NEUCIR-370; No.

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NEUROCIRUGÍA

www.elsevier.es/neurocirugia

Special article

LINAC radiosurgery treatment for vestibular

schwannoma

Ángela Ros-Sanjuán a,∗ , Sara Iglesias-Moroño a , Marta Troya-Castilla a , Bernarda

Márquez-Márquez a , Ismael Herruzo-Cabrera b , Miguel Ángel Arráez-Sánchez a
a Department of Neurosurgery, Regional University Hospital of Malaga, Malaga, Spain
b Radiation Oncology Department, Regional University Hospital of Malaga, Malaga, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aims of our study were to evaluate tumour response in a series of patients
Received 18 November 2018 with vestibular schwannoma (VS) treated with linear accelerator stereotactic radiosurgery
Accepted 21 December 2018 (LINAC-RS), to describe the complications and to analyze the variables associated with the
Available online xxx response to treatment.
Material and methods: This retrospective descriptive study included 64 patients treated from
Keywords: 2010 to 2016 with a minimum follow-up of one year, excluding patients with neurofibro-
Stereotactic radiosurgery matosis. Clinical–radiological parameters were evaluated. The treatment was performed
Linear accelerator using LINAC-RS. The prescribed dose was 12 Gy at 90% isodose.
LINAC-RS Results: The mean age at treatment was 53 years, 56% were women. Ninety-eight percent
Vestibular schwannoma of the patients had hearing loss, 71% with grade III according to the Gardner–Robertson
Classification. The mean volume at treatment was 2.92 cc and the mean follow-up,
40.95 months. The overall therapeutic success was 90%, reaching 100% at 12 and 24 months,
and 86% after 36 months of follow-up. The radiological result was significantly related to
the initial tumour volume (p < 0.037). In 20 patients there was evidence of transient tumour
growth compatible with pseudoprogression. Acute complications were present in 37.5%, and
transitory complications in 50%. Chronic complications were found in 20%, with 84% being
permanent. The rate of acute complications was lower in patients with regression (p < 0.016).
Chronic complications were more frequent in the 41–60 year old age group (p < 0.040).
Conclusions: In our study, the overall tumour control was in accordance with other published
series. The radiological result significantly related to the tumour volume at the commence-
ment of treatment. The rate of acute complications was lower in patients with regression.
© 2019 Sociedad Española de Neurocirugı́a. Published by Elsevier España, S.L.U. All rights
reserved.

∗
Corresponding author.
E-mail address: rossanjuanangela@gmail.com (Á. Ros-Sanjuán).
https://doi.org/10.1016/j.neucir.2018.12.005
1130-1473/© 2019 Sociedad Española de Neurocirugı́a. Published by Elsevier España, S.L.U. All rights reserved.

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Tratamiento con radiocirugía micromultiláminas de schwannomas

vestibulares

r e s u m e n

Palabras clave: Objetivo: Los objetivos del estudio fueron evaluar la respuesta tumoral en una serie
Radiocirugía estereotáxica de pacientes con schwannoma vestibular (SV) tratados con radiocirugía (RC) mediante
Acelerador lineal acelerador lineal de electrones (LINAC), describir las complicaciones y analizar las variables
Rc-LINAC relacionadas con la respuesta al tratamiento.
Schwannoma vestibular Material y métodos: Estudio descriptivo retrospectivo de 64 pacientes tratados entre 2010-
2016 con seguimiento mínimo de un año, excluyendo pacientes con neurofibromatosis. Se
evaluaron parámetros clínico-radiológicos. El tratamiento se realizó mediante RC-LINAC. La
dosis prescrita fue de 12 Gy al 90% de isodosis.
Resultados: La edad media al tratamiento fue de 53 años, 56% mujeres. El 98% de los pacientes
presentaban hipoacusia, el 71% grado iii según la clasificación Gardner-Robertson. El volu-
men medio al tratamiento fue de 2,92 cc, y la media de seguimiento 40,95 meses. El éxito
terapéutico global fue del 90% siendo del 100% a los 12 y 24 meses y del 86% a partir de los
36 meses de seguimiento. El resultado radiológico se relacionaba con el volumen tumoral ini-
cial (p < 0,037). En 20 pacientes se evidenció un crecimiento tumoral transitorio compatible
con seudoprogresión. El 37,5% tuvieron complicaciones agudas siendo transitorias el 50%.
Se recogieron complicaciones crónicas en el 20%, siendo permanentes en el 84%. La tasa de
complicaciones agudas era menor en pacientes con regresión (p < 0,016). Las complicaciones
crónicas fueron más frecuentes en el grupo de 41-60 años (p < 0,040).
Conclusiones: En nuestra serie, el control tumoral global obtenido es acorde con otras series
publicadas. El resultado radiológico estaba relacionado con el volumen tumoral inicial al
tratamiento. La tasa de complicaciones agudas fue menor en pacientes con regresión.
© 2019 Sociedad Española de Neurocirugı́a. Publicado por Elsevier España, S.L.U. Todos
los derechos reservados.

