Radicality and revision surgery in vestibular schwannoma treatment: balancing optimal outcomes with unavoidable necessity

Revision microsurgery for vestibular schwannoma (VS) after failure of prior microsurgery and/or stereotactic irradiation represents a technically demanding scenario with uncertain functional outcomes. We aimed to evaluate operative strategy, extent of resection, tumor control, and functional results—primarily facial nerve outcomes—in patients undergoing revision VS surgery in a high-volume tertiary center.

A retrospective single-center cohort study included consecutive patients who underwent revision VS microsurgery between 1998 and 2025. Demographic, radiological, surgical, and audiological data were analyzed. Primary endpoint was long-term facial nerve function assessed by House–Brackmann (HB) grading. Secondary endpoints included extent of resection, tumor control on follow-up MRI, hearing outcome, and perioperative morbidity.

Nineteen patients (2.6% of 741 treated VS cases) underwent revision surgery. Most tumors were advanced (Koos grade 4, 74%). Gross total resection was achieved in 79%. Immediate postoperative HB VI occurred in 58%, improving over time to 11% at last follow-up. Favorable long-term facial function (HB I–III) was observed in 68%. Hearing preservation was not achieved. Perioperative complications occurred in 42%, most commonly cerebrospinal fluid pseudocyst. Radiological tumor control reached 95% during a mean follow-up of 136 months.

Revision VS microsurgery provides high rates of tumor control with acceptable facial nerve outcomes but limited hearing preservation. It should be reserved for carefully selected patients and performed in experienced centers with cranial nerve reconstruction expertise.