CLINICAL RESEARCH

Vestibular Schwannoma Koos Grade I International Study of Active

Surveillance Versus Stereotactic Radiosurgery: The VISAS-K1 Study
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Othman Bin-Alamer, MBBS *, Hussam Abou-Al-Shaar, MD*, Selcuk Peker, MD‡, Yavuz Samanci, MD‡, Isabelle Pelcher, BA§,
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Sabrina Begley, BS§, Anuj Goenka, MD||, Michael Schulder, MD§, Jean-Nicolas Tourigny, MD, MSc¶, David Mathieu, MD¶,
Andréanne Hamel, BSc¶, Robert G. Briggs, MD#, Cheng Yu, PhD#, Gabriel Zada, MD, MS#, Steven L. Giannotta, MD#,
Herwin Speckter, MSc**, Sarai Palque, MD**, Manjul Tripathi, MCh‡‡, Saurabh Kumar, MS‡‡, Rupinder Kaur, BSc‡‡,
Narendra Kumar, MD‡‡, Brandon Rogowski, BS§§, Matthew J. Shepard, MD||||, Bryan A. Johnson, MD, MBA¶¶, Daniel M. Trifiletti, MD¶¶,
Ronald E. Warnick, MD##, Samantha Dayawansa, MD, PhD***, Elad Mashiach, MD‡‡‡, Fernando De Nigris Vasconcellos, MD‡‡‡,
Kenneth Bernstein, MS§§§, Zane Schnurman, MD‡‡‡, Juan Alzate, MD‡‡‡, Douglas Kondziolka, MD, MSc‡‡‡,
Jason P. Sheehan, MD, PhD ***
*Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; ‡Department of Neurosurgery, Koc University School of Medicine,
Istanbul, Turkey; §Department of Neurosurgery, Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA; ||Department of Radiation Medicine,
Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA; ¶Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du
CHUS, Sherbrooke, Quebec, Canada; #Department of Neurosurgery, University of Southern California, Los Angeles, California, USA; **Dominican Gamma Knife Center and Radiology
Department, CEDIMAT, Santo Domingo, Dominican Republic; ‡‡Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh,
India; §§Drexel University School of Medicine, Philadelphia, Pennsylvania, USA; ||||Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA;
¶¶
Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA; ##Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio, USA; ***Department of
Neurosurgery, University of Virginia, Charlottesville, Virginia, USA; ‡‡‡Department of Neurosurgery, NYU Langone, Manhattan, New York, USA; §§§Department of Radiation Oncology,
NYU Langone, Manhattan, New York, USA
Correspondence: Jason P. Sheehan, MD, PhD, Department of Neurological Surgery, University of Virginia Health System, Box 800212, Charlottesville, VA 22908, USA. Email:
[email protected]
Received, May 08, 2024; Accepted, July 06, 2024; Published Online, November 6, 2024.

Neurosurgery 96:41–49, 2025 https://doi.org/10.1227/neu.0000000000003215

© Congress of Neurological Surgeons 2024. All rights reserved.

BACKGROUND AND OBJECTIVE: This investigation evaluates the safety and efficacy of stereotactic radiosurgery (SRS)
vs observation for Koos grade I vestibular schwannomas (VS).
METHODS: In a multicenter study, we retrospectively analyzed data of patients with Koos grade I VS who underwent
SRS (SRS group) or were observed (observation group). Propensity score matching was used to equilibrate demo-
graphics, tumor size, and audiometric data across groups. The outcome analyzed included tumor control, preservation of
serviceable hearing, and neurological function.
RESULTS: The study matched 142 patients, providing a median follow-up period of 36 months. SRS significantly
enhanced tumor control compared with observation, with a 100% control rate at both 5- and 8-year marks in the SRS
group vs 48.6% and 29.5% in the observation group at the same time intervals, respectively (P < .001). Preservation of
serviceable hearing outcomes between groups showed no significant difference at 5 and 8 years, ensuring a comparable
quality of auditory function (SRS 70.1% vs observation 53.4% at 5 years; P = .33). Furthermore, SRS was associated with a
reduced likelihood of tinnitus (odds ratio [OR] = 0.46, P = .04), vestibular dysfunction (OR = 0.17, P = .002), and overall
cranial nerve dysfunction (OR = 0.49, P = .03) at last follow-up.
CONCLUSION: SRS management of patients with Koos grade I VS was associated with superior tumor control and
reduced odds for cranial nerve dysfunction, while not compromising hearing preservation compared with observation.
These findings support the safety and efficacy of SRS as a primary care approach for this patient population.
KEY WORDS: Vestibular schwannoma, Stereotactic radiosurgery, Observation, Tumor control, Hearing preservation, Neurological outcomes

