My strategies for a section of large acoustic neuromas have evolved from gross total aggressive resection to radical subtotal removal with preservation of facial nerve function. This is a 32 year old male who presented with a right-sided hearing loss, and on MRI evaluation, was known to have a relatively large medially-located acoustic neuroma. He underwent a suboccipital or a retromastoid craniotomy in the lateral position. The suboccipital muscles were mobilized inferiorly. The emissary vein was interrupted and controlled. Borehole was placed at the prism junction of the transfer since sigmoid sinuses. The dura was in size around the venous sinuses. I ignored all dissection, identify the lower cranial nerves early. Debulking of the tumor allowed mobilization of the inferior pole of the tumor from the lower cranial nerves and the brain stem. A plan can be relatively easily found in this area for these tumors. Now the tumor capsule is being rolled in the lateral direction and the breast stem is being protected as much as possible. Sharp dissection is used at the areas where the peel plans against the brainstem are more identifiable. My dissection continued along the more medial aspect of the brainstem, whereas you can see the tumor is quite adherent to the peel of that brain stem. This is relatively typical for large encystic tumors. Sharp dissection is used as much as possible. Here is the eighth cranial nerve that's being disconnected. Stimulation mapping will next identify the facial nerve near the brain stem. Here's the facial nerve that was identified early. The nerve is very much engulfed by the tumor. I re-diverted my attention superiorly where the tumor was further debulked from the trigeminal nerve. However, a portion of the tumor was left behind to protect facial function. As you can see, even though small piece of tumor was left behind, the appearance of this residual tumor on MRI is relatively very minimal and small, and this patient recovered from his surgery without any facial function deficit. Thank you.
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