PREOPERATIVE MANAGEMENT OF

CP ANGLE TUMOR.
Dr.SHABIH AYESHAH.
RESIDENT NEUROSURGERY.
PRESENTATION.

 Intracanalicular: Hearing loss (UL progressive ), tinnitus, vertigo

 Cisternal: – Worsened hearing and dysequilibrium •
 Compressive: – Occasional occipital headache
– CN V: reduced facial sensations, corneal hypesthesia
– CN VII :loss of taste and reduced lacrimation , LMN facial
weakness.
– CN VIII : progressive hearing loss,Tinnitus,vertigo
– CN IX,X : swallowing difficulty, hoarseness
 Hydrocephalic: Fourth ventricle compressed and obstructed – Headache,
visual changes, altered mental status – Nausea and vomiting
 Cerebellar involvement – Incoordination , widely based gate , tendency to
fall towards affected side
 Brainstem involvement: ‐ Ataxia, weakness and numbness of arms and legs
with exaggerated tendon reflexes.
INVESTIGATIONS.

 Audiometric Testing.
 Electrophysiologic Testing.
 CT Brain contrast with bone cuts.
 MRI brain contrast
 Audiometric Testing.
 Pure‐tone testing: – SNHL‐ most commonly high frequency (65%).
 Speech discrimination: – Scores out of proportion with pure‐tone thresholds.
 Acoustic reflex thresholds: – typically elevated or absent. – If present then
reflex decay measured. – The sensitivity is 85% for detecting retrocochlear
problem.
 Electrophysiologic Testing.
 ABR: Most sensitive & specific audiologic test. •
 In patients with VS , the ABR is partially or completely absent , or there is a
delay in latency of wave V on the affected side.
 RADIOLOGICAL FINDINGS IN DIFFERENT CP ANGLE TUMORS.

 VESTIBULAR SCHWANNOMA.
 CT – Non‐contrast: usually isodense to brain, calcification is rare
– IV Contrast: Over 90% of non‐treated tumors enhance
homogenously.
 MRI – T1W – isointense to brain, hyperintense to CSF
– T2W – hyperintense to brain, iso/hypo‐intense to CSF
– Intense enhancement of tumor on T1C
 MENINGIOMA.
 CT scan: -Noncontrast; slightly increased density
- IV Contrast; enhances uniformly.
-Hyperostosis of the cranial vault may also be seen.

 MRI scan: -T1W: Iso to hyperintense to brain.

-T2W: hypointense to brain.
-T1C: stong homogenous enhancement.
 EPIDERMOID CYST.
Radiologic Features – Cistern oriented with variable shape with a
cauliflower surface appearance
 ARACHANOID CYST.
Treatment Options.

 Observation
 Surgical resection
 Radiotherapy (EBRT, FSRT, SRS)
 OBSERVATION.
 Indications.
– Advanced age
– Poor health
– Lack of symptoms
– Non progression of symptoms
– Only hearing ear
 Contraindications.
– Young patient
– Healthy patient
– Symptomatic progression
– Compression of brainstem structures
 MRI recommended every 6 to 12 months in patients without baseline hearing
loss and stable or slow growth rates, especially elderly patients.
 30%-50% of tumors show no growth or regression on serial imaging studies
 Growth rate is highest for those that grow in first year.
 Progressive decrease in rate of growth if growth starts later.
 No predictive relationship between growth rate and tumor size at
presentation.
 Stereotactic Radiosurgery.
 Indications.
– Small tumors
– Functional hearing
– Older patients (>75)
– Medically unstable patients
– Small residual lesion
 Contraindications
– Tumors > 3 cm
– Prior radiotherapy
– Tumor compressing brainstem
 GOALS OF GAMMA KNIFE TREATMENT:
1. Arrest tumor growth.
2. Preserve facial nerve function.
3. Preserve trigeminal nerve function.
4. Preserve hearing.

 Modern SRS series:

-lower doses 12-13Gy
-MRI-based planning, improved conformality in plans (multiple isocenters
improved planning systems)
• PFS: 92-100%
• CN V preservation: 92-100%
• CN VII preservation: 94-100%
• Hearing preservation: 60-68%
 SURGICAL INTERVENTION.
Approaches (based on size, location, and consideration of hearing
preservation).

 BASIC REQUISITE FOR SURGERY;

• CT scan brain plain and contrast
• Bone cuts of the skull base with 1.5 mm cuts to visualise the high lying jugular
• MRI scan brain plain and contrast study

 APPROACHES.
1. Retromastoid suboccipital (retrosigmoid).
2. Middle cranial fossa (transtemporal).
3. Translabyrinthine.
4. Retrolabyrinthine.