Vestibular schwannoma surgery in the elderly

Objective: To compare the outcome among patients greater than 65 years old undergoing microsurgical resection of a sporadic, unilateral vestibular schwannoma (VS) to patients 65 years or younger. Methods: Retrospective review of all patients with unilateral, sporadic VS operated by the senior authors from 1999 through 2015 was conducted. We reviewed and compared the patient demographic, clinical, surgical, and follow-up data between the two age cohorts. Results: There were 550 patients included in the analysis. 481 (88 %) were up to 65 years of age and 69 (12 %) were over 65 years of age. Tumors in the older group tended to be larger and more likely cystic. Additionally, subtotal resection (STR) was more common in patients greater than 65 years old. Major complications in both age groups included CSF leak, infection, hydrocephalus, and dysphagia. Mean follow-up in the patients older than 65 years old was 3.5 years (range 0.1-11.0 years) and 3.8 years (range 0.2-14.0 years) in the younger group. Preoperative hearing function was significantly worse in the older cohort. The majority of both groups did not have serviceable hearing at last follow-up. Acceptable postoperative facial nerve function (House-Brackmann grade 1 or 2) was seen in 393 (82.1 %) of younger patients and 50 (72.5 %) older postsurgical patients (p = 0.035). Additionally, recurrence rates, defined as residual tumor growth or recurrence of completely resected tumor, were higher in the elderly group (8.7 % vs. 3.3 %) compared to the younger patients (p = 0.033). Conclusions: Our retrospective review, not surprisingly, reveals patients over the age of 65 years who undergo surgery at our institution tended to have larger tumors and cystic tumors, compared to the younger cohort and presented with worse hearing. They also tended to receive less aggressive resections and even with this, there was a higher likelihood of worse facial nerve outcome. We think these results are explained by significant selection bias in that most patients over the age of 65 years are counselled to consider stereotactic radiosurgery as primary treatment if their symptoms and tumor size allows. Most notably, when subtotal tumor resection is elected, careful surveillance of any tumor remnant is extremely important as regrowth occurs in almost 10 % of patients in our series.