% of patients, remain static in
size in 40% to 50% of patients, and decrease in size in the
remaining 10% to 20% of patients.19,20,34 An estimated 20%
to 40% of patients for whom conservative therapy is initially
recommended will require microsurgery or radiosurgery in
their future.20,33,35,36 Patients with worsening vertigo were more
likely to undergo treatment due to decreased quality of life.37
Some authors propose that vestibular schwannomas 2 cm or
greater in size should be treated, as these tumors are likely to
continue growing.34
Surgical management of vestibular schwannomas has been
the mainstay of treatment for these tumors. Preservation of
neurologic function is of utmost importance and includes
hearing in those patients with serviceable hearing and facial
muscle function in all patients (Video 43.1).
Hearing preservation during microsurgery for vestibular
schwannomas is dependent on several factors, including pre-
operative hearing status, tumor size, and nerve of origin.
Approximately 40% to 55% of patients with serviceable
hearing prior to surgery will retain the same level of auditory
function after surgery.38,39 Intuitively, surgical resection of
smaller tumors results in less hearing loss than larger tumors.39
Hearing preservation surgery is most often successful in
patients with small VSs (<1 cm), with rates exceeding 90% in
these cases.40 Patients with better preoperative hearing are more
CHAPTER 43  Cerebellopontine Angle Tumors 627
TABLE
43.1  House-Brackmann Facial Nerve Grading System
Grade Description
1 Normal facial muscle function
2 Slight asymmetry, usually unnoticeable at rest,
most identifiable in the forehead and mouth
3 Moderate asymmetry with preservation of eye
closure; only slight movement of the forehead
4 Moderate asymmetry, noticeable at rest, with
incomplete eye closure; forehead without
movement
5 Severe asymmetry with only slight movement of the
eyelid and mouth
6 Absent facial muscle function
Adapted from House JW, Brackmann DE. Facial nerve grading system.
Otolaryngol Head Neck Surg. 1985;93:146–147.
likely to retain hearing after surgery.38,41 Tumors growing from
the superior vestibular nerve are also less likely to cause intra-
operative hearing loss than those growing from the inferior
vestibular nerve.41
Loss of facial nerve function during vestibular schwannoma
surgery is a significant source of morbidity. Facial nerve func-
tion is assessed by the House-Brackmann (HB) scale (Table
43.1).42 The immediate postoperative HB grade is predictive
of long-term function with poor initial grades being unlikely
to recover facial nerve function in the follow-up period.43 In
patients with near-total and gross-total resections, facial nerve
preservation is estimated in 74% of cases of large vestibular
schwannomas.44 As with hearing preservation, larger tumors
predispose patients to postoperative facial palsy.45 Attempts to
mitigate this effect have led to the option of planned subtotal
surgical resection with postoperative radiosurgery to the resid-
ual tumor. This strategy has preserved facial nerves in greater
than 90% of cases without compromising tumor control rates
in cases of small tumors.46–48 Debate remains regarding the
efficacy of subtotal resections with moderate to large residual
tumor volumes, as concerns exist regarding the durability of
tumor control (Video 43.2).49
Selection of surgical approach can be difficult and often is
a matter of the surgeon’s preference. Nonetheless, certain VSs
lend themselves to a particular approach. In patients with small
tumors isolated to the IAC, the middle fossa approach is safe
with a small risk of intraoperative hearing loss. The inability
to adequately visualize the CP angle cistern makes it less favor-
able in large tumors. Patients with preoperative hearing loss
can be treated with the translabyrinthine approach, which
affords excellent tumor visualization and ability to protect
facial nerve function but is not suitable for patients with ser-
viceable hearing. For tumors of all sizes, the retrosigmoid
approach is versatile in its ability to preserve both hearing and
facial nerve function.44,50–52
628 PART 6 Tumors
Meningiomas
Meningiomas constitute the second most common tumor type
in the CP angle, accounting for approximately 10% of CP
angle lesions in total. In addition to hearing loss, patients with
CP angle meningiomas also frequently present with headache
and ataxia from cerebellar compression.53 Due to their large
size at the time of presentation, meningiomas frequently
present with symptoms of cranial nerve V and X dysfunction
(trigeminal neuralgia, facial dysesthesias, facial numbness, dif-
ficulty swallowing). Meningiomas of the CP angle are classified
by the location of their dural tail with regard to the internal
auditory canal. Tumors with tails anterior to the IAC are clas-
sified as premeatal, and those with tails posterior to the IAC
are postmeatal.54 CP angle meningiomas extend into the IAC
in 17% of cases, but arise from the IAC itself in a significantly
smaller percentage of cases (2%).55,56
Meningiomas are important to differentiate from vestibular
schwannomas on radiology studies (Fig. 43.4). Unlike vestibu-
lar schwannomas, the slow-growing trait of meningiomas often
leads to intratumoral calcifications best seen on CT. The
administration of gadolinium contrast agents leads to homo­
geneous enhancement of meningiomas with identification of
a dural tail. Hyperostosis is a common radiographic finding
associated with meningiomas, manifested in the CP angle by
either hyperostosis of the temporal bone or narrowing of the
IAC in cases of intrameatal meningiomas.26,55
Surgical resection of CP angle meningiomas is considered
more challenging than that of vestibular schwannomas.
Increased tumor vascularity; tumor invasion into the IAC,
jugular foramen, and other areas; adherence to neurovascular
• Figure 43.4  Left-sided CPA meningioma extending from the internal auditory canal to the CPA cistern.
Postgadolinium axial T1-weighted image on the left shows a homogeneously enhancing mass. Magnified
bone-window axial CT image on the right shows intratumoral calcification and hyperostosis of the internal
auditory canal and petrous face.
structures; and the need to resect adjacent dura all increase the
complexity of meningioma surgery in the posterior fossa.57
Despite these obstacles, surgical resection of meningiomas has
been shown to result in fewer postoperative cranial nerve defi-
cits than vestibular schwannoma surgery, with facial function
preservation in upward of 90% of cases and hearing preserva-
tion in upward of 70% of patients.58,59 Cases requiring explora-
tion of the IAC for tumor removal carry a higher risk of cranial
nerve deficit, a finding attributable to tumor invasion of the
involved nerves rather than surgical opening of the IAC.56
Epidermoid Cysts
Epidermoid cysts constitute the third most common cerebel-
lopontine mass, accounting for 1% of all intracranial neo-
plasms with 50% of these lesions located in the cerebellopontine
angle. Usually presenting between the third and fifth decades
of life, epidermoid cysts are benign congenital lesions and
thought to be the result of abnormally migrated ectodermal
cells during neural tube formation and separation. Clinically,
patients with epidermoid cysts present similar to those with
vestibular schwannomas and meningiomas, with symptoms
related to cranial nerve dysfunction, especially trigeminal neu-
ralgia and hemifacial spasm, and brainstem and cerebellar
compression.60,61
Detection of epidermoid cysts is radiographically challeng-
ing. CT images will reveal well-circumscribed hypodense cysts
that are often indistinguishable from normal cerebrospinal
fluid.61 Epidermoid cysts are best visualized on MRI; although
they have a propensity to match cerebrospinal fluid signal
on nearly all sequences, they appear in stark contrast to
 CHAPTER 43  Cerebellopontine Angle Tumors 629