between 2010 and 2016, whose minimum follow-up time was

Introduction 12 months. Patients with neurofibromatosis were excluded.

Vestibular schwannomas (VS) represent 6–10% of intracranial

Indication for treatment and description of the technique
neoplasms1 and 80–90% of cerebellopontine angle tumors.2
The therapeutic option (expectant behavior, surgery, or radio-
Our study was conducted in the skull base unit of the neuro-
surgery – RS) varies depending on the characteristics of the
surgery service at a tertiary hospital in which there are two
patient and the radiological features of the tumor. RS is a
neurosurgeons specialized in radiosurgery. In bulky schwan-
radiotherapy technique first used by Lars Leksell in 1951. Local
nomas (Koos grade III in young patients or cystic tumors
control rates are similar for surgery and RS (95%), with the
and Koos grade IV), and in patients with trigeminal neu-
latter described as offering better hearing preservation (60%)
ralgia due to the compressive effect of the lesion, surgery
and facial nerve preservation (98%). However, this technique
is considered the first therapeutic option. With the inten-
is not without complications. Treatment with a linear electron
tion of preserving facial nerve function, less radical surgeries
accelerator (LINAC) with a micro-multileaf collimator is an
are currently performed and radiosurgery treatment is used
RS modality described in 1984 that has shown similar results
as an adjuvant treatment or at progression, depending on
compared to other types such as GammaKnife, proton beam
each case. In tumors with Koos grades III and IV in elderly
or Cyberknife and has been used in our center since 2010.
patients with an excessive surgical risk or who refuse surgical
The objectives of our study were to evaluate tumor
treatment, radiosurgery or fractionated stereotactic radio-
response in a series of patients with VS treated using LINAC-
therapy is proposed, respectively. The follow-up option is
RS, describe complications after the procedure and analyze
offered to patients with schwannomas smaller than 1.5 cm
variables related to response to treatment and complications.
in maximum diameter that are paucisymptomatic and with
no evidence of accelerated growth, especially older patients
Material and methods (lower potential risk of growth). All potential candidates for
treatment with radiosurgery are evaluated by a multidisci-
Patient cohort plinary committee (neurosurgery, radiotherapeutic oncology,
medical physics and radiology) to determine if it is ultimately
This was a retrospective descriptive study of patients diag- the best option for the patient. The main limiting factor for RS
nosed with VS, treated in our center using LINAC-RS treatment is the dose tolerance for the adjacent organs at risk

Please cite this article in press as: Ros-Sanjuán Á, et al. LINAC radiosurgery treatment for vestibular schwannoma. Neurocirugia. 2019.
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Fig. 1 – LINAC-RS treatment planning. (A) Cranial scout of the patient with placement of the stereotactic frame.
(B) Contrast-enhanced T1-sequence brain MRI (tumor with homogeneous uptake in right cerebellopontine angle) during
therapeutic planning. Organs at risk are contoured, including cochlea, brainstem and tumor lesion. (C) 3D view after
planning. (D) Relationship of the tumor (purple color) with the organs at risk. (E) Isodose curves in an irradiated volume
in axial and (F) coronal slices.