ABBREVIATIONS: IRRF, International Radiosurgery Research

V
estibular schwannomas (VS), benign tumors of the ves-
Foundation; SHP, serviceable hearing preservation; SRS, stereotactic
tibulocochlear nerve, manifest with symptoms like hearing
radiosurgery; VS, vestibular schwannomas.
loss and balance issues.1,2 Their incidence, of around 2.93

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 BIN-ALAMER ET AL

cases per 100 000 people in the United States, underscores a significantly impaired patients’ quality of life. Vestibular dysfunction was
significant health concern.3 The management options for VS vary defined based on a combination of clinical symptoms (vertigo, dizziness,
from active surveillance to surgical resection and stereotactic imbalance, and nystagmus) supplemented by objective vestibular func-
radiosurgery (SRS), each tailored to the individual patient’s goals tion tests where available. Tinnitus was recorded when reported by
patients as significantly affecting their daily activities. Initial audiometric
and tumor’s characteristics.2,4,5 The debate around optimal
assessments followed American Academy of Otolaryngology-Head and
management for Koos grade I VS remains.1,6,7 Ample evidence
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Neck Surgery guidelines, categorizing hearing into 4 levels (A, B, C, and

highlights the role of SRS, particularly Gamma Knife radio- D), where A and B represented serviceable hearing.16,17 During sub-
surgery, in managing tumor growth and safeguarding auditory sequent follow-ups, patients underwent consistent imaging assessments in
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function.8-11 However, others still advocate for an expectant addition to periodic clinical and audiometric re-evaluations, identifying
approach, recommending observation for patients without symptomatic patients by CN impairments or hearing decline.
symptoms, given the perceived and possible risks associated with
SRS.8,10,12-14 Using data compiled by the International Radio- Intervention and Follow-Up
surgery Research Foundation (IRRF), this study compares SRS SRS was performed in a single session using the Gamma Knife system,
and observation outcomes in patients with Koos grade I VS, leveraging contrast-enhanced MRI or computed tomography scans for
focusing on tumor control, hearing preservation, and neurological precision targeting with a multi-isocentric approach. Procedure specifics,
function, to inform patient management decisions. including dosage, were customized according to prevailing radiosurgical
standards and available technology, using stereotactic frame fixation. Follow-up
for both SRS and observation cohorts occurred semiannually for the initial 1 to
METHODS 2 years and then annually without any crossover between groups. Evaluations
included clinical assessments, radiological imaging, and audiometry.
Study Design and Population
This investigation was designed to assess the impact of SRS vs ob- Study Outcomes
servation on patients with Koos grade I sporadic VS, with a focus on The study aimed to compare SRS and observation for Koos grade I VS,
tumor control, serviceable hearing preservation (SHP), and neurological focusing on tumor control and SHP. Tumor control was evaluated by
function outcomes. Through IRRF, data were retrospectively gathered neuroimaging, defining a volumetric change <25% as stable and a
from participating centers that either implemented SRS (SRS group) or volumetric change ≥25% change as progression or regression. SHP was
followed a watchful waiting approach (observation group) for patients assessed using audiometry, with American Academy of Otolaryngology-
with Koos Grade I VS. The data were contributed by several international Head and Neck Surgery classes A or B indicating SHP and shifting to
institutions, including Koç University School of Medicine in Turkey; classes C or D signifying loss.
Donald & Barbara Zucker School of Medicine at Hofstra/Northwell in Secondary outcomes included CN dysfunction, tinnitus, and vestibular
the United States; Université de Sherbrooke in Canada; University of dysfunction, linked to tumor growth or SRS. Vestibular dysfunction as-
