acoustic neuroma k. kevin ho, m.d. vicente a. resto, m.d., ph.d. department of otolaryngology...
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Acoustic NeuromaAcoustic Neuroma
K. Kevin Ho, M.D.Vicente A. Resto, M.D., Ph.D.
Department of OtolaryngologyUniversity of Texas Medical Branch
Neurinoma del Acustico
Prof. Agdo. Dr. Gustavo Costas
Asist. Dr. Rogelio Charlone
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HistoriaHistoria 1905 Dr. Harvey Cushing1905 Dr. Harvey Cushing
Diseccion meticulosaDiseccion meticulosa Mortalidad: 20 % (1917) Mortalidad: 20 % (1917) 4% 4%
(1931)(1931)
1916 Dr. Walter Dandy1916 Dr. Walter Dandy
Remocion completa del NARemocion completa del NA Mortalidad: 10%Mortalidad: 10%
1960 Dr. William House1960 Dr. William House Abordaje Translaberintico Abordaje Translaberintico
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EpidemiologiaEpidemiologia
6 - 9 % de los tumores intracraneales6 - 9 % de los tumores intracraneales 80 - 90% de los tumores del CPA 80 - 90% de los tumores del CPA Incidencia en US: 10 por millon / añoIncidencia en US: 10 por millon / año 95% unilateral95% unilateral 5% Neurofibromatosis tipo 2 5% Neurofibromatosis tipo 2
(bilateral)(bilateral) No se conoce predileccion por genero No se conoce predileccion por genero
o razao raza
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PatogeniaPatogenia
Tumor Benigno. Rara la Tumor Benigno. Rara la degeneracion degeneracion
maligna.maligna. La mayoria se origina dentro del La mayoria se origina dentro del
CAI.CAI.
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Jackler Staging SystemJackler Staging System
StageStage Tumor SizeTumor Size
IntracanalicularIntracanalicular Tumor confined to Tumor confined to IACIAC
I (small)I (small) < 10 mm< 10 mm
II (medium)II (medium) 11-25 mm11-25 mm
III (Large)III (Large) 25-40 mm25-40 mm
IV (Giant)IV (Giant) > 40 mm> 40 mm
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Fases del crecimiento Fases del crecimiento tumoraltumoral
Intracanalicular:Intracanalicular: Hipoacusia, tinnitus, vertigo Hipoacusia, tinnitus, vertigo
Cisternal:Cisternal: Aumento de la hipoacusia y desequilibrioAumento de la hipoacusia y desequilibrio
Compresiva:Compresiva: Ocasional cefalea occipitalOcasional cefalea occipital Alteracion V par cranealAlteracion V par craneal
Hidrocefalia:Hidrocefalia: Cuarto ventriculo compresion y Cuarto ventriculo compresion y
obstruccionobstruccion Cefaleas, alteracion visual.Cefaleas, alteracion visual.
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Phases of Tumor GrowthPhases of Tumor Growth
Jackler RK. 2000, p. 180: Tumors of the Ear and Temporal Bone
Intracanalicular Cisternal
Compressive Hydrocephalic
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HipoacusiaHipoacusia
Sintoma inicial mas frecuenteSintoma inicial mas frecuente HNS Asimetrica HNS Asimetrica Mas afectadas las frecuencias altas Mas afectadas las frecuencias altas Disminucion en la discriminacion de Disminucion en la discriminacion de
la palabrala palabra
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Clasificacion de la Clasificacion de la audicionaudicionen el NAen el NA
100 70 50 0 0
30
50
A
DB
C
PTT
(dB)
SDS (%)
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Myrseth: Neurosurgery, Volume 59(1).July 2006.67-76
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Fisiopatologia de la Fisiopatologia de la HipoacusiaHipoacusia
en el Neurinoma del en el Neurinoma del acusticoacustico Etiologia desconocidaEtiologia desconocida
Compresion del nervio coclear Compresion del nervio coclear
Oclusion vascular de la arteria Oclusion vascular de la arteria auditiva internaauditiva interna
Alteracion bioquimica de los Alteracion bioquimica de los fluidos del oido inernofluidos del oido inerno
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Normal or Symmetrical Normal or Symmetrical Hearing in Acoustic Hearing in Acoustic
Neuroma Neuroma SelesniSelesnick 1993ck 1993
Shaan Shaan
19931993LustigLustig
19981998MagdziMagdzi
arzarz
20002000
AN AN patientpatient
ss
126126 100100 546546 369369
NormaNormal l
hearinhearing g
55
(4%)(4%)66
(6%)(6%)2929
(5%)(5%)1010
(3%)(3%)