(cochlea, brainstem, cranial nerves V and VII). Radiosurgical Variables

treatment was performed with a Varian 600DBX linear elec-
tron accelerator with 6 MV photons, coupled with a Brainlab
M3 micro-multileaf collimator. A Brainlab iPlan 4.5 planning
system was used for clinical dosimetry calculation. For immo-
bilization, an invasive stereotactic frame was placed onto the
skull after injection of local anesthetic at the four fixation
points. 3D planning was conducted using computed tomogra-
phy under stereotactic conditions combined with a previous
contrast-enhanced axial T1- and T2-weighted brain MRI with
1-mm slice thickness. The prescribed dose in all cases was
12 Gy at 90% isodose (Fig. 1).
The following variables were recorded: age (grouped as:
<41 years, 41–60 years, >60 years), sex, symptomatology
at treatment (such as cranial nerve V or VII involvement,
headache, tinnitus, dizziness, nausea, and instability), degree
of hearing loss according to the Gardner–Robertson Classifi-
cation, reason for treatment and history of previous surgery.
Radiological variables were: tumor laterality, location (intra-
canalicular or intra-extracanalicular) and Koos grade.3 Two-
dimensional tumor volume was calculated by measuring the
lesion in the three axes of space on contrast-enhanced T1 MRI

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sequences (anteroposterior [A]; mediolateral [B]; craniocau-

Table 1 – Clinical and radiological descriptive variables.
dal [C]) and applying the simplified version of the ellipsoidal
Clinical variables No. (%)
volume formula ([A × B × C]/2)4–6 initially and subsequent to
treatment observed in controls at 6, 12, 24 months and from Age (years) 53 [23–76]
36 months. Tumor volume was divided in different size ranges: <41 14 (22)
<0.50 cc, 0.51–1.99 cc, 2–5.99 cc and >6 cc. Follow-up in months 41–60 29 (45)
>60 21 (33)
was calculated from treatment to the last revision in consul-
tation. We recorded the clinical results of treatment, acute Sex M:F 28:36 (44:56)
complications (during the first 3 months), chronic complica- Reason for treatment
tions (from 3 months), and the number of patients with reso- Lesion >1.5 cm 24 (38)
lution of these. Complications were defined as new symptoms Growth 14 (22)
after treatment or worsening of already known symptoms. Rest post-surgery 14 (22)
Treatment success was considered to be those cases in which Clinical deterioration 7 (11)
Desire of the patient 4 (7)
radiological follow-up showed a regression (>10% decrease
compared to the pre-RS volume) or stabilization of the lesion Pre-RS variables
with respect to the initial volume (<10% change). Treatment Cranial nerve V involvement 11 (17)
Cranial nerve VII involvement 5 (8)
failure was defined as findings consistent with progression
Hearing loss 63 (98)
(>10% increase) beyond 20–24 months. Pseudoprogression was
defined as a transitory growth (>10% compared to the initial Gardner–Robertson
volume) after treatment followed by tumor stability or regres- II 6 (10)
III 45 (71)
sion with a minimum follow-up of 24 months.
IV 11 (17)
V 1 (1.5)
Statistical analysis Headache 4 (6)
Tinnitus 35 (55)
For the analysis of quantitative variables, Student’s t-test was VDI 22 (34)
Casual 2 (3)
used, considering normality criteria. For qualitative variables,
the Chi-Pearson test and the Fisher test were used (if the value Radiological variables
of the expected event was less than 5). p values <0.05 were Location
Intra-extracanalicular 51 (80)
considered statistically significant. IBM SPSS Statistics version
Intracanalicular 13 (20)
22.00 was used for the statistical analysis.
Lateralization
Right 31 (48)
Left 33 (52)
Results
Pre-RS tumor volume
<0.5 cc 8 (12.5)
A total of 64 patients were included and their clinical char-
0.51–1.99 cc 24 (37.5)
acteristics are shown in Table 1. The mean age at treatment 2.00–5.99 cc 24 (37.5)
was 53 years, and 56% were women. Ninety-eight percent >6.00 cc 8 (12.5)
of the patients had hearing loss at the commencement of
treatment, with Gardner–Robertson Classification grade III VDI: vertigo, dizziness, instability; Pre-RS: prior to radiosurgery
treatment.
being the most frequent (71%). The tumor location was pre-
dominantly intra-extracanalicular (80%), with no differences
regarding lateralization. The distribution according to Koos age, Koos classification, tumor location or clinical improve-
grade is shown in Fig. 2. The mean tumor volume at treatment ment.
was 2.92 ± 2.95 cc (0.092–14.94) and the mean at follow-up Twenty-four patients (37.5%) experienced complications
was 40.95 ± 15.63 months (14–86). Table 2 describes tumor (eight had acute and chronic complications). Fifty-eight
control in three groups of patients at the completion of follow- percent of the complications were related to vertigo,
up. The overall therapeutic success was 90% (58/64) reaching nausea or instability (14/24). The following acute compli-
100% at 12 and 24 months, in 3 and 17 patients respec- cations were found in 18 patients: dizziness and nausea
tively. Treatment success from 36 months on was 86% (a in six (self-limited in four), transient headache in two
total of 44 patients completed this follow-up). No loss to and instability in six (three with no subsequent improve-
follow-up was reported. Transient tumor growth followed by ment). There was one case each of trigeminal neuralgia,
regression or stabilization compatible with pseudoprogression hearing loss, facial hemispasm and tinnitus, and these
was observed in 20 (31%) patients. Patients with radiologi- complications were permanent. Fifty percent of the acute
cal results consistent with progression had a mean follow-up complications (9/18) were resolved within one year and
of 48 months (36–72), verified with at least two consecu- most required outpatient management. The rate of acute
tive MRIs. Tumor control was analyzed at the conclusion complications was significantly related to the radiological out-
of follow-up, revealing a statistically significant relationship come at completion of follow-up, with fewer complications
with pre-RS tumor volume, finding a greater decrease in in patients with regression during follow-up (p < 0.016). In
lesions with volumes between 0.51 and 5.99 cc (p < 0.037). No 13 patients (20%) the following chronic complications were
association was found between radiological control and sex, recorded: three with definitive hearing loss, four with chronic

