Decision-making in sporadic vestibular schwannoma

Over the last 20 years, there has been a marked shift from active intervention to radiologic observation in the management of vestibular schwannomas, prompted by our understanding that a substantial proportion of these tumors do not demonstrate significant growth following diagnosis. In parallel with this, when active intervention does take place, our outcome measures are increasingly focused on preserving neurologic function, rather than on complete tumor removal at any cost. These principles of management are now widely accepted in most major skull-base centers throughout the world, but a number of areas of controversy in the management of these tumors remain. The chapter aims to provide an overview of such topics including intervention for hearing preservation, radiosurgery vs surgery, choice of surgical approach, and the management of residual tumor following surgical resection. Ultimately, our intention was not to add yet another voice to the debate as to which are the "right" approaches, but to prompt the reader to consider the evidence surrounding these areas of contention when coming to a shared decision with their patients as to which management strategies to adopt.