Southern California in the United States; CEDIMAT in the Dominican sessments encompassed clinical symptoms and, where applicable, function
Republic; Postgraduate Institute of Medical Education and Research tests. Facial weakness was measured using House–Brackmann scores.18
(PGIMER) in India; Allegheny Health Network in the United States;
Mayo Clinic in Florida, United States; Jewish Hospital/Mayfield Clinic
in the United States; and New York University Langone Health in the Statistical Analysis
United States. The data have been deposited in an IRRF institutional Medians and IQR (25th-75th percentiles) summarized continuous
database, and the authors do not plan to share the data. variables, whereas frequencies and percentages described categorical
Ethical oversight, aligned with Institutional Review Board approvals variables. The Mann–Whitney U test and the Pearson χ 2 test were used
and patient consent as necessary, was consistently applied across all sites. for continuous and categorical variables, respectively. To assess tumor
Data accuracy and privacy were rigorously maintained by IRRF repre- control, SHP, and neurological outcomes, we conducted propensity score
sentatives at each center, ensuring deidentification before transfer to the matching. Matching was performed at a 1:1 ratio without replacement
IRRF office. We ensured adherence to privacy standards and the Preferred using propensity scores for age, sex, tumor volume, pure tone average, and
Reporting Of CasE Series in Surgery guidelines for surgical case report.15 speech discrimination scores, using the “MatchIt” package in R with the
The study focused on adult (age ≥18 years) patients with a minimum “nearest” method. The quality of the match was determined by the
6-month follow-up postdiagnosis in the observation group and post-SRS absolute standardized difference. Values below 0.10 indicate a well-
in the SRS group. Patients were included during various time intervals balanced match, and values between 0.10 and 0.20 indicate a moder-
depending on when SRS was introduced to each individual center across ately balanced match. Two separate matchings were performed (1 for
the past 4 decades. Exclusion criteria were bilateral VS or neurofibro- tumor control and neurological outcomes and the other specifically for
matosis. Initial evaluations included demographic data, neuroimaging for SHP). All covariates in these matchings had an absolute standardized
tumor volume, clinical symptoms, cranial nerve (CN) deficits, and difference below 0.15. Primary end points included tumor progression
baseline audiometry. VS detection and monitoring were performed ra- and the loss of serviceable hearing, determined by the earliest MRI in-
diologically. Variables analyzed comprised demographics, neurological dicating tumor progression and the earliest audiogram showing loss of
signs, CN impairments at initial and latest follow-ups, initial tumor serviceable hearing. Kaplan–Meier curves estimated tumor control and
volume (via SRS planning software or radiological measurements), and SHP, with differences between survival functions analyzed using the log-
baseline audiometric tests. All symptoms, such as tinnitus and vestibular rank test. Five-year and 8-year rates were reported with 95% CI. A 2-
dysfunction, were documented if they emerged progressively and tailed P-value <.05 was considered significant. All statistical analyses were

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 THE VISAS-K1 STUDY

performed using R software (Version 4.1.1, 2021-09-0; RStudio, Inc.; R (95% CI: 38.5%-64.1%) at 5 years, and further to 33% (95% CI:
Foundation for Statistical Computing). 22.2%-49.2%) at 8 years.
There is no significant difference in SHP rates between the
Data Availability groups (Figure 2, log-rank test, P = .75). The SRS group had SHP
Data will be made available upon reasonable request.
rates of 79.7% (95% CI: 72.4%-87.6%) at 3 years, 64.6% (95%
CI: 54.5%-76.6%) at 5 years, and 37% (95% CI: 24.8%-55.1%)
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at 8 years. In comparison, the observation group displayed SHP

rates of 75.1% (95% CI: 64.2%-87.9%) at 3 years, 56.9% (95%
RESULTS
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CI: 43.7%-74.1%) at 5 years, and 35.6% (95% CI: 17.3%-