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Discussion

Clinical characteristics

The mean age at diagnosis of VS in our study was simi-

lar to that of other published studies (55 years).7,8 Hearing
loss is a frequent form of presentation in up to 95%, tinnitus
in >60%, trigeminal nerve involvement in 12–19% and facial
nerve involvement in 17%.7 A higher incidence of schwanno-
mas in Caucasian patients has been described.7 As risk factors
for the development of VS, prolonged exposure to noise or abu-
sive use of mobile phones (>2 h per day for 10 years) could be
associated.9 In our series, there was a predominance of Koos
grade II and III lesions, as in other published series: 39% in both
cases. Only 3% were grade IV, while in other series the figure
was approximately 26%10 or even 44%.11 This difference may
be attributable to the fact that the policy of our center was to
offer surgical treatment to young patients with Koos grade IV
and fractionated stereotactic radiotherapy to older patients or
patients who refused surgical treatment.

Treatment

The choice of therapy depends on clinical factors such as

Fig. 2 – Koos classification. Radiological findings of the
series according to Koos classification: Koos I (0–10 mm
intrameatal): 19%; Koos II (<2 cm intra-extrameatal): 39%;
Koos III (<3 cm intra-extrameatal in contact with brain
stem): 39%; Koos IV (>3 cm intra-extrameatal with
brainstem compression): 3%.
instability, one patient developed self-limited headache, three
patients developed atypical facial pain with resolution in
one case, two patients developed nausea and vomiting
and another developed hydrocephalus after 24 months of
follow-up, requiring a ventriculoperitoneal shunt. These com-
plications were permanent in 84%. Chronic complications
were significantly more frequent in the 41–60 age group
(p < 0.040).
age, the functional status and hearing preservation, as well as
radiological factors including tumor growth during follow-up,
Koos grade or brainstem compression, both indirect indicators
of tumor volume.10 Furthermore, personal preference or the
medical center may influence therapeutic management.7,12
Within radiotherapy treatment, RS has shown similar results
to fractionated radiotherapy (FRT), the latter being espe-
cially useful in large irregular lesions in which surgery is not
possible.13,14 Among the different types of RS, the results of
treatment with LINAC are currently similar to those obtained
with GammaKnife.8,15,16
Expectant management, known as “wait-and-scan”,12,16
may be indicated in patients with lesions <1 cm17 with pre-
served hearing, while in lesions between 1 and 3 cm along
with comorbidity and advanced age, RS is usually the treat-
ment of choice.13,18 Similarly, in young people with preserved
hearing in whom there is no contraindication due to size or
compression of vital structures, RS is preferable to surgery for

Table 2 – Radiological results at completion of follow-up.

