This document describes the medical history, examination, diagnosis, and treatment for a 38-year-old male patient presenting with decreased hearing in his left ear over 7 months and falling to his left side over 5 months. MRI and CT scans revealed a left cerebellopontine angle schwannoma with hydrocephalus. The patient underwent VP shunt placement followed by a left retrosigmoid approach for tumor resection. Post-operatively, the patient was monitored for complications which can include cranial nerve injuries, CSF leakage, meningitis, and recurrence of the tumor. The outcomes for this type of surgery generally have high rates of gross total resection, hearing preservation, and facial nerve function preservation depending on the size and classification of the

1. DR.MUMTAZ ALI
Department of Neurosurgery
Jinnah Postgraduate Medical Center, Karachi

2. HISTORY
 38 year old,male ,married, NKCM ,right handed,
farmer ,resident of Larkana and presented to OPD
with complains of :
 Decrease hearing in Left ear – 7 month
 Falling to left side -05 months.
 No history of headache, seizures , vomiting, decrease
vision, weakness, speech ,urinary incontinence ,memory
impairment.

3. Decrease hearing in Left ear
 started 07 months back which is gradual , progressive and
associated with high pitched tinnitus.
 He first noticed it while having a phone talk.
 It has progressed further and became apparent with time .
 It was partial still can hear some loud voices, but cant hear
whispering
 No hx of working in noisy environment , never exposed to
bombblast and firing
 No hx of pain in ear or discharge , fever, ear trauma and ear
pricking.
 No hx of fascial numbness , weakness , change in voice ,
difficulty in swallowing ,subcutaneous nodules.

4. Falling to left side
 Started 05 months back
 It is gradual and progressive , sways on left side.
 He can walk with support.
 Fall is not associated with vertigo.

5. Cranial Review
 No hx of lack of intrest & will power , anger anxiety , urinary
incontinence ,change in behaviour , dressing , combing
hairs ,calculation and memory problems.
 No hx of Anosmia , diplopia , visual halos , numbness over
face , asymmetry on face , dribbling from mouth , dsphagia
 No hx of drop attacks
 No hx of gynaecomastia , dec libido ,change in voice , inc in
body parts size , black spots over body , polyurea ,
polyphagia , polydypsia , heat & cold intolerance ,
constipation and diarrhea.

6.  No hx of low grade fever , night sweats ,weight loss and
TB contact.
 Past medical hx ,personal hx , family hx , drug hx ,
allergic hx , socioeconomic hx : non-significant.

7.  Level : Left CP angle lesion extended to cerebellum.
 Differential Diagnosis :
Left cp angle vestibular schwanoma
left cp angle meningioma
left cp angle epidermoid
left cp angle arachnoid cyst

8. GPE
 A middle age pt , well dressed ,good looking ,well
oriented with time place and person with normal built
and height with canula in right hand with following
vitals and non vitals
 Pulse : 78 bpm , BP : 120/80 mm hg , RR : 16
breaths/min , T: A/F
 Pallorness , clubbing , koilynchia dehydration , cynosis
, jaundice , lymphadenopathy , edema not present.
 No buldge on scalp palpation and scar mark of Vp
shunt presnet on head
 No thydroid swelling is palpated on deglutition

9.  MENTAL STATE ASSESSMENT: 30/30
 Primitive reflexes : not present
 Lobar examination : normal
 Speech : fluent and comprehensible
 Cranial nerve examination :
 Fundoscopy : bilateral papilledema
 Nystagmus present in both eyes
 Corneal reflex is diminished on left side
 Whisper test = +ve , Rhinne’s test = air conduction > bone
conduction , Weber test = lateralized to right ear
 Gag reflex is absent on left side , uvula is lateralized to left side on Ah
test.

10. Cerebellar examination:
 Nystgmus: + in both eyes( vertical and horizontal both)
 Finger nose test : + on left side
 Heel shin on left side +
 Dysdidochokinesia : + left side
 Rhomberg’s +
 walk not possible as patient can’t walk.
Motor and sensory examination : unremarkable
systemic examination : unremarkable
 Level : Left CP angle lesion extended to cerebellum.
 Differential Diagnosis :
Left cp angle vestibular schwanoma
left cp angle meningioma
left cp angle epidermoid
left cp angle arachnoid cyst

11. Investigations
 SPECIFIC :
 MRI brain with contrast
 CT scan temporal bone
 Audiometrics
 ABR
 ROUTINE:
 CBC , UCE , PT/APTT/INR, Hep B & c , CXR

17. DIAGNOSIS
Left CP angle Schwanomma with
Hydrocephalus

18. Management
 Admission
 Counselling
 Optimization
 Preop Care
 Surgery :
 HCP : VP shunt
 Definitive : Retrosigmoid Approach and tumor resection
 Postop Care
 Followup
 Rehabilitation

19. Post VP shunt CT scan

20. Left retrosigmoid Approach
 After consent and counselling pt is shifted to ot.
 position: lateral decubitus with left side up, head in
pins rotated
 incision : C shaped parallel to ear pinna
 craniotomy : angle b/w transverse and sphenoid sinus
 Bone wax : apply all openings in bone to prevent csf
leak
 Durotomy : C shaped based on both sinuses
 Microscopic dissection :
 CSF drain : cp angle cissterns and cisterna magna
 Petrosal vein : sacrificed to relax cerebellum

21.  Identification of fascial nerve : with nerve stimulator
on posterior aspect of tumor and pontomedullary
sulcus
 Identification of thin layer of arachnoid : to preserve
chochlear artery
 Extracanalicular portion removed
 Intracanalicular portion removed
 Hemostasis secured
 Wound closed in layers

22. Complications
 VII CN injury
 VIII CN injury
 Lower cranial nerve injury
 Brainstem injury
 CSF leak
 Meningitis
 Vascular injury
 Craniotomy complications

23. Outcome
 LCR after microscopic surgery : 97%
 Recurrence rate after total resection : 7-11%
 Mortality : 1%
 Overall outcome 97-99%
 Hearing preservation rate : Depends on Gardner and
Robertson classification and size of tumor
GR class A : 91% , Class B : 33%
<1 cm =57% , 1-2 cm = 33% , > 2 cm = 6%
 Facial nerve preservation rate : overall : 98.5%
< 1cm = 95-100% , 1-2 cm = 80-92 % , > 2cm =50-76%

24. Thankyou