Patient and Tumor Characteristics in the 73.1%) at 8 years.
Unmatched Cohorts In the analysis of unmatched cohorts, the SRS group demon-
strated a significant reduction in the incidence of tinnitus (odds ratio
The analysis of unmatched cohorts included 261 patients with
[OR] = 0.46, 95% CI: 0.22-0.96, P = .04) and vestibular dys-
Koos grade I VS: 182 underwent SRS and 79 were observed
function (OR = 0.17, 95% CI: 0.05-0.50, P = .002) as compared
(Table 1). Median age was similar across groups, 56.5 years (IQR,
with the observation group (Table 2). However, there was no sig-
47-64) for SRS and 56 years (IQR, 43.5-64) for observation (P =
nificant difference between the groups in worsened CN V function
.47). Groups had comparable sex distribution, with 51.6% fe-
(OR = 1.3, 95% CI: 0.16-26.7, P = .82) or worsened CN VII
males in the SRS cohort and 53.2% in the observation group (P =
function (OR = 0.87, 95% CI: 0.17-6.3, P = .87). Further analysis
.93). The SRS group had a significantly higher rate of patients
highlighted significantly lower odds for composite clinical outcomes
with symptomatic presentation (79.1%) than the observation
of tumor progression and/or deteriorated function of various CNs
group (65.8%, P = .03). The SRS group had a significantly larger
(Table 2).
tumor (0.17 cc [IQR, 0.10-0.26]) compared with the observation
group (0.08 cc [IQR, 0.04-0.13], P < .001). The proportion of Clinical Outcomes in the Matched Cohort
patients with serviceable hearing was comparable between the SRS
In the matched cohorts, tumor control outcomes significantly
(74.7%) and observation groups (77.2%, P = .79). Detailed
favored the SRS over observation (Figure 3, log-rank test, P <
patients and tumor characteristics are listed in Table 1.
.001) with the absence of any progression events. The SRS-
managed patients exhibited a 100% (95% CI: 100%-100%)
Patient and Tumor Characteristics in the tumor control rate at 3-, 5-, and 8-year intervals, with no events of
Matched Cohorts tumor progression recorded. Conversely, the observation group
The matched cohort analysis involved 142 patients with Koos demonstrated a decline in tumor control over time, with rates
grade I VS, with 71 managed by SRS and 71 observed (Table 1). dropping to 63.5% (95% CI: 52.5%-76.8%) at 3 years, 48.6%
Median age was comparable across the groups, at 58 years (IQR, (95% CI: 36.8%-64.0%) at 5 years, and 29.5% (95% CI: 18.5%-
47-64.5) for the SRS and 56 years (IQR, 43.5-65.5) for the 47.1%) at 8 years.
observation (P = .48) group. Females constituted 49.3% in the The comparison of SHP between SRS and observation groups
SRS group and 54.9% in the observation group (P = .60). in the matched cohorts revealed no statistically significant dif-
Symptomatic presentations were reported in 80.3% of the SRS ference (Figure 4, log-rank test, P = .33). At the 3-year interval,
group vs 63.4% of the observation group (P = .04). Median tumor the SHP rates were 73.5% (95% CI: 61.5%-87.7%) for the SRS
volumes were comparable, at 0.1 cc (IQR, 0.08-0.16) for SRS and group and 82.9% (95% CI: 72.6%-94.6%) for the observation
0.09 cc (IQR, 0.04-0.15) for observation (P = .08). Rates of ser- group. At the 5-year interval, the SHP rates were 70.1% (95% CI:
viceable hearing were 80.3% for SRS and 77.5% for observation (P = 55.5%-88.5%) for the SRS group and 53.4% (95% CI: 38.8%-
.81). Both groups had comparable follow-up duration, 36 months 73.5%) for the observation group. By the 8-year mark, SHP rates
(IQR, 15.5-61.5) in the SRS group and 42 months (IQR, 18.5-63) were 44.6% (95% CI: 24.7%-80.6%) for the SRS group and 26.7%
in the observation group (P = .66). Detailed characteristics and (95% CI: 9.53%-74.9%) for the observation group.
outcomes for the matched cohorts are presented in Table 1. The analysis of matched cohorts revealed no significant dif-
ference in the rate of tinnitus between the SRS and observation
Clinical Outcomes in the Unmatched Cohort groups (OR = 0.51, 95% CI: 0.15-1.6, P = .26) (Table 2). The
In the analysis of unmatched cohorts, the SRS group exhibited odds of experiencing vestibular dysfunction or worsened CN V
significantly enhanced tumor control relative to the observation function were nearly 0 (95% CI: N/A-Inf, P > .99), indicating no
cohort (Figure 1, log-rank test, P < .001). The SRS cohort significant disparity between the groups. The likelihood of
achieved a tumor control rate of 99.2% (95% CI: 97.6%-100%) worsened CN VII function was also not significantly different
at 3-year, 5-year, and 8-year time points, with a solitary event of (OR = 0.49, 95% CI: 0.02-5.3, P = .57). Composite clinical
tumor progression noted. Conversely, the observation cohort outcomes further underscored the efficacy of SRS, with signifi-
displayed a marked decrease in tumor control rates, declining cantly lower odds for tumor progression and/or deteriorated
to 63.2% (95% CI: 52.7%-75.7%) at 3 years, to 49.7% function of various CNs (Table 2).