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Tumor Size and HearingTumor Size and HearingNormal Normal HearingHearing
(29 Patients)(29 Patients)
All ANsAll ANs
(126 Patients)(126 Patients)
% Small % Small
(< 1cm)(< 1cm)4545 2424
% Medium % Medium (1-3 cm)(1-3 cm)
4242 5959
% Large % Large
(> 3 cm)(> 3 cm)1212 1616
Lustig LR. Am J Otology 1998: 19; 212-8
El tamaño tumoral no se relaciona con los sintomas audiovestibulares
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DiagnosticoDiagnostico
Duracion de los Sintomas antes del Duracion de los Sintomas antes del DiagnosticoDiagnostico
Symptoms Years
Hearing Loss 3.9Vertigo 3.6Tinnitus 3.4Headache 2.2Dysequilibrium 1.7Trigeminal 0.9Facial 0.6
Jackler RK. 2000. Tumors of the Ear and Temporal Bone
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Sintomas y SignosSintomas y Signos HipoacusiaHipoacusia VertigoVertigo InestabilidadInestabilidad TinnitusTinnitus CefaleasCefaleas NistagmusNistagmus
Horizontal (vestibular) lesiones chicasHorizontal (vestibular) lesiones chicas Vertical (brainstem compression) lesiones Vertical (brainstem compression) lesiones
grandesgrandes Alteracion de los pares craneales Alteracion de los pares craneales
V, VIIV, VII Pares bajos (IX-XII)Pares bajos (IX-XII)
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Frecuencia de los Frecuencia de los SintomasSintomas
Hearing LossHearing Loss ((85-97% 85-97% ; ; 94%94% ) ) Tinnitus Tinnitus ((56-70%56-70% ; 64 %) ; 64 %) Dysequilibrium Dysequilibrium ((46-70%46-70% ; 56 %) ; 56 %) Vertigo Vertigo ((5-70 %5-70 % ; ;
39% ) 39% ) Facial nerve Facial nerve ((10-77%10-77% ; 38 %) ; 38 %) Trigeminal nerve Trigeminal nerve ((16-63%16-63% ; 26 %) ; 26 %) Headache Headache ((12-38%12-38% ; 25% ) ; 25% ) Visual symptomsVisual symptoms ((1- 15 %1- 15 % ; 7% ) ; 7% ) Lower cranial nerves: Dysphagia, Hoarseness, Lower cranial nerves: Dysphagia, Hoarseness,
Aspiration, Shoulder weakness (Jugular foramen Aspiration, Shoulder weakness (Jugular foramen syndrome)syndrome)
Jackler RK. 2000, p. 182: Tumors of the Ear and Temporal Bone
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DiagnosticoDiagnostico Historia y examen fisicoHistoria y examen fisico Paraclinica:Paraclinica:
AudiogramaAudiograma ABRABR OAEOAE
Estudios vestibulares ( ENG, Estudios vestibulares ( ENG, posturografo)posturografo)
ImagenologiaImagenologia RMRM Gold StandardGold Standard TCTC
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Audiometria y Audiometria y LogoaudiometriaLogoaudiometria
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ABR patologia ABR patologia retrococlearretrococlear
10-20 %10-20 % solamente onda solamente onda II
40-60 %40-60 % retardo retardo en la latencia en la latencia de onda Vde onda V
10-15 %10-15 % normal normal
Fraysse B et al. First International Conf. on Acoustic Neuroma. 1992
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ABRABR
La Sensibilidad aumenta con el La Sensibilidad aumenta con el tamano tumoraltamano tumoral
Sensibilidad: > 90 % para tumores > 3 Sensibilidad: > 90 % para tumores > 3 cm cm
No respuesta en HNS severa a No respuesta en HNS severa a profundas profundas (Rupa 2003)(Rupa 2003)
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ABR: Sensitivity & Tumor ABR: Sensitivity & Tumor sizesize
Gordon ML. American Journal of Otology. 1995; 16: 136-9
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OAEOAE
CCE, Oido internoCCE, Oido interno No es el primer estudio a realizarNo es el primer estudio a realizar Presencia de OAE in HNS ↔ Presencia de OAE in HNS ↔
RetrococlearRetrococlear 50 % NA presentan perdida auditiva 50 % NA presentan perdida auditiva
coclear y retrococlear coclear y retrococlear Evaluacion coclear previo a la cirugiaEvaluacion coclear previo a la cirugia
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RM cerebral con y sin RM cerebral con y sin gadoliniogadolinio
T1: T1: Isointenso cerebroIsointenso cerebro, , hiperintenso LCRhiperintenso LCR
T2: T2: Hiperintenso cerebro, Hiperintenso cerebro, hipointenso hipointenso LCRLCR
T1+Gad: T1+Gad: Realce del tejidoRealce del tejido
T1 pre-Gad T1 post-GadT2
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