Treatment Options for Acoustic Neuroma (Vestibular Schwannoma)

Management Algorithm Based on Tumor Size and Symptoms

The American Academy of Neurology recommends observation with serial MRI and audiological monitoring as the management of choice for small asymptomatic tumors, with an evidence level of III and recommendation level C 2, 3
Annual MRI follow-up for 5 years is recommended for small asymptomatic tumors, with longer intervals thereafter if stable, according to the American Academy of Neurology 4, 5
Stereotactic radiosurgery is an alternative to observation for small asymptomatic tumors, with an evidence level of II and recommendation level B, as recommended by the American Society for Therapeutic Radiology and Oncology 3
Surgery is not recommended for small asymptomatic tumors due to high risk of functional deterioration, with an evidence class of III and recommendation level C, as stated by the Congress of Neurological Surgeons 2, 3

The American Academy of Neurology recommends annual MRI and audiometry for 5 years, then every 2 years if stable, for conservatively managed, radiated, and incompletely resected tumors 4
The Congress of Neurological Surgeons recommends MRI controls postoperatively and after 2, 5, and 10 years for gross total resection 4, 7

Surgical treatment at a high-volume center is recommended due to impact on outcomes, with an evidence class of IV and good practice point, as recommended by the American College of Surgeons 3
Risk for tumor regrowth after subtotal resection rises with residual tumor volume, according to the National Comprehensive Cancer Network 6

The American Academy of Neurology recommends discussion of patients with vestibular schwannoma in multidisciplinary tumor boards, especially for medium-sized tumors 3, 5
The American College of Radiology states that quality of life outcomes cannot be predicted based on management strategy alone 4, 8
Poor quality of life is more likely in patients with large, symptomatic tumors that require resection, as reported by the American Society of Clinical Oncology 8