Evolution 12 months 24 months >36 months Total

Mean follow-up (months) 40.95 (14–86) ± SD 15.631

Mean tumor volume pre-RS (cc) 2.92 (0.092–14.94) ± SD 2.95
Progression – – 6 6
Regression 3 17(5a ) 31(10a ) 51(15a )
Stability – – 7(5a ) 7 (5a )
Patients 3 (5%) 17 (26%) 44 (69%) 64
Tumor control 3/3 100% 17/17 100% 38/44 86% 84%

SD: Standard Deviation; cc: cubic centimeters; Pre-RS: prior to radiosurgery.

a
Patients with transient tumor growth.

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comparable results with respect to tumor control and a lower

rate of complications.9,13,16,18–22 Some studies have reported
expectant management in Koos grade I lesions because of
their low rate of progression to be comparable to Koos I
lesions treated with RS.19,22,23 According to current guide-
lines, observation is indicated in patients with VS < 2 cm or
intracanalicular without tinnitus.24 Other authors, however,
report that expectant management requires strict follow-up
and that 14.5% of these cases will end up requiring treat-
ment, discouraging this measure in young people with signs
of hearing loss,9,16,25 where RS assumes a great therapeutic
role.2,13,21 Surgical treatment, currently the most common, is
indicated for lesions with mass effect and compression, espe-
cially if they are >3 cm.1,7,19,25 Young people with less atrophy
may present a greater degree of compression, thus indicat-
ing surgical decompression.10 In cases of VS Koos grade IV,
the combined approach using subtotal surgical excision with
functional monitoring followed by RS treatment reduces the
risk of facial nerve damage.12,18 (Fig. 3)

Treatment success

Tumor control after treatment with LINAC-RS varies between

81 and 100% at 3 years,8,15,26 and up to 90% at 5.8 years.8,22
In other studies, the success rate is 88% at 10 years.22 Similar
results were found in our series in which tumor control at the
end of follow-up was 90%. With GammaKnife, control has also
been described to be about 97% at 3 years,9 92% at 7 years,19
and 84.8% at 10 years25 (Table 3). In our series, 20 patients
presented transient growth (31%), consistent with pseudo-
progression, defined as transient growth of >20% followed by
stability or reduction, with a 31% rate described in the series.26
Peak incidence is described at around 6–9 months post-
treatment9,19,27 decreasing from the fifteenth month.26 Van de
Langenberg et al.26 reported pseudoprogression in 54% after
treatment with LINAC and others of up to 40%.8 In patients
treated with GammaKnife, pseudoprogression is described
as between 15 and 30% after a minimum follow-up of 24
months.19,26,27 In the study by Boari et al.,9 of the 332 patients
treated with GammaKnife, 54% showed an increase in volume
at 6 months, decreasing to 22% at 3 years, and only 5% showed
progression. To date, part of the pathophysiology remains Fig. 3 – Pseudoprogression and treatment success. Tumor
unknown.28 Although risk factors have been described that in 67-year-old female patient with severe hearing loss
could be related to age, irradiated dose or tumor volume, more (Gardner–Robertson IV). History of subtotal surgical
studies are needed to clarify these hypotheses.27 The recently resection of left VS one year earlier and
published study by Breshears et al.28 reported transient growth ventriculoperitoneal shunt for post-surgical hydrocephalus.
of 44% in one year with peak growth in 90% of cases during the (A) Treatment with LINAC-RS in 2012 of the rest of the
first 3.5 years after treatment. tumor after surgery (initial TV 3.2 cc). (B) Post-RS control
In our study, six patients showed growth >10% with respect MRI after 9 months of treatment, compatible with
to the initial volume during a minimum follow-up of 36 pseudoprogression (TV 4.2 cc). (C) Progressive regression in
months. The definition of progression according to each study control MRI at 24 months (TV 3.2 cc). (D) Control MRI
was defined as: increase >10%11,16 ; increase >20%10,26 ; growth at 36 months post-RS (TV 0.75 cc). TV: tumor volume.
>2 mm in two planes16,17,19 and even growth ≥3 mm,22 in a
minimum follow-up of 24 months26,27 and up to 36 months.8
A follow up as long as 6.9 years has been described as nec- with evidence of growth not requiring salvage treatment.15,25
essary in order to identify true cases of pseudoprogression.28 Furthermore, alternative treatment is not currently standard-
The rate of progression in our series could be overestimated ized and there is controversy regarding the management
due to a short follow-up period. In some studies, treatment of second-line treatment in these patients,15,25,28 with RS
failure is defined as progression requiring an alternative being an accepted retreatment option.24 Surgery as a sec-
treatment, without specifying a clear definition in those cases ond line after initial treatment with RS presents a greater

