BACKGROUND AND OBJECTIVES: Intratumoral hemorrhage (ITH) in vestibular schwannoma (VS) after stereotactic radiosurgery (SRS) is exceedingly rare. The aim of this study was to define its incidence and describe its management and outcomes in this subset of patients. METHODS: A retrospective multi-institutional study was conducted, screening 9565 patients with VS managed with SRS at 10 centers affiliated with the International Radiosurgery Research Foundation. RESULTS: A total of 25 patients developed ITH (cumulative incidence of 0.26%) after SRS management, with a median ITH size of 1.2 cm 3 . Most of the patients had Koos grade II-IV VS, and the median age was 62 years. After ITH development, 21 patients were observed, 2 had urgent surgical intervention, and 2 were initially observed and had late resection because of delayed hemorrhagic expansion and/or clinical deterioration. The histopathology of the resected tumors showed typical, benign VS histology without sclerosis, along with chronic inflammatory cells and multiple fragments of hemorrhage. At the last follow-up, 17 patients improved and 8 remained clinically stable. CONCLUSION: ITH after SRS for VS is extremely rare but has various clinical manifestations and severity. The management paradigm should be individualized based on patient-specific factors, rapidity of clinical and/or radiographic progression, ITH expansion, and overall patient condition.

Clinical Oncology Department Ain Shams University Cairo Egypt

Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA

Department of Neurological Surgery University of Virginia Charlottesville Virginia USA

Department of Neurosurgery Allegheny Health Network Pittsburgh Pennsylvania USA

Department of Neurosurgery Koc University School of Medicine Istanbul Turkey

Department of Neurosurgery Neurological Institute Taipei Veteran General Hospital Taipei Taiwan

Department of Neurosurgery Post Graduate Institute of Medical Education and Research Chandigarh India

Department of Neurosurgery Université de Sherbrooke Centre de recherche du CHUS Sherbrooke Quebec Canada

Department of Neurosurgery University of Alberta Edmonton Canada

Division of Radiation Oncology Allegheny Health Network Cancer Institute Allegheny Health Network Pittsburgh Pennsylvania USA

Gamma Knife Center Cairo Nasser Institute Hospital Cairo Egypt

Neurosurgery Department Ain Shams University Cairo Egypt

Neurosurgery Department Benha University Qalubya Egypt

Radiation Oncology Department National Cancer Institute Cairo University Cairo Egypt

School of Medicine National Yang Ming University Taipei Taiwan

Stereotactic and Radiation Neurosurgery Na Homolce Hospital Prague Czech Republic

See more in PubMed

Moscovici S, Limb R, Azriel A, Briggs R, Hall N, Kaye AH. Repeated spontaneous intra-tumoural and subarachnoid haemorrhage in an anticoagulated patient with a previously-irradiated vestibular Schwannoma: case report. J Clin Neurosci. 2020;73:323-325.

Niknafs YS, Wang AC, Than KD, Etame AB, Thompson BG, Sullivan SE. Hemorrhagic vestibular schwannoma: review of the literature. World Neurosurg. 2014;82(5):751-756.

Bin-Alamer O, Fogg D, Wei Z, et al. Intratumoral hemorrhage in vestibular schwannomas after stereotactic radiosurgery. J Neurosurg. 2023;138(2):413-419.

Carlson ML, Tombers NM, Driscoll CLW, et al. Clinically significant intratumoral hemorrhage in patients with vestibular schwannoma. Laryngoscope. 2017;127(6):1420-1426.

Odabasi AO, Buchman CA, Morcos JJ. Tumor-associated hemorrhage in patients with acoustic neuroma. Am J Otol. 2000;21(5):706-711.

Mathkour M, Helbig B, McCormack E, Amenta PS. Acute presentation of vestibular schwannoma secondary to intratumoral hemorrhage: a case report and literature review. World Neurosurg. 2019;129:157-163.

Agha RA, Borrelli MR, Farwana R, et al. The PROCESS 2018 statement: updating consensus preferred reporting of CasE series in surgery (PROCESS) guidelines. Int J Surg. 2018;60:279-282.

Mousavi SH, Kano H, Faraji AH, et al. Hearing preservation up to 3 years after gamma knife radiosurgery for Gardner-Robertson class I patients with vestibular Schwannomas. Neurosurgery. 2015;76(5):584-591;discussion 590-1.

Last JM. A Dictionary of Epidemiology, 4th ed. Oxford U; 2001.

Lunsford LD. Vestibular schwannomas. Neurochirurgie. 2004;50(2-3 Pt 2):151-152.

Régis J, Carron R, Delsanti C, et al. Radiosurgery for vestibular schwannomas. Neurosurg Clin N Am. 2013;24(4):521-530.

Ogino A, Lunsford LD, Long H, et al. Stereotactic radiosurgery as the first-line treatment for intracanalicular vestibular schwannomas. J Neurosurg. 2021;135(4):1051-1057.

Ogino A, Lunsford LD, Long H, et al. Stereotactic radiosurgery as the primary management for patients with Koos grade IV vestibular schwannomas. J Neurosurg. 2021;135(4):1058-1066.

Pikis S, Mantziaris G, Kormath Anand R, et al. Stereotactic radiosurgery for Koos grade IV vestibular schwannoma: a multi-institutional study. J Neurosurg. 2023;138(2):405-412.

Dehdashti AR, Kiehl TR, Guha A. Vestibular Schwannomas presenting with haemorrhage: clinical presentation and histopathological evaluation of an unusual entity. Br J Neurosurg. 2009;23(4):431-436.

Thamburaj K, Radhakrishnan VV, Thomas B, Nair S, Menon G. Intratumoral microhemorrhages on T2*-weighted gradient-echo imaging helps differentiate vestibular schwannoma from meningioma. AJNR Am J Neuroradiol. 2008;29(3):552-557.

Park CK, Kim DC, Park SH, et al. Microhemorrhage, a possible mechanism for cyst formation in vestibular schwannomas. J Neurosurg. 2006;105(4):576-580.

Charabi S, Klinken L, Mantoni M, Tos M, Thomsen J. Histology and neuro-imaging in cystic acoustic neuromas. Acta Otolaryngol. 1993;113(4):519-523.

Lee JP, Wang ADJ. Acoustic neurinoma presenting as intratumoral bleeding. Neurosurgery. 1989;24(5):764-768.

Benhaiem-Sigaux N, Ricolfi F, Torres Díaz A, Keravel Y, Poirier J. Haemorrhagic acoustic neuroma with features of a vascular malformation. A case report. Neuroradiology. 1999;41(10):795-798.

Thomsen Samih Charabi Mirko Tos J, Charabi S, Tos M, Mantoni M, Charabi B. Intracanalicular vestibular schwannoma--therapeutic options. Acta Otolaryngol. 2000;120:38-40.

Berkowitz O, Iyer AK, Kano H, Talbott EO, Lunsford LD. Epidemiology and environmental risk factors associated with vestibular schwannoma. World Neurosurg. 2015;84(6):1674-1680.

Lee DJ, Westra WH, Staecker H, Long D, Niparko JK. Clinical and histopathologic features of recurrent vestibular schwannoma (acoustic neuroma) after stereotactic radiosurgery. Otol Neurotol. 2003;24(4):650-660.