Surgical Removal of Giant Acoustic Neuromas Joana Silva 1 , António Cerejo 1 , Filipe Duarte 1 , Fernando Silveira 2 , Rui Vaz 1 INTRODUCTION Radical surgical removal of giant acoustic neuromas is a challenging task. Dysfunc- tion of facial nerve and hearing loss can occur after surgery, and mortality and se- rious morbidity are possible when tumors reach huge dimensions (7, 16). Currently, surgery is the main option in the manage- ment of giant acoustic neuromas. Al- though alternatives to radical surgery can be considered (as staged resection or par- tial removal followed by radiosurgery [4, 6, 11]), complete removal of the tumor in a single operation is possible and is the treatment of choice (14). The outcome in a series of 29 patients with giant acoustic neuromas (40 mm in maximum diameter) submitted to rad- ical resection in a single operation was retrospectively analyzed, namely, the postoperative results concerning facial function and hearing. Surgical morbidity and evolution after surgery of preopera- tive neurologic conditions, like hydro- cephalus or facial hypoesthesia, were also studied. MATERIAL AND METHODS Patient Population Twenty-nine patients with giant acoustic neu- roma consecutively operated in our Department between 2005 and 2010 were included in the study. The mean age was 45 years (14-72 years), and there were 12 female and 17 male patients. Clinical Presentation Some degree of hypoacousia was present in all cases, without any cases of normal hearing ( Ta- ble 1). Tinnitus was referred in all cases. Three patients had facial dysesthesia and there were two cases of trigeminal neuralgia (one on the contralateral side). In one case, there was diplo- pia due to sixth-nerve palsy. Ataxia was present in eight cases, and nystagmus in two cases. One patient had a history of swallowing distur- bances. Signs of intracranial hypertension led to diagnosis in three patients, and, in two cases, there was loss of vision associated with hydro- cephalus. Neuroradiologic Findings Tumor size ranged from 40 to 61 mm, in maxi- mum diameter. Five of the tumors were cystic ( Figure 1), and 24 were solid ( Figure 2). Radio- logic signs of hydrocephalus were present in six patients at the time of diagnosis.  OBJECTIVE: The authors present the outcome of radical surgical removal of giant acoustic neuromas.  METHODS: Twenty-nine patients with acoustic neuroma with maximum diameter greater than 40 mm, submitted to surgery between the years 2005 and 2010, were reviewed by a retrospective study. The extension of tumor removal, surgical morbidity, facial nerve function, hearing, and evolution after surgery of preoperative neurologic conditions were the studied parameters.  RESULTS: All tumors were completely removed by a retrosigmoid approach, without perioperative mortality. As complications related to the surgery, there were three cases of local cerebrospinal fluid leak, one case of nasal cerebrospinal fluid leak, two cases of meningitis, one pseudomeningocele, and one case of transient lower cranial nerve dysfunction. The anatomic integrity of the facial nerve was preserved in 86% and facial function in 72%. In the 21 patients who did not need hypoglossal–facial anastomosis (72%), facial function was excellent or good (HB I-II) in 13 cases (45%), fair (HB III) in 5 cases (17%), and poor (HB IV) in 3 cases (10%). Before surgery, 12 patients (41%) had useful (H2) or moderate (H3) hearing. In 7 of these 12 patients (58%), it was possible to preserve some hearing function (with moderate hearing), after surgical removal of the tumors. Six patients presented with radiologic signs of hydrocephalus, two of them with visual disturbances. Two patients presented with trigeminal neuralgia (one contralateral), three with facial sensory loss and one with swallowing problems, that disappeared after surgery.  CONCLUSIONS: Total removal of large acoustic neuroma can be achieved by retrosigmoid approach with acceptable morbidity and no mortality. Preoperative neurologic symptoms recovered after surgery in most cases. Facial function preservation was possible in the majority of cases. Even in large tumors, hearing preservation should be attempted if the patient has useful hearing preoperatively. Key words  Facial nerve preservation  Giant vestibular schwannoma  Hearing preservation  Radical surgery Abbreviations and Acronyms CSF: Cerebrospinal fluid HB: House-Brackmann grading system MRI: Magnetic resonance imaging From the Departments of 1 Neurosurgery and 2 Neurophysiology, Hospital São João, University of Porto, Porto, Portugal To whom correspondence should be addressed: Joana Silva, M.D. [E-mail: joana.msilva@ymail.com] Citation: World Neurosurg. (2012) 77, 5/6:731-735. DOI: 10.1016/j.wneu.2011.08.019 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved. PEER-REVIEW REPORTS WORLD NEUROSURGERY 77 [5/6]: 731-735, MAY/JUNE 2012 www.WORLDNEUROSURGERY.org 731