NEUROSURGICAL

FOCUS Neurosurg Focus Video 5 (2):V9, 2021

VIDEO
Dorsal displacement of the facial nerve in vestibular
schwannoma surgery
Gustavo S. Jung, MD,1 Joel Fernando Sanabria Duarte, MD,2 Afonso H. de Aragão, MD,2
Ronaldo Pereira Vosgerau, MD,3 and Ricardo Ramina, MD, PhD1
1
Department of Neurological Surgery, Skull Base Division; 2Department of Neurological Surgery, Post-Graduate Program; and
3
Department of Radiology, Neuroradiology Division, Neurological Institute of Curitiba, Paraná, Brazil

The course of the facial nerve (FN) has been extensively investigated in patients with vestibular schwannomas (VSs). FN
running dorsally to the tumor capsule accounts for less than 3% of the cases. Diffusion tensor imaging (DTI)–based fiber
tracking helps to preoperatively identify the FN. During surgery, a higher risk of injury is associated with the dorsal loca-
tion of the FN. The authors demonstrate the nuances and tricks to identify and preserve a dorsal displaced FN during
resection of a large VS, T3b according to the Hannover classification, through the retrosigmoid-transmeatal approach.
The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2182
https://thejns.org/doi/abs/10.3171/2021.7.FOCVID2182
KEYWORDS acoustic neuroma; facial nerve; facial palsy; vestibular schwannoma

Transcript the pinna is designed, and a retrosigmoid craniotomy is

This is Dr. Gustavo Jung and I’ll demonstrate the mi- elevated in a standard fashion.
crosurgical resection of a vestibular schwannoma with the 2:06 Dural Incision and Arachnoid Dissection. The
facial nerve dorsally displaced and the technique to iden- dura is incised in C-shape fashion and a perpendicular cut
tify the course of the facial nerve during surgery. is made toward the sigmoid-transverse junction to increase
0:35 Patient History. This 57-year-old male discov- the view angle of the petrous surface. The dura is elevated
ered a large vestibular schwannoma during a diagnostic with 4-0 Prolene sutures.
workup for right-side tinnitus. It was classified as a T3b 2:22 Tumor Exposure. The inferior surface of the
vestibular schwannoma according to the Hannover classi- cerebellum is gently retracted, and the cerebellum-medul-
fication and stage III according to Koos classification. The lary cistern is opened to brain relaxation. The microscope
patient had an AAOHNS hearing class B and a House- is turned toward the tentorial surface of the cerebellum
Brackmann grade I facial nerve function. inspecting for cerebellar bridge veins and Dandy’s vein.
1:03 Preoperative Imaging. The T1 postgadolini- A small bridge vein is coagulated around the jugular fora-
men and cut. The arachnoid membrane is adherent to the
um MRI demonstrated a CP angle mass compressing the
dorsal surface of the tumor. To avoid injury to the nerves or
brainstem with extension to the most lateral part of the in-
the tumor capsule, the arachnoid is released from the lower
ternal auditory canal. The tumor was predominantly solid, cranial nerves; at this place it is not tightly adherent to the
and a CSF cleft sign was not visible between the tumor and tumor capsule. The arachnoid layer becomes visible at the
the brainstem. The CISS MRI did not raise any suspicion dorsal surface of the VS. A nerve structure is visible on the
on the facial nerve’s position and DTI-based fiber tracking dorsal surface of the tumor and EMG activity of the facial
was not acquired in this case. nerve is recorded. A further dissection of the arachnoid
1:36 Patient Positioning, Skin Incision and Crani- around the lower cranial nerves is necessary to expose the
otomy. The patient was positioned supine with the head brainstem. A progressive 1.0- and 2.0-mA stimulus is used
turned approximately 60° to the left side. The right shoul- and only mild response is observed. The brainstem is in-
der was elevated with a cushion to facilitate head turning. spected, and the facial nerve is visualized running dorsally
Facial nerve monitoring and brainstem auditory evoked to the tumor capsule. The inferior vestibular nerve and the
response were used. A straight skin incision 4 cm behind proximal portion of the facial nerve are identified. Some

SUBMITTED May 20, 2021. ACCEPTED July 19, 2021.

INCLUDE WHEN CITING DOI: 10.3171/2021.7.FOCVID2182.

© 2021 The authors, CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/) Neurosurg Focus Video Volume 5 • October 2021 1

Unauthenticated | Downloaded 10/02/21 01:26 AM UTC

Jung et al.