• Figure 43.5  Epidermoid cyst of the right CPA with compression of the brainstem and displacement
of the basilar artery (left panel; axial T2-weighted image). The tumor matches the signal of cerebrospinal
fluid on all sequences except diffusion-weighted imaging, where it is markedly hyperintense compared to
normal cerebrospinal fluid (right panel.)

cerebrospinal fluid on diffusion-weighted imaging (Fig. 43.5).

The hyperintense signal of epidermoid cysts on diffusion-
weighted MRI is the result of T2 shine-through rather than
true diffusion restriction.62
Due to recurrence rates of over 90% following subtotal
resection, surgical strategy is directed at total removal of all cyst
contents and cyst wall material without sacrificing neurologic
function.63 As epidermoid cysts have a tendency to expand the
cerebellopontine angle and grow around neurovascular struc-
tures rather than displace them, achieving complete resection
is difficult. Emerging and increasingly prevalent use of the
endoscope has enabled greater resections than were possible
with microsurgical technique alone (Video 43.3).64,65 Some
authors have proposed isolated use of the endoscope in order
to reduce brain retraction and decrease associated complica-
tions.66,67 In cases of epidermoid cysts that expand multiple
intracranial locations such as the cerebellopontine angle in the
posterior fossa, middle fossa, and basal cisterns, surgeons are
encouraged to pursue multistage procedures to obtain com-
plete resection.68

• Figure 43.6  Axial T2-weighted image of a left CPA arachnoid cyst.

