Management strategies will generally differ to some degree between neurosurgical centres and also will depend upon patient preference. However, small and medium-sized tumours which are radiologically stable on surveillance imaging can usually be managed with an expectant approach and ongoing surveillance at gradually lengthening intervals. A population of these tumours will grow to a certain size and then stop growing and if they are asymptomatic, the symptoms they produce are manageable and the associated mass effect upon adjacent brain structures is minimal then doing nothing is always a good option.
Those small and medium-sized tumours that are showing signs of growth on surveillance imaging can be managed with stereotactic radiosurgery which is a day case procedure where radiation is delivered very accurately to the tumour and carries a high chance of arresting growth with a very low complication rate.
Surgical excision tends to be reserved for large tumours causing brain stem compression, large tumours that are growing, medium-sized tumours where stereotactic radiosurgery has been unsuccessful in controlling growth and those patients who prefer the option of surgery because they struggle with the psychological effects of knowing that the tumour is there. Surgery is the only way the patient can be rid of the tumour.
The timing of diagnosis and the size of the tumour will ultimately dictate the preferred management strategies and so a missed diagnosis when the tumour is small will profoundly impact upon the gravity of the treatment and the potential complications the patient must endure potentially for the rest of their life.
A very common subject for medical negligence therefore revolves around a missed diagnosis when the tumour is small.
There are two separate subgroups of patients where the diagnosis is missed.
- There are those patients who present with symptoms that could be attributed to an acoustic neuroma, the clinician requesting the scan states on the request form that there is a clinical suspicion of an acoustic neuroma and dedicated scans to look for this tumour have been requested and yet the diagnosis is still missed. This would be more difficult to defend.
- The other subgroup comprises those patients where an acoustic neuroma is incidental and would be an unexpected finding and despite careful scrutiny of the scans the reporting Radiologist has not seen the tumour.