mild EMG response is also evoked during the stimulation 7:52 Conclusions and References. In summary, ves-
of the upper pole of the tumor, making unpredictable the tibular schwannomas are challenging lesions regardless
precise course of the facial nerve. the position of the facial nerve. Dorsal displacement of the
4:10 Internal Auditory Canal Drilling. To better facial nerve is rare and accounts for less than 3% of the
delineate the trajectory of the facial nerve, the distal por- cases.1–3 DTI-based fiber tracking can help to the identify
tion of the FN is exposed inside the IAC. A dural flap is the facial nerve course preoperatively,4,5 but its accuracy is
harvested and kept attached over the jugular foramen. We intermediate when the nerve is running dorsally.6 Starting
start drilling the IAC with a large cutting burr, creating arachnoid dissection at the lower pole of the tumor (around
a safety cavity to prevent the drill slide. Smaller cutting the jugular foramen—where it is looser) helps to release the
burrs are used until an eggshell bone is left over the IAC. arachnoid in the dorsal surface of the tumor. This strategy
Diamond drills are used to expose the dura inside the IAC associated with the neuromonitoring may avoid injury to
and enlarge the bone cavity sufficiently to access the lat- the tumor capsule and dorsally displaced nerves. In those
eral portion of the tumor. cases, our strategy is to first identity the nerve at brainstem
and then open the IAC to dissect the facial nerve within
4:54 Removal of Intrameatal Tumor and Facial the IAC. The nerve is usually very adherent to the tumor
Nerve Identification. The dura inside the IAC is incised capsule at the meatus entrance. The electric stimulation of
with microscissors, and the inferior vestibular nerve is dis- this cisternal-meatal transition of facial nerve will help in
sected away from the tumor. The tumor within the IAC is its identification and dissection. Thank you.
dissected with a blunt hook dissector and removed. The
facial nerve is identified and stimulation on the upper and
lower portions of the cisternal-meatal region identify the References
facial nerve running dorsal inferiorly. 1. Casselman JW, Kuhweide R, Deimling M, Ampe W, De-
haene I, Meeus L. Constructive interference in steady state-
5:22 Removal of the Cisternal Tumor. After identi- 3DFT MR imaging of the inner ear and cerebellopontine
fying the facial nerve running dorsal inferiorly, intracap- angle. AJNR Am J Neuroradiol. 1993;​14(1):​47-57.
sular tumor debulking is done and the attention is kept to 2. Sampath P, Rini D, Long DM. Microanatomical variations
the upper pole of the tumor. The arachnoid is first dissect- in the cerebellopontine angle associated with vestibular
ed in the upper pole of the tumor coming from the meatus schwannomas (acoustic neuromas):​a retrospective study of
up to the facial nerve at the brainstem. The inferior por- 1006 consecutive cases. J Neurosurg. 2000;​92(1):​70-78.
3. Mastronardi L, Cacciotti G, Roperto R, Di Scipio E, Tonelli
tion of the tumor is dissected from lateral to medial, and MP, Carpineta E. Position and course of facial nerve and
additional debulking is done. A decrease in the amplitude postoperative facial nerve results in vestibular schwannoma
of waves III and V in the AED is recorded, and papaver- microsurgery. World Neurosurg. 2016;​94:​174-180.
ine solution is instilled until waves recovery. The cochlear 4. Kakizawa Y, Seguchi T, Kodama K, et al. Anatomical study
nerve is identified anterior to the inferior vestibular nerve of the trigeminal and facial cranial nerves with the aid of
and the facial nerve. 3.0-tesla magnetic resonance imaging. J Neurosurg. 2008;​
Bimanual dissection with a tumor forceps in nondomi- 108(3):​483-490.
5. Chen DQ, Quan J, Guha A, Tymianski M, Mikulis D, Ho-
nant hand and a blunt hook dissector in the dominant daie M. Three-dimensional in vivo modeling of vestibular
hand, the facial nerve is dissected from the tumor capsule schwannomas and surrounding cranial nerves with diffusion
all the way to the IAC. Preservation of facial nerve func- imaging tractography. Neurosurgery. 2011;​68(4):​1077-1083.
tion is confirmed with proximal and distal electric stimu- 6. Gerganov VM, Giordano M, Samii M, Samii A. Diffusion
lation with 1.0 mA. tensor imaging-based fiber tracking for prediction of the
position of the facial nerve in relation to large vestibular
6:41 Internal Auditory Canal Reconstruction. The schwannomas. J Neurosurg. 2011;​115(6):​1087-1093.
vascularized dural flap is rotated into the IAC covering
the nerves. A 0.5-mm hook dissector is used to inspect the
walls of IAC for the presence of opened mastoid air cells. Disclosures
These cells are occluded with small pieces of muscle, and The authors report no conflict of interest concerning the materi-
the IAC is completely occluded with a larger piece of mus- als or methods used in this study or the findings specified in this
cle, Surgicel, and fibrin glue. publication.
7:07 Dural Closure. The dura is closed in watertight Author Contributions
fashion with 4-0 Prolene sutures, and the mastoid air cells Primary surgeon: Ramina. Assistant surgeon: Jung. Editing
are closed with bone wax. The bone flap is repositioned and drafting the video and abstract: Jung, Duarte, de Aragão.
and fixed with titanium plates. Critically revising the work: Jung, Duarte, de Aragão, Ramina.
7:21 Postoperative Course. Postoperative MRI did Reviewed submitted version of the work: Jung, Duarte, de
not show any residual lesion, and the facial nerve is well Aragão. Approved the final version of the work on behalf of all
authors: Jung. Supervision: Ramina. Diagnostic imaging consul-
visualized in the CISS MRI. The patient remained 1 day tant: Vosgerau.
in the ICU and was discharged home in the postopera-
tive day 4. The patient remained stable with a House- Correspondence
Brackmann grade III facial palsy that recovered to grade Gustavo S. Jung: Neurological Institute of Curitiba, Paraná,
I 4 months after surgery with physiotherapy. Hearing de- Brazil. gustavosjung@gmail.com.
creased to AAOHNS class C.

2 Neurosurg Focus Video Volume 5 • October 2021

Unauthenticated | Downloaded 10/02/21 01:26 AM UTC