• Isabelle M Germano, Jason Sheehan, Johnathan Parish, Tyler Atkins, Anthony Asher, Constantinos G Hadjipanayis, Stuart H Burri, Sheryl Green, and Jeffrey J Olson.
• Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
• Neurosurgery. 2018 Feb 1; 82 (2): E49-E51.

QuestionWhat are the indications for stereotactic radiosurgery (SRS) treatment vs observation for patients with intracanalicular vestibular schwannomas without evidence of radiographic progression?RecommendationLevel 3: If tinnitus is not observed at presentation, it is recommended that intracanalicular vestibular schwannomas and small tumors (<2 cm) without tinnitus be observed as observation does not have a negative impact on tumor growth or hearing preservation compared to treatment.QuestionIs there a difference in outcome based on radiosurgery equipment used: Gamma Knife (Elekta, Stockholm, Sweden) vs linear accelerator-based radiosurgery vs proton beam?RecommendationThere are no studies that compare 2 or all 3 modalities. Thus, recommendations on outcome based on modality cannot be made.QuestionIs there a difference in outcome based on the dose delivered?RecommendationLevel 3: As there is no difference in radiographic control using different doses, it is recommended that for single fraction SRS doses, <13 Gy be used to facilitate hearing preservation and minimize new onset or worsening of preexisting cranial nerve deficits.QuestionIs there a difference in outcome based on the number of fractions?RecommendationAs there is no difference in radiographic control and clinical outcome using single or multiple fractions, no recommendations can be given.QuestionWhat is the best time sequence for follow-up images after SRS?RecommendationLevel 3: Follow-up imaging should be obtained at intervals after SRS based on clinical indications, a patient's personal circumstances, or institutional protocols. Long-term follow-up with serial magnetic resonance imagings to evaluate for recurrence is recommended. No recommendations can be given regarding the interval of these studies.QuestionIs there a role for retreatment?RecommendationLevel 3: When there has been progression of tumor after SRS, SRS can be safely and effectively performed as a retreatment.QuestionWhat is the risk of radiation-induced malignant transformation of vestibular schwannomas treated with SRS?RecommendationLevel 3: Patients should be informed that there is minimal risk of malignant transformation of vestibular schwannomas after SRS.QuestionWhat are the indications for SRS in patients with neurofibromatosis type 2?RecommendationLevel 3: Radiosurgery is a treatment option for patients with neurofibromatosis type 2 whose vestibular schwannomas are enlarging and/or causing hearing loss.  The full guideline can be found at: https://www.cns.org/guidelines/guidelines-management-patients-vestibular-schwannoma/chapter_7.Copyright © 2017 by the Congress of Neurological Surgeons

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