Unexpected Complications Following Accidental Petrosal Vein Damage during Standard Retrosigmoid Surgery for a Large Vestibular Schwannoma: Introspection and Lessons Learned.

We present the case of a patient with a vestibular schwannoma (VS) who developed vascular complications following surgery and discuss the potential mechanisms. Additionally, we systematically searched the literature to identify citations on vascular and brain stem complications following VS surgery. We excluded the articles related to facial and vestibulocochlear nerve-related complications and other complications, such as headache, tinnitus, and ataxia. We also excluded the articles related to recurrent vestibular schwannoma because our article focuses on primary VS surgery-related complications due to vascular injury. We have clearly come a long way in managing vestibular schwannoma (VS) surgery over the past century. In the early twentieth century, VS surgery entailed high morbidity and mortality. The principles of microneurosurgery have improved the outcomes of surgery on VSs to a great extent. The current concept in modern VS surgery is maximal safe resection with minimal complications and minimal cranial nerve deficits. The management of VS has undergone a paradigm shift from reducing mortality to facial nerve preservation and the preservation of hearing. Surgery of the cerebellopontine (CP) angle requires a unique skill set and is a craft in that any iatrogenic damage can have devastating results on the neurovascular structures and brain stem in the vicinity. As with other neurosurgical procedures, the goal of VS surgery is to minimize complications, but complications are always possible, from the positioning of the patient under general anaesthesia to complications during the various steps of VS surgery. In spite of advancements in surgical techniques and better illumination provided by modern high-end microscopes, the surgical removal of large and giant vestibular schwannomas with good preservation of facial nerve function continues to be one of the most challenging operations in modern neurosurgery. The complexity of operating on the vestibular schwannoma is attributable not only to the difficult anatomy in the CP angle but also to the presence of multiple vital neurovascular structures and the brain stem in the vicinity. The various complications arising out of surgery for vestibular schwannomas range from one or more cranial nerve deficits to life-endangering complications associated with vascular and/or brain stem damage. The senior author, who has a personal experience with consecutively operating on 835 such cases of large and giant vestibular schwannoma, describes the clinical course following petrosal vein damage to a patient who underwent a standard retrosigmoid operation for a large vestibular schwannoma. We retrospectively analyse the critical management issues that could have reduced the unexpected morbidity resulting in a prolonged hospital stay.