VESTIBULAR SCHWANNOMA PLAN EVALUATION SHEET

1. DR KANHU CHRAN PATRO
VESTIBULAR SCHWANNOMA SRS PLAN EVALUATION
1. NAME UMR
2. COMORBIDITY AGE
3. DIAGNOSIS SIDE
4. IMAGING A. SIDE AND SIZE
B. INTRACANALICULARPART LENGTH
C. BRAINSTEM COMPRESSION
D. TRIGEMINAL COMPRESSION
E. BONY EROSION ON CT
F. HYDROCEPHALUS
G. 7/8TH
NERVE STATUS
5. KOOS GRADING I II III IV
6. GARDNER-ROBERTSON HEARING GRADES I II III IV V
7. HOUSE-BRACKMAN SCALE OF FACIAL FUNCTION I II III IV V VI
8. TINNITUS GRADING I II III IV V
9. VERTIGO GRADING I II III IV V
10. ANYTRIGEMINAL / PAINDISTRIBUTION PAIN SCORE
11. SURGERYOPINION
12. PATIENT PREFERENCE
13. PRIOR SURGERY YES NO TYPE INTERVAL
14. PRIOR SRS YES NO DOSE INTERVAL
15. CTV VOLUME PTV MARGIN PTV VOLUME
16. PLAN TYPE-[3DCRT/VMAT/DCR/IMRS]
17. MONITOR UNITS

2. DR KANHU CHRAN PATRO
18. 1. PRESCRIBED MARGINALISODOSE
2. D MAX
3. D95%
4. D100%
5. V95%
6. V100%
7. V120%
8. V130%
9. DISTANCE BETWEEN 80% ISODOSE AND 60% ISODOSE-[<2mm]
10. DISTANCE BETWEEN 80% ISODOSE AND 40% ISODOSE-[<8mm]
11. CONFIRMITY INDEX [IDEAL 1] VOLUME OF PRESCRIPTION ISODOSE/VOLUME OF PTV
12. HOMOGENITY INDEX [BETWEEN 1.1-1.3] - MAX DOSE/ PRESCRIPTION DOSE
13. GRADIENT INDEX- [BETWEEN 0.3-0.9] [RAD OF PRESCRIPTION ISODOSE – RAD OF HALF PRESCRIPTION ISODOSE]
19. BRAIN-GTV[12Gy volume]<10CC
20. OAR SINGLE FRACTION 5 FRACTIONS ACHIEVED
1. RIGHT EYE MAX<8Gy MAX <22.5Gy
2. LEFT EYE MAX<8Gy MAX <22.5Gy
3. RIGHT OPTIC NERVE MAX<8Gy MAX <22.5Gy
4. LEFT OPTIC NERVE MAX<8Gy MAX <22.5Gy
5. OPTIC CHIASM MAX<8Gy MAX <22.5Gy
6. BRAIN STEM MAX <10-15Gy MAX <23-31Gy
7. RT. COCHLEA MEAN <4-9Gy MEAN <25Gy
8. LT. COCHLEA MEAN <4-9Gy MEAN <25Gy