Complications of vestibular schwannoma surgery and how to minimize them

Microsurgical resection remains a cornerstone in the management of vestibular schwannomas (VS), particularly when tumor size or growth patterns necessitate intervention. While surgery aims to halt further progression and stabilize or improve neurologic function, it also carries the potential for notable complications. This chapter comprehensively reviews such complications, examining their incidence, clinical manifestations, risk factors, and management strategies. Key themes include the importance of tumor size, tumor morphology (e.g., solid vs. cystic), and the surgical approach (translabyrinthine, retrosigmoid, or middle fossa) in determining the likelihood of adverse events. Detailed emphasis is placed on common issues such as brain swelling, cranial nerve injuries (especially facial nerve dysfunction), and cerebrospinal fluid (CSF) leaks, which may present as otorrhea, rhinorrhea, or wound leakage. Further topics include infection risks (bacterial and aseptic meningitis), vascular complications (arterial and venous injury, venous sinus thrombosis), and postoperative hydrocephalus. Each complication is linked to potential preventative measures, including meticulous dissection of the tumor capsule to preserve the pial-arachnoid plane, judicious use of intraoperative monitoring to protect cranial nerve function, and thorough sealing of air cells to minimize the risk of CSF fistula. Management principles ranging from conservative measures like bed rest and lumbar drainage to surgical interventions such as duraplasty and blind sac closure are also outlined. Throughout, the chapter underscores the multidisciplinary nature of VS surgery, highlighting collaborative efforts between neurosurgeons, otolaryngologists, neuroradiologists, and anesthesiologists to optimize outcomes. By systematically addressing these challenges, surgeons can tailor their approach to each patient's anatomy and clinical status, ultimately reducing surgical morbidity and improving long-term recovery.