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Table 3 – Review of the literature on RS treatment for VS.

Study N RS Modality Follow-up Success > 2 Success > 5 Cranial nerve V Cranial nerve VII
(months) years years involvement (%) involvement (%)

Anderson (2014)14 48 LINAC 83.6 – 97% 10.5 2.1

Benghiat (2014)15 99 LINAC 29 100% – 8 2
Boari (2014)9 379 GK 75 – 97.1% 4 1.3
Wangerid (2014)19 128 GK 86 – 92% 2 3
Ikonomidis (2015)17 84 LINAC 39 91% 1.2 1.2
Ellenbogen (2015)8 49 LINAC 70 – 96% 2 2
Klijn (2016)25 420 GK 60 – 91.3% 3.1 1
Bowden (2017)11 219 GK 49 99.4% 96.4% 3 0.9
Rueß (2018)22 335 LINAC (270)CK(65) 30 98% 89% 3.8 3.6
Own series 64 LINAC 40 90% – 1.5 1.5

LINAC: linear accelerator; GK: gammaknife; CK: cyberknife.

probability of subtotal resection and seventh cranial nerve Complications

involvement.29 No risk factors related to tumor progression
have been found.17,19,22 When monitoring these patients,
MRI performed from 24 months onwards would be useful
to distinguish pseudo-progression from true progression
and avoid unnecessary treatments,24 which should not be
considered before 36 months and provided that there is a
clear trend towards growth in successive control MRIs. Early
MRI (at 6 or 12 months) facilitates the management of pos-
sible complications. An increase in volume in asymptomatic
patients treated with RS requires expectant management.26,28
Some studies have reported that tumor stability of at least
5 years indicates that tumor growth is unlikely in later years7
and that hearing loss is greater in the first few years after
diagnosis.16
Radiological tumor control after RS is independent of the
clinical response of the patient with respect to pretreatment
symptoms.27 The primary objective of RS treatment is radio-
logical control, with the lowest rate of complications enabling
the stabilization of established symptoms.15,22 In addition,
tumor response does not appear to be related to the initial
Koos grade.10,11 The response rate was equal in Koos grades
I and II vs grades III and IV.19 In our series, although tumor
response was not significantly related to the Koos grade, we
found statistically significant differences in response to treat-
ment according to pre-RS volume (p < 0.037), with a greater
decrease in lesions with a volume between 0.51 and 5.99 cc.
The initial tumor size has been described as a factor related
to subsequent radiological control5 demonstrating greater
reduction in volume, especially in macrocystic VS compared
to homogeneous and microcystic VS.11 The tumor volume and
tolerance dose for organs at risk are the main limiting factors
of RS treatment. For this reason, in large tumors (Koos IV) RS
is rejected from the outset and surgical treatment or fraction-
ated stereotactic radiotherapy is chosen. Only two patients in
our series presented Koos grade IV at the start of treatment.
Both had a personal history of subtotal surgery and sequelae
prior to RS treatment (facial palsy, grade IV hearing loss in
one, and dizziness and vertigo in the other). With a follow-up
longer than 36 months, the first patient showed tumor regres-
sion without clinical improvement and the second showed
radiological stabilization but required the implantation of a
ventriculoperitoneal shunt at 24 months for chronic hydro-
cephalus.
The rate of complications from RS is significantly lower than
that from surgical treatment. Hearing preservation with
surgical treatment is 5% compared to 65% with RS.7,13,18
Boari et al.9 report that hearing preservation after RS varies
according to age, with 92% in Gardner–Robertson grade I at
<55 years compared to 42.9% at >55 years. Hearing preser-
vation in these patients (grade I) is approximately >75–100%
at 2 years, >50–75% at 5 years and >25–50% at 10 years.22,30
Mulfer16 showed preservation of 44–68% in those patients
with preserved discrimination prior to treatment, requiring
a minimum follow-up of 10 years in order to establish an
accurate value. The degree of pretreatment hearing has been
considered a prognostic factor for subsequent preservation,
and hearing deterioration is less if hearing remains stable
after the first 6 months of RS treatment.17 In addition to age
and auditory function prior to treatment, the dose of irradia-
tion is of vital importance in the prognosis18,30 ; the Koos grade,
however, is not.17 In our series, a high percentage of patients
presented no useful hearing at diagnosis. Nevertheless, no
significant differences in hearing prognosis have been found
in the literature in patients treated with conservative manage-
ment compared to those treated with RS, although the latter
has demonstrated better local tumor control.2,23 Dizziness,
nausea and instability are the most frequent complications
found in our series (14 patients). The presence of tinnitus is
not usually resolved with treatment, with an improvement
of only 20%.9 The incidence of paralysis and temporary
facial weakness after surgery is 8% and 14%, respectively,
higher than with RS with 7.7% and 4.8%, respectively.7 An
improved radiotherapy technique has considerably reduced
the rate of complications22,24 including those related to
facial and trigeminal nerve neuropathy from 19% and 16%
to 1.5% and 1.2–3%.8,9,13,15,18,25 Other related complications
are hydrocephalus (4.4%) and malignant transformation
(<1%).7,16,24 According to the Common Terminology Criteria
for Adverse Events Classification, the complications described
in our study varied between grades 1 and 3, similar results
to other studies,22 with no complications requiring urgent
intervention or involving a short-term life-threatening risk
(grade 4), nor deaths related to adverse effects of treatment
(grade 5). The rate of acute complications was significantly
related to the radiological result at completion of follow-up

