Vestibular schwannoma management: an evidence-based comparison of stereotactic radiosurgery and microsurgical resection.

BACKGROUND: The best management of vestibular schwannoma (VS) patients is controversial.

METHODS: A comparison of surgical resection and stereotactic radiosurgery based on recent studies using evidence-based medicine standards. Level 1 evidence is derived from randomized clinical trials, whereas levels 2, 3, 4, and 5 refer to prospective cohort studies, case-control series, case series, and expert opinions, respectively.

RESULTS: The vast majority of studies on VS management are either retrospective case series or opinions (level 4 and 5 evidence). Five retrospective case-control series (level 3 evidence) have shown improved cranial nerve outcomes, better cost effectiveness, and less impact on patients' activities of daily living for patients having radiosurgery. One prospective cohort study (level 2 evidence) found outcomes were superior for patients having radiosurgery compared to surgical resection with regard to facial movement, hearing preservation and quality of life measures. No randomized clinical trial has been performed to compare these two techniques.

CONCLUSION: The best quality of evidence (levels 2 and 3) show superior outcomes for VS patients having stereotactic radiosurgery compared to surgical resection allowing a grade B recommendation for this approach. Unless long-term follow-up shows frequent tumor progression at currently used radiation doses, radiosurgery should be considered the best management strategy for the majority of VS patients.