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McMenomey and Kaylie propose microsurgery as the best therapy for acoustic neuromas, and for most patients with this tumor, I agree with their conclusion. The microsurgical techniques used today for tumor removal have been practiced for more than 35 years, and the advances in imaging techniques and intraoperative cranial nerve monitoring have helped to improve overall results. Numerous large studies of surgical results have demonstrated comparable and predictable outcomes in experienced hands. For small tumors (<20-mm extension into the cerebellopontine angle), the results of facial function and hearing preservation are comparable or superior to those reported by radiosurgery. Cerebrospinal fluid leaks are an occasional postoperative problem but can be managed conservatively in most cases. Only 2% of patients must be returned to the operating room for surgical closure of the leak. Major complications such as meningitis, stroke, intracranial bleeding, or hydrocephalus are rare, and the mortality rate is less than 1%.
Newton J. Coker, MD
During my fellowship, Professor Ugo Fisch advised me to review with caution the outcomes of "those surgeons who are reporting good results but constantly changing their techniques." I believe this advice can be applied to "radiosurgeons" who are frequently changing their stereotactic treatment protocols to reduce the complication rates for facial paralysis, hearing loss, peritumor edema, trigeminal neuropathy, and hydrocephalus. Short-term results, usually reported with less than 5 years of follow-up, "appear" encouraging, but there are no long-term data on control of tumor growth with implementation of the newer protocols that reduce, fractionate, or stage the radiation delivery to the tumor. Are we watching the natural growth history of acoustic neuromas during this relatively short period of follow-up? What are the control rates at 10 and 20 years? What will be the morbidity and mortality for those patients eventually requiring surgical removal of their enlarging tumors? Are we going to see malignant tumors or other late complications develop as a result of radiosurgery? In regard to long-term outcomes and potential complications, there remain a number of critical questions to be answered.
For those patients who require tumor treatment because of tumor size, growth, or complications, microsurgery should continue to be the standard of therapy; radiosurgery should play a complementary role. Inour practice, radiosurgery is recommended to elderly or medically infirm patients. Nevertheless, consultation with the radiosurgeon is provided to all patients whowant more information about this treatment modality.
All patients should be made aware of the treatment options—watchful waiting, microsurgery, and radiosurgery—as well as the pros and cons of each option. As physicians, it is incumbent upon us to see that information is presented honestly to each patient and that each patient is fully informed before he or she consents to treatment.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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