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 BIN-ALAMER ET AL

TABLE 1. Comparison of Patient Characteristics and Outcomes Between SRS and Observation in Unmatched and Matched Cohorts

Variable SRS (N = 182) Observation (N = 79) P-value

Unmatched cohort
Age, y 56.5 (IQR, 47-64) 56 (IQR, 43.5-64) .47
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Female sex 94 (51.6%) 42 (53.2%) .93

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Symptomatica 144 (79.1%) 52 (65.8%) .03

Tinnitus 42 (23.1%) 48 (60.8%)

Vestibular dysfunction 23 (12.6%) 27 (34.2%)

Facial weakness 1 (0.5%) 1 (1.3%)

Median tumor volume, cc 0.17 (IQR, 0.10-0.26) 0.08 (IQR, 0.04-0.13) <.001

Median PTA 28 (IQR, 17.5-45.8) 26.3 (IQR, 14.5-44.4) .23

Median SDS 92% (IQR, 72%-100%) 93% (IQR, 71%-100%) .72

Serviceable hearing (AAO-HNS classes A and B) 136 (74.7%) 61 (77.2%) .79

Median margin dose 12.5 (IQR, 12-12.5) N/A N/A

Median maximum dose 25 (IQR, 24-25) N/A N/A

Median average dose to the cochlea 3.5 (IQR, 2.7-4.2) N/A N/A

Follow-up duration 32.5 (IQR, 15-55.8) 45 (IQR, 19-73) .11

Variable SRS (N = 71) Observation (N = 71) P-value

Matched cohort
Age, y 58 (IQR, 47-64.5) 56 (IQR, 43.5-65.5) .48

Female sex 35 (49.3%) 39 (54.9%) .60

a
Symptomatic 57 (80.3%) 45 (63.4%) .04

CN V symptom 0 0

Tinnitus 46 (64.8%) 42 (59.2%)

Vestibular dysfunction 31 (43.7%) 23 (32.4%)

Facial weakness 0 1 (1.4%)

Median tumor volume, cc 0.1 (IQR, 0.08-0.16) 0.09 (IQR, 0.04-0.15) .08

Median PTA 25 (IQR, 16.5-39.8) 29.4 (IQR, 15.3-46.1) .91

Median SDS 96% (IQR, 80%-100%) 93% (IQR, 71%-100%) .62

Serviceable hearing (AAO-HNS classes A and B) 57 (80.3%) 55 (77.5%) .81

Median margin dose 12.5 (IQR, 12-12.5) N/A N/A

Median maximum dose 25 (IQR, 22.7-25) N/A N/A

Median average dose to the cochlea 3.3 (IQR, 2.5-4.1) N/A N/A

Follow-up duration 36 (IQR, 15.5-61.5) 42 (IQR, 18.5-63) .66

AAO-HNS, the American Academy of Otolaryngology-Head and Neck Surgery; CN, cranial nerve; PTA, pure tone average; SDS, speech discrimination scores; SRS, stereotactic
radiosurgery.
a
One patient can have multiple symptoms.
Reprinted from International Journal of Radiation Oncology*Biology*Physics, Bin-Alamer O., Abou-Al-Shaar H, Peker S., Samanci Y., et al. “Vestibular Schwannoma International
Study of Active Surveillance Versus Stereotactic Radiosurgery: The VISAS Study,” Copyright 2024, with permission from Elsevier.

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 THE VISAS-K1 STUDY
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FIGURE 1. Tumor control in unmatched cohorts. SRS, stereotactic radiosurgery.