Arachnoid Cysts
Arachnoid cysts are benign, developmental collections of cere-
brospinal fluid. Though they are common intracranial masses,
they rarely occur in the CP angle and are most frequently
asymptomatic (Fig. 43.6). CP angle arachnoid cysts may
become symptomatic when they exert sufficient pressure on
the brainstem, cerebellum, or cranial nerves, and obstruct
the normal circulation of CSF to result in compromise of
neurologic function. Common presenting symptoms include
headache, nausea, ataxia, trigeminal neuralgia, facial numb-
ness, hemifacial spasm, and hearing loss.69–71 Surgical resection
of the cyst and its wall have been reported to afford excellent
clinical outcomes, with many cases of complete and near-
complete resolution of symptoms.72 Options for fenestration
include microsurgical or endoscopic release of the arachnoid
630 PART 6 Tumors
membranes into the prepontine cistern and, in cases of recal-
citrant cysts, shunting of the cyst.
Metastatic Tumors
Metastatic involvement of the CP angle from primary tumors
distant from the central nervous system, though rare, can lead
to significant neurologic compromise. Clinical and radio-
graphic evaluation of patients with metastatic lesions in the CP
angle can be misleading, with initial diagnostic studies being
consistent with tumors such as schwannomas.73,74 Due to the
invasiveness of metastases leading to early neural compression,
symptom onset in these patients is more rapid than that of
more common lesions in the CP angle.75,76 The aggressive
nature of metastatic lesions in addition to the morbidity caused
by the primary tumor portends the poor prognosis in the
majority of these patients.77
Radiosurgery for Cerebellopontine
Angle Masses
The history of cerebellopontine angle surgery is rich with
advances in diagnostic and surgical technology. These efforts
have culminated in the current approach to treatment, of
which stereotactic radiosurgery is a mainstay. Radiosurgery was
first utilized for the treatment of CPA masses in 1969 when
Lars Leksell employed radiosurgery for the treatment of an
acoustic neuroma. The first patient to undergo Gamma Knife
radiosurgery was a young, female patient with NF2. Tumor
control was achieved for the following 12 years, at which point
CT revealed medial growth and the tumor was surgically
resected.78 Advancements in imaging techniques following the
first attempted radiosurgical treatment of a CPA mass have
allowed for increasingly accurate localization in addition to
improved delivery of radiation dose. These have led to improved
tumor growth control and reduced unwanted radiation-
associated tissue damage. Further amendments to dosing mea-
surements coupled with the advent of high-resolution MRI
have minimized complications associated with radiosurgery
and given rise to excellent long-term arrest of CPA tumor
growth.
Stereotactic radiosurgery involves the precise delivery of a
single, high dose of radiation to a target within a closed-skull,
single-treatment session. The therapy can be used to treat intra-
cranial tumors that are otherwise surgically inaccessible and
may be either the primary treatment method or an adjunctive
therapy to surgical resection. The timeline for treatment effi-
cacy for radiosurgery depends on tumor type; slow-growing
pathologies such as vascular malformations and schwannomas
respond more slowly, whereas fast-growing pathologies such as
metastatic lesions respond more quickly. Hence, stereotactic
radiosurgery may be an inappropriate treatment option for
patients presenting with profound clinical symptoms or dis-
comfort owing to mass effect from their intracranial mass. In
such cases, surgical resection is often the necessary first-line
treatment.
Radiosurgery, or stereotactic radiosurgery (SRS), can be
performed using linear accelerator (LINAC)-based systems,
Gamma Knife, or proton beam–based systems. Though the
principle of administering high-dose radiation to an intracranial
target is the same across the three techniques, the specific
protocols differ with regard to patient immobilization, image
planning, and radiation dose delivery. Proton beams provide
the best control of penetration depth compared to either gamma
or photon beams. With Gamma Knife therapy, 201 collimated
beams of gamma radiation derived from Co-60 are focused
precisely on the lesion of interest. This creates a localized radia-
tion field with relative sparing of healthy surrounding tissue.
The LINAC system uses a linear accelerator as its source of
electrons, but it has fewer beams than the Gamma Knife.
Since Leksell first utilized Gamma Knife radiation therapy
for the treatment of an acoustic neuroma in 1969, Gamma
Knife radiosurgery has emerged and evolved into an important
treatment option for patients with small to moderate-sized
acoustic neuromas owing to its excellent outcomes and prefer-
ence among patients over microsurgery. Gamma Knife radio-
surgery is presently the most commonly utilized treatment
method for acoustic neuromas up to 3 cm.
Although interstudy variability with regard to definition of
tumor control makes concrete generalization somewhat diffi-
cult, Gamma Knife therapy consistently demonstrates equal to
or greater than 94% effectiveness in achieving “tumor control”
that is defined as no need for further radiation treatment or
surgical resection.79 Furthermore, Gamma Knife therapy has
consistently demonstrated excellent results with regard to the
preservation of facial and trigeminal nerve function. In a 2009
meta-analysis of 2204 patients undergoing Gamma Knife
radiosurgery for acoustic neuromas, significant facial nerve
dysfunction was exhibited in 3.8% of cases, with multiple
studies reporting rates between 0 and 3%.80
The goals of Gamma Knife treatment of acoustic neuro-
mas are fourfold: (1) arrest tumor growth, (2) preserve facial
nerve function, (3) preserve trigeminal nerve function, and (4)
preserve hearing. Hearing preservation remains the sobering
outcome with respect to the otherwise high rates of success
for Gamma Knife treatment. Among 4234 patients included
in a systematic review with an average recorded follow-up time
of 44.4 months, overall hearing preservation neared 51%.
However, when patients were further characterized based on
radiation dose, hearing preservation rate climbed to 60.5%
for those receiving less than 13 Gy.81 Additional studies have
supported this finding, namely that preservation of hearing
is significantly tied to preprocedure hearing status and the
radiation dose delivered. Radiation doses of less than 13 Gy
to treat patients with better preprocedure Gardner-Robertson
hearing class is associated with the highest rates of hearing
preservation.82
Though somewhat controversial still, the available evidence
to date suggests that radiosurgery is the best available treatment
for solitary vestibular schwannomas up to 30 mm in cisternal
diameter.83 Although microsurgery achieves similar success
rates with regard to tumor control and cranial nerve preserva-
tion, Gamma Knife radiosurgery evades some of the inherent