Please cite this article in press as: Ros-Sanjuán Á, et al. LINAC radiosurgery treatment for vestibular schwannoma. Neurocirugia. 2019.
https://doi.org/10.1016/j.neucir.2018.12.005
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NEUCIR-370; No. of Pages 9
ARTICLE IN PRESS
8 n e u r o c i r u g i a . 2 0 1 9;x x x(x x):xxx–xxx
and was lower in patients with regression (p < 0.016). This
could be a spurious result given the small sample size of our
series. Moreover, chronic complications were significantly
more frequent in the 41–60 age group (p < 0.040). This could
be due to the fact that elderly patients suffer from a degree
of cerebral atrophy that could avoid adverse effects derived
from the mass effect on the brainstem. Younger patients, in
contrast, may have greater functional and recovery capacity.
More studies would be needed to confirm this.
Little information has been reported about the functional
impact and quality of life in these patients.19,20,31 Health scale
scores show poorer outcomes in elderly patients with sys-
temic disease and associated neurological deficit.19 Measures
should be taken to improve the support of these patients with
regard to expectations concerning the course of the disease,
possibly with psychological support being the most important
factor.20,31
Limitations
The retrospective nature of our series as well as the recent
implementation of this technique in our center has so far only
allowed for the analysis of the series with a short follow-up
time and a small sample size.
Conclusion
Radiosurgery is a consolidated treatment option for VSs that
are not free of complications, although they are generally well
tolerated and transitory, demonstrating in our series a tumor
control in accordance with other published series. The radio-
logical result at the completion of follow-up was significantly
related to the volume at the start of treatment. The rate of
acute complications was significantly related to the radiologi-
cal outcome at the end of follow-up, with fewer complications
in patients with evidence of regression during follow-up.
Informed consent
Informed consent was obtained from all participants included
in the study, which was approved by the Hospital Ethics Com-
mittee.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Acknowledgements
The authors thank Maria Repice for her help with the English
version of this text.
Please cite this article in press as: Ros-Sanjuán Á, et al. LINAC radiosurgery treatment for vestibular schwannoma. Neurocirugia. 2019.
https://doi.org/10.1016/j.neucir.2018.12.005
Descargado para Anonymous User (n/a) en Universidad Nacional Autonoma de Mexico de ClinicalKey.es por Elsevier en mayo 08, 2019.
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