DISCUSSION SRS as an effective treatment for Koos grade I VS, achieving high
tumor control while preserving neurological function.
Comparing SRS with observation for Koos grade I VS, we found
SRS superior in tumor control, with a 100% rate at 5 and 8 years vs
significantly lower rates in the observation group (48.6% at 5 years Tumor Control
and 29.5% at 8 years, P < .001). SHP rates were similar between Our matched cohort analysis demonstrated that SRS signifi-
groups, but SRS effectively reduced the worsening of CN dys- cantly improves tumor control in Koos grade I VS, achieving a
function, tinnitus, and vestibular dysfunction. These results endorse 100% control rate at both 5- and 8-year marks, compared with

FIGURE 2. Serviceable hearing preservation in unmatched cohorts. SRS, stereotactic radiosurgery.

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 BIN-ALAMER ET AL

TABLE 2. The Odd Ratios of End Points Comparing SRS With Observation

Variables OR 95% CI P-value

Unmatched cohorts
Tinnitus 0.46 (0.22-0.96) .04
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Vestibular dysfunction 0.17 (0.05-0.50) .002

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Worsened CN V function 1.3 (0.16-26.7) .82

Worsened CN VII function 0.87 (0.17-6.3) .87

Any worsened CN function 0.49 (0.26-0.93) .03

Tumor progression and/or any worsened CN function 0.12 (0.07-0.22) <.001

Tumor progression and/or vestibulopathy 0.03 (0.01-0.06) <.001

Tumor progression and/or worsened CN V function 0.02 (0.006-0.052) <.001

Tumor progression and/or worsened CN VII function 0.02 (0.008-0.06) <.001

Tumor progression and/or hearing decline 0.3 (0.17-0.53) <.001

Matched cohorts

Tinnitus 0.51 (0.15-1.6) .26

Vestibular dysfunction Near 0 N/A-Inf >.99

Worsened CN V function Near 0 N/A-Inf >.99

Worsened VII function 0.49 (0.02-5.3) .57

Any worsened CN function 0.26 (0.08-0.75) .02

Tumor progression and/or any CN dysfunction 0.07 (0.02-0.19) <.001

Tumor progression and/or vestibulopathy Near 0 N/A-Inf .989

Tumor progression and/or CN V dysfunction Near 0 N/A-Inf .989

Tumor progression and/or CN VII dysfunction 0.02 (0.001-0.10) <.001

Tumor progression and/or hearing decline 0.17 (0.07-0.39) <.001

CN, cranial nerve; OR, odds ratio; SRS, stereotactic radiosurgery.

Reprinted from International Journal of Radiation Oncology*Biology*Physics, Bin-Alamer O., Abou-Al-Shaar H, Peker S., Samanci Y., et al. “Vestibular Schwannoma International
Study of Active Surveillance Versus Stereotactic Radiosurgery: The VISAS Study,” Copyright 2024, with permission from Elsevier.

lower rates in the observation group (48.6% at 5 years, 29.5% at National Unit for Vestibular Schwannoma with 100 patients
8 years, P < .001). This significant difference highlights the ef- showed that those undergoing early SRS had better tumor volume
ficacy of SRS in primary VS management, aligning with previous reduction after 4 years (V4:V0 ratio of 0.87) compared with
research that supports its high tumor control rates.9,19-22 observation (1.51, P = .002), with only 2% requiring further
Régis et al22 demonstrated a 3% treatment failure rate among treatment vs 42% in the observation group.27 Nevertheless,
patients with Koos grade I VS treated with SRS, as opposed to a observation remains a considered strategy for individuals with
74% failure rate observed among patients under conservative asymptomatic and stable tumors or those contending with other
observation (P < .001). Another study detailed their experience significant medical concerns.
with SRS in 209 patients with Koos grade I VS and reported a
10-year tumor control rate of 92.1%.19 Several studies suggest Hearing Preservation
that opting for observation in cases of small VS correlates with Our analysis found no significant difference in SHP rates
tumor progression rates varying from 22% to 75% over follow-up between SRS and observation groups, consistent with the liter-
periods spanning 26–80 months, necessitating further interven- ature, suggesting that management approach—SRS or
tion in 15% to 74% of cases.22-26 A pivotal trial by the Norwegian observation—might not significantly affect hearing outcomes in