dangers associated microsurgery including the possibility for
surgical hemorrhage or anesthetic complications. The question
as to whether Gamma Knife radiotherapy will become the
optimal first-line treatment for larger acoustic neuromas con-
tinues to be explored.
Selected Key References
Abolfotoh M, Bi WL, Hong CK, et al. The combined microscopic-
endoscopic technique for radical resection of cerebellopontine angle
tumors. J Neurosurg. 2015;123:1301-1311.
Boari N, Bailo M, Gagliardi F, et al. Gamma Knife radiosurgery for
vestibular schwannoma: clinical results at long-term follow-up in a
series of 379 patients. J Neurosurg. 2014;121(suppl):123-142.
CHAPTER 43  Cerebellopontine Angle Tumors 631
Breivik CN, Varughese JK, Wentzel-Larsen T, et al. Conservative man-
agement of vestibular schwannoma–a prospective cohort study: treat-
ment, symptoms, and quality of life. Neurosurgery. 2012;70:1072-1080,
discussion 1080.
House JW, Brackmann DE. Facial nerve grading system. Otolaryngol
Head Neck Surg. 1985;93:146-147.
Matsushima K, Yagmurlu K, Kohno M, et al. Anatomy and approaches
along the cerebellar-brainstem fissures. J Neurosurg. 2016;124:248-263.
Safavi-Abbasi S, Di Rocco F, Bambakidis N, et al. Has management of
epidermoid tumors of the cerebellopontine angle improved? A surgi-
cal synopsis of the past and present. Skull Base. 2008;18:85-98.
Schmidt RF, Boghani Z, Choudhry OJ, et al. Incidental vestibular
schwannomas: a review of prevalence, growth rate, and management
challenges. Neurosurg Focus. 2012;33:E4.
Please go to ExpertConsult.com to view the complete list of references.

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