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FIGURE 3. Tumor control in matched cohorts. SRS, stereotactic radiosurgery.

patients with small VS.9,19,28-30 Schnurman et al29 and Akpinar observation cases may directly affect auditory function, SRS poses
et al28 highlighted minimal SHP differences between SRS-treated a risk of cochlear damage through radiation, potentially exacer-
and observed patients, suggesting similar hearing preservation bating sensorineural hearing loss.9,19,28-30 Although our study did
across treatments. The potential equivalence in hearing outcomes not directly link SRS to improved SHP, literature, such as Akpinar
could be attributed to the dual effects of natural disease pro- et al,28 suggests that early SRS might benefit long-term hearing
gression and radiation exposure. While tumor growth in preservation. This indicates that the timing of SRS could be

FIGURE 4. Serviceable hearing preservation in matched cohorts. SRS, stereotactic radiosurgery.

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© Congress of Neurological Surgeons 2024. Unauthorized reproduction of this article is prohibited.

 BIN-ALAMER ET AL

crucial for optimal outcomes, emphasizing a strategic approach to information regarding whether any of the tumors were contin-
VS management. uingly growing before SRS. Another limitation is the lack of data
on the time from diagnosis or symptom onset to SRS procedure.
Neurological Outcomes After Intervention In addition, this study lacks data on the median and interquartile
Our study found that SRS significantly reduces neurological range for pure tone average and word recognition score at specific
impairment risks compared with observation. In unmatched time points. Expanding the study to include more participants
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cohorts, SRS was associated with lower incidence of tinnitus and extending follow-up periods would enhance the robustness of
(OR = 0.46, P = .04) and vestibular dysfunction (OR = 0.17, P = our findings.
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.002), as well as a decrease in any CN function deterioration,

observed in both unmatched (OR = 0.49, P = .03) and matched
cohorts (OR = 0.26, P = .02). There was also a noted decrease in CONCLUSION
the likelihood of composite outcomes involving tumor progres- In Koos grade I VS, SRS demonstrates superior tumor control
sion and neurological issues. However, no significant differences and lower risks of neurological deficits compared with observa-
were found in the risks of CN V and CN VII dysfunction between tion. SHP outcomes between SRS and observation were com-
SRS and observation groups, in both matched and unmatched parable, indicating a similar auditory impact from SRS
analyses. Our finding aligns with the existing literature, re- intervention. For effective tumor management and reduced
inforcing SRS’s role in achieving comprehensive tumor control neurological complications, SRS seems to be preferable over
alongside reducing neurological deficits for patients with Koos observation. Further prospective randomized studies are needed to
grade I VS.6,20,31-34 validate these observations and delineate the superiority of SRS in
Neurological well-being significantly affects quality of life in this patient population.
patients with VS.35 While an observation approach may pre-
cipitate adverse outcomes, early SRS is posited to foster long-term
tumor control and mitigate neurological function deterioration. Funding
Crucially, the onset of neurological dysfunctions under obser- This study did not receive any funding or financial support.
vation may not be reversible with subsequent SRS. Hence, while
conservative management is a valid approach for Koos I VS, it is Disclosures
imperative to acknowledge that established neurological symp-
Daniel Trifiletti reports clinical trial research support from the Florida
toms at the time of treatment might persist despite tumor control Department of Health, Varian Medical Systems, Novocure, and Blue
through SRS. Our strategy for managing patients with Koos grade Earth Diagnostics Ltd.; publishing fees from Springer Inc.; and con-
I VS has traditionally involved treating larger tumors and those sulting fees from Boston Scientific Corporation. The other authors have
causing symptoms with SRS, while smaller, asymptomatic tumors no personal, financial, or institutional interest in any of the drugs,
were observed. However, the findings from this study, along with materials, or devices described in this article. Michael Schulder is a
other published studies, indicate that even asymptomatic patients consultant for Accuray and Elekta. Kenneth Bernstein is a consultant for
with smaller tumors may benefit from SRS over observation at the NeuroPoint Alliance.
time of diagnosis.27 These results suggest a